Fieldstrength Magazine - Issue 57

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Publication for the Philips MRI Community Issue 57 – 2020

MRI Magazine

Fast scanning, fast


workflow, high quality
More time for advanced MRI
in neurology clinic

Institute boosts MRI quality


and speed with Ambition

UBC advances their


MS imaging with Elition 3.0T

Up to 20 extra patients
per week at Cobalt
Editorial

Dear
Friends,
Our vision for MR builds on the quadruple aim of healthcare which strives to
reduce cost, improve outcomes, and improve patient- and staff satisfaction.
In MRI, we therefore develop products that can help reduce cost per procedure,
allow to serve more patients, help reduce pressure on staff and support more
confident diagnoses.

It’s inspiring to see how our customers use our technology to help them advance
on this quadruple aim. In this issue of FieldStrength you can read about the Miami
Cardiac & Vascular Institute seeing a boost in MRI quality, speed and patient
comfort after installing an Ingenia Ambition 1.5T scanner with the BlueSeal magnet,
that contains only 7 liters of helium and is designed for helium-free operation.

In the article about University of British Columbia you can read how switching
to Ingenia Elition 3.0T has created many new opportunities for the researchers
to advance their imaging of multiple sclerosis. Ingenia Elition helped Fondation
Rothschild to shorten scans, allowing them to add advanced sequences or
switch to higher resolution for improving diagnostic confidence.

Over the past two years, many customers started to use our Compressed
SENSE acceleration technology and experienced how it helped them improve
in many ways, ranging from scanning more patients to reduced staff over time,
technologists having more time with their patient or improved diagnostic
confidence thanks to improved resolution or the ability to add more sequences
in the same time slot. Read more in the articles about Cobalt in the UK and about
Ikazia Hospital in the Netherlands. There is also an educational article that can
help you understand what makes Compressed SENSE so powerful.

I am proud that together with our customers we are making this impact in
healthcare and we constantly strive to improve patient care.

Enjoy reading!

Martijn Hartjes
Head of Global Product Marketing MR, Philips

2 FieldStrength - Issue 57 - 2020 | IMSRM


In this issue

Fast scanning,
fast workflow,
high quality
6 23
MRI
Safety

MRI
Sequence MRI
Optimization Hardware

Proton
MR-sim
Pre-treatment
Hub

MRI MRI
Examination Daily QA

12 18 32 26
MRI
Screening

News
4 Philips demonstrates innovation leadership in MRI 23 Faster* MRI examinations and more comfort
 Fast scanning, fast workflow and BlueSeal magnet for for patients
helium-free operation.  ompressed SENSE acceleration helps scan more patients.
C
Ikazia Hospital, Netherlands
38 Top ranking in the Dow Jones Sustainability Indices
Striving to make the world healthier and more sustainable 26 Compressed SENSE pilot reaps rewards for Cobalt
through innovation. Fast MRI helped increase productivity, up to 20 extra
patients per week*.
Users experience speed, comfort, confidence Cobalt, United Kingdom
6 Institute sees boost in MRI quality, speed and
patient comfort 32 Building MR-simulation competency in radiotherapy
Advantages of Ambition with fully sealed BlueSeal magnet. MR-sim training program for proton beam radiotherapy service.
Miami Cardiac & Vascular Institute, Florida, USA The Christie Hospital, United Kingdom

12 UBC researchers advance their MS imaging Education


Switching to Ingenia Elition created new opportunities for 30 Understanding how Compressed SENSE makes
multiple sclerosis imaging. MRI faster
University of British Columbia, Canada It can be used in all anatomical contrasts, enabling scans to
be up to 50% faster with virtually equal image quality*.
18 Scanning faster* and have more time for advanced
MRI techniques Research
Fondation Rothschild creates more time for advanced neuro 37 How a co-research approach tackles MRI challenges
exams by faster* scanning, thus boosting diagnostic confidence with AI
Fondation Rothschild, Paris, France Top performers in fastMRI image reconstruction challenge.

*Compared to Philips scans without Compressed SENSE

Results from case studies are not predictive of results in other cases. Results in other cases may vary.
Results obtained by facilities described in this issue may not be typical for all facilities.

www.philips.com/fieldstrength 3
MR news

Philips demonstrates
innovation leadership in MRI
At the most recent RSNA, Philips highlighted the success of its Compressed
SENSE MRI acceleration technology as well as additional features to save
time and enhance workflow. Also in the spotlight was the Ambition 1.5T MRI
scanner, the industry’s first and only commercially available, fully sealed
magnet for productive, helium-free operations [1]. User results illustrate its
excellent imaging capabilities.

Faster scanning times can increase productivity “Our accelerated Compressed SENSE
while benefitting patients and staff scanning technology, combined
Improving MRI speed and workflow is a key area of attention
for many imaging providers. Compressed SENSE is an with a host of smart innovations,
advanced solution that can reduce scan times by up to 50% enables a step-change in MR speed,
[2]. It can be used for all anatomical scans throughout the
productivity and workflow, while
body, both 2D and 3D. Philips recently marked that one million
patients were already scanned with Compressed SENSE improving the experience for patients
acceleration. The User experience articles in this issue provide and staff.”
examples of results obtained at different facilities.
Arjen Radder, General Manager for MR at Philips

SPEED

COMFORT

CONFIDENCE

4 FieldStrength - Issue 57 - 2020


Driving a breakthrough in workflow experience
Combining powerfully with Compressed SENSE, our latest The technologist can initiate the exam with a single touch.
SmartWorkflow solution integrates guided patient setup Scanning begins immediately after the door is closed, and the
and scanning automation, along with technology such as system automatically centers, plans, scans and processes the
VitalEye, VitalScreen and SmartExam [3], helping to save resulting images. As a result, patient setup can be done in less
time and reduce staff stress by simplifying the number of than one minute, even for less experienced operators [4]. With
workflow steps. this breakthrough in workflow, a fully automated MR exam is
now one step closer.

Guided Touchless One-touch Automated planning,


exam setup patient sensing auto-start scanning and processing

VitalScreen VitalEye SmartTouch SmartExam

Workflow innovations key to improving the Only MRI scanner with fully sealed magnet
experience of staff and patients receives customer and industry recognition
Research commissioned by Philips highlights the need The Ambition 1.5T MRI scanner is the industry’s first and
for radiology staff empowerment and workflow-focused only commercially available fully sealed magnet for more
innovation. With pressure on imaging departments mounting productive, helium-free operations [1]. Since its launch last year,
amid rising patient volumes and a global shortage of qualified the breakthrough technology has received an enthusiastic
staff, improvements in workflow and efficiency, supported by reception from healthcare providers worldwide, reducing the
data integration and AI, can improve the experience of staff and chance of potentially lengthy and costly disruptions,
patients and, more broadly, enhance clinical outcomes while and virtually eliminating dependency on a commodity
reducing costs. with an unpredictable supply.

Our evidence-based research approach and people-centric The fully-sealed system does not require a vent pipe and is
design thinking help facilities uncover new opportunities to around 900 kg lighter than its predecessor [5]. This significantly
improve the patient, family and staff experience. With over 1500 reduces the siting challenges presented by conventional
installations worldwide, Ambient Experience solutions can magnets and is lowering construction costs.
benefit many areas – from waiting areas and uptake rooms to
procedure and recovery rooms and even entire departments. The Ambition 1.5T MR was recently recognized by the U.S.
Association for Medical Imaging Management (AHRA), winning
its inaugural Innovation Award. Refer to page 6 to read about
the excellent imaging results with Ambition at Miami Cardiac &
Vascular Insitute. «

1 The Ambition 1.5T MR contains less than 0.5% of the helium of a conventional system and this is permanently sealed inside the device.
2 Using Compressed SENSE technology and compared to Philips exams without Compressed SENSE.
3 SmartExam is not available to patients with MR Conditional Implants.
4 Based on in-house testing.
5 Compared to the 1.5T ZBO magnet.

www.philips.com/fieldstrength 5
User experiences

Miami Cardiac & Vascular Institute benefits from the advantages of


Ingenia Ambition with BlueSeal magnet, designed for helium-free operation

Institute sees boost in


MRI quality, speed and
patient comfort
When it was time to replace its old MRI system, Miami Cardiac & Vascular Institute chose
the Ingenia Ambition 1.5T scanner after evaluating several MRI systems. This “7-liter liquid
helium MRI system” has delivered simple siting, workflow efficiency and many patient
comfort features. Most important, however, was the superb quality of the images. Since
its installation in 2018, the exceptional image quality provided by Ingenia Ambition has
offered diagnostic confidence to the Institute’s radiologists. The machine’s outstanding
performance has more than justified their choice.

“Compressed SENSE is not just faster imaging, it’s a


way to improve both image quality and scan time”

Quality, patient comfort and workflow drive says interventional radiologist Constantino Peña, MD, the
purchase decision Institute’s Medical Director of Vascular Imaging. “In selecting
“After scanning many thousands of patients with our Achieva an MRI machine, we wanted state-of-the-art technology that
MRI system, a 16-year-old magnet, it was time to investigate was easy to install, easy to use, and that would be easy on the
the latest technology,” says Carol Melvin, Chief Operating patient. But most definitely, it had to give us high quality images.
Officer at Miami Cardiac & Vascular Institute, part of Baptist That's how we how we settled on the Ingenia Ambition.”
Health South Florida.
Apart from its excellent imaging capabilities, several other
“Our aim is to offer patients the care that they need in a less factors ultimately led Miami Cardiac & Vascular Institute to
invasive way, which is why diagnostic imaging is key to us,” select Ingenia Ambition. The industry-first fully sealed BlueSeal
Melvin says. “Among our biggest challenges is staying current magnet contains just seven liters (v. 1,500 liters) of liquid helium
with technology that will enable us to maintain world-class and is completely sealed, so helium cannot escape, which helps
care. But just because we had used a Philips system before increase operational efficiency. In addition, its light weight, small
didn’t compel us to automatically acquire Philips again. We went footprint and no need for a vent pipe simplify system siting.
through our due diligence and evaluated the MRIs of multiple
vendors to ensure an informed decision. It was important that According to the Institute’s team, however, the most impressive
our physicians and technologists embrace the new system.” attribute of Ingenia Ambition is a combination of speed and
exceptional quality of imaging, workflow enhancers and patient
“Challenges facing us every day are how to maximize our image comfort solutions that have been particularly beneficial in its first
quality in order to answer diagnostic questions for our patients,” six months of operation.

6 FieldStrength - Issue 57 - 2020


Constantino Peña, MD Carlos Avila, RT Carol Melvin
Interventional radiologist at Miami Cardiac & Technologist at Miami Cardiac & Vascular Chief Operating Officer for Miami Cardiac &
Vascular Institute who, as Medical Director of Institute since 2004, who has been involved in Vascular Institute, Baptist Health South Florida.
Vascular Imaging, also performs CTA, MRA, and building cardiac and vascular MRI for 11 years.
noninvasive arterial examinations.

“The ability to adjust Compressed SENSE to enable shorter


breath-holds translates to a much smoother cine”

Compressed SENSE acceleration helps clinicians to the best possible image quality,” Dr. Peña says. “That makes
balance speed vs. image detail the difference and allows us to determine whether someone
When asked about the most remarkable features of Ingenia needs to proceed to therapy or treatment and prevents us from
Ambition, Carlos Avila, the Institute’s Lead Technologist needing a significant number of invasive procedures.”
responds without hesitation: “The most impactful changes
come from Compressed SENSE and mDIXON XD.” “Compressed SENSE is not just faster imaging, it’s a way
to improve both image quality and scan time – the user
Compressed SENSE allows up to 50% faster* scanning. It works controls how to balance that. In some scans, we may want to
for all anatomical scan sequences and in all body areas. And, acquire images quicker, while for other scans we want to use
as always in MRI, scanning speed may be traded to obtain more Compressed SENSE to increase resolution so that we see more
anatomical detail, which may have even more impact at the detail,” Dr. Peña says.
Institute. The mDIXON XD methods provides robust fat-free, high
SNR imaging and significant time savings in MR angiography (MRA). Shorter breath-holds help patients and benefit
diagnostic confidence
“High quality imaging has allowed us to move away from Owing to their condition, many patients at Miami Cardiac &
invasive angiography to noninvasive methods such as MRA. Vascular Institute have difficulty performing breath-holds as
When relying on these types of images, it's important to have needed, for instance in MRI cine scans of the heart and in
MRA examinations.
*Compared to Philips scans without Compressed SENSE

Avila says that Compressed SENSE allows them to reduce breath-


Cor 3D T2
3D dynamic hold time to 3 to 4 seconds in cardiac cine scans. “At the same
MRA of head time, we can now – based on cardiac frequency – obtain as many
and neck as 30 to 40 cardiac phases without sacrificing resolution, while
Excellent image before Ingenia Ambition, we were acquiring only 20 phases.
quality is obtained in
this dynamic scan., “This ability to use Compressed SENSE for obtaining higher
C-SENSE factor 5.4,
scan time is 1:20 min, temporal resolution translates to a much smoother cine.
voxel size is 0.8 x This allows me to better assess heart function,” Dr. Peña says.
0.8 x 1.6 mm, Ingenia
Ambition, 1.5T.
“In MRA, the capacity to acquire a sequence in a single breath-
hold provides images that are motion-free and high in contrast
and detail, advantages that aid in diagnosis,” he says. “With
Compressed SENSE, we can reduce the time for the single
breath-hold to just 2-3 seconds. Before Ingenia Ambition and
Compressed SENSE, the breath-hold requirement was about
8 to 9 seconds, which was too long for some patients.” »

Results from case studies are not predictive of results in other cases. Results in other cases may vary. www.philips.com/fieldstrength 7
User experiences

MRA run-off study with mDIXON Subtractionless MRA run-off studies with
The subtractionless peripheral MR angiography shows improved exceptional spatial and temporal resolution
vessel-to-background contrast and high resolution. Ingenia “In our peripheral MRA run-off studies with Ambition we realize
Ambition 1.5T. key benefits, including outstanding image quality and significantly
reduced breath-hold and scan times, which not only benefit the
Station Ingenia Ambition
patient, but also provide the opportunity to add sequences that
Pelvis Voxels 1.3 x 1.3 x 3.2 mm, FOV 430 mm, 125 slices could aid in diagnosis,” Dr. Peña says.

Upper legs Voxels 1.3 x 1.3 x 3.2 mm, FOV 430 mm, 125 slices
“Before we had Ingenia Ambition, our CE-MRA run-off
Lower legs Voxels 1.0 x 1.0 x 2.0 mm, FOV 430 mm, 125 slices studies would first acquire a dynamic pre-contrast scan with
20-25-second breath-holds, then inject the contrast, do
another acquisition and then subtract the two,” says Avila.
“Now, mDIXON XD allows us to complete the study in just one
single pass – without need for a pre-exam – which eliminates
subtraction artifacts and almost halves the scan time. In addition,
mDIXON provides much better background suppression, which
really improves vessel-to-background contrast. And, thanks to
Compressed SENSE, the single breath-hold is not long and we
improve image resolution.”

Time saved enables addition of useful


diagnostic sequences
The time saved by Compressed SENSE and mDIXON XD is
sometimes used to include additional sequences. An example
are peripheral MRA studies, in which Compressed SENSE
and mDIXON XD help achieve a 5- to 10-minute reduction in
scanning time. This brings the total time down, from the 45
minutes needed with their previous system to about 30 to 35
minutes on Ingenia Ambition, thus providing ample time to
include additional sequences.

“These scans are so fast now that we have been able to add
a non-contrast MRA sequence within the same timeslot. We
compare the respective image quality with the goal to determine
whether the non-contrast sequence could be an alternative for
patients who can’t tolerate gadolinium contrast agents due to
poor kidney function,” says Avila. “We find the image quality of
the non-contrast sequence so good that we can now also offer
peripheral MRA to these patients whom we had been unable to
serve before Ambition, so that has been great.”

Another example is the foot examination for diabetic patients,


which has improved dramatically. “The forefoot is generally
difficult to image with MRI because of the inhomogeneities that
the toes create – it’s hard to obtain good fat saturation in that
area. Here, mDIXON made a huge difference right away, we
obtain much better image quality,” Dr. Peña says.

“Because mDIXON XD provides


subtractionless fat-free imaging,
we get much better background
suppression, which really helps the
vessels stand out”

8 FieldStrength - Issue 57 - 2020


“Using mDIXON, Compressed SENSE and the dS FootAnkle coil, “On our previous system we had to
we have been able to reduce the scan time, so that we can now sacrifice image resolution to get to
also include an additional 3D STIR sequence to visualize both
arteries and veins in the foot.”
5- or 6-second temporal resolution,
while on Ambition, we don’t have to
Avila adds: “In addition, since most of these patients are in sacrifice image quality”
a significant amount of pain, it’s important to perform the
examination as quickly as possible. With Compressed SENSE and
mDIXON we have been able to reduce the scan time from about
45 minutes to just 15 minutes. Not only does this improve patient MRA of foot using 4D-TRAK XD
comfort, we see that it also helps us acquire images without The images obtained with Ingenia Ambition show large coverage
motion artifacts, which is critical to making a confident diagnosis.” and high, uniform signal. More vessels are visible than in a previous
exam of the same patient on Achieva. The movies show a higher
temporal resolution in the Ambition acquisition than in a previous
High temporal resolution for detailed timing in MRA Achieva 1.5T exam. Both exams use a FOV of 300 mm and voxel
The team at Miami Cardiac & Vascular Institute also appreciates height and width of 0.78 mm.
Ingenia Ambition’s capabilities for fast dynamic CE-MRA. Achieva 1.5T Ingenia Ambition
“With 4D TRAK XD, we get much better temporal and spatial
resolution. Previously, with the Achieva we needed 6 seconds
per dynamic, but now we can shorten that to 2 seconds per
dynamic,” Avila says. “As a result, we can see the transition from
arterial to venous phase with much higher temporal resolution.
This is important, for example, for imaging arteriovenous
malformations, which are quite vascular.”

“On our previous system we really had to sacrifice image


resolution to get to 5- or 6-second temporal resolution, while now
– using 4D TRAK XD on Ambition – we no longer have to sacrifice
image quality,” Dr. Peña says. » 2:30 min. TE 1 ms, TR 4 ms 4D Trak XD 1:54 min. TE 1 ms, TR 3 ms

mDIXON MRA in chest Short breath hold cardiac cine


Performed on Ingenia Ambition. These are some images of a cardiac cine scan with a short breath-hold time. A high
FOV 430 mm, voxels 1.3 x 1.3 x3.0 mm, temporal resolution provides a smooth cine, which helps in assessing heart function.
130 slices, Breath hold 16.6 sec Ingenia Ambition.

Results from case studies are not predictive of results in other cases. Results in other cases may vary. www.philips.com/fieldstrength 9
User experiences

“We used to have maybe two patients each week


who we had to convince to have the scan.
With Ambition that has become the exception”

VitalEye VitalScreen

So many features that enhance patient comfort comments about the comfort of the room and the system.
“The ambient lighting, the wide bore diameter, the comfort They are happy about the conditions, the path through the
mattress, the monitor in the back offering video and information machine and the visual experience.”
during the scan, the sound reduction – all of it has made a big
difference for our patients,” Avila says. “Before Ambition, we He adds that the coil’s tilting device also often helps to make the
would have maybe two patients each week for whom we had to exam easier to undergo. “For patients who have shortness of
take time to convince them to have the scan. That has become breath, being able to elevate their head often helps them a lot.
the exception now. Once we lay them down on the support, I can We can lift that tilt device all the way up and still put the mirror
see it in their eyes – their anxiety level drops. I haven’t turned on, so patients can see outside of the bore,” Avila says.
away a patient yet.”

According to Avila, patients have been very positive across the


board. “Many patients at the Institute require repeated MRI “Never before have we gotten so many
scanning. Some of them may have had an experience of feeling
terrified in a previous MRI exam, but when they come to this new
comments from patients about how good
room, it’s like a new post. Patients often spontaneously share their MRI experience was”

3D T2 with VitalEye 3D T2 with VitalEye


Free breathing abdominal MRI
with VitalEye
Ascites can be hard to image, but excellent
result is obtained with Ingenia Ambition. This
high resolution image demonstrates the high
quality that can be obtained with VitalEye
and the patient just breathing normally. The
acquisition time is fast thanks to the accuracy of
the respiratory gating with VitalEye** and it also
saves the time needed to put a respiratory belt
on the patient.

10 FieldStrength - Issue 57 - 2020


Workflow tools for a challenging clinical For Miami Cardiac & Vascular Institute,
environment Ingenia Ambition excels with diagnostic quality
Ingenia Ambition came with tools that help Miami Cardiac & and patient comfort
Vascular Institute technologists in streamlining their workflow. The Ingenia Ambition experiences at Miami Cardiac & Vascular
Both technologist and patient comfort benefit from VitalEye, Institute demonstrate that exceptional diagnostic capabilities,
a solution for detecting patient physiology and breathing outstanding patient comfort and productivity attributes can
movement, according to Avila. co-exist on a single imaging platform.

“With VitalEye, we can get high-resolution acquisitions with “We’ve been pleasantly surprised with Ingenia Ambition –
the patient free-breathing. This is much easier for the patient it’s next-generation MR technology,” Dr. Peña says. “When
than breath-holds. Moreover, it eliminates the longer set-up comparing it to our previous MR system, we notice that we
times needed for putting a respiratory belt on the patient and improved by being able to include more sequences in a study
provides superior image quality**,” Avila says. “VitalEye serves and we see improved quality of many sequences.”
as a guide for us to trigger the acquisition and for the scanner
to trigger the AutoVoice commands. Its high-quality reading “It’s also remarkable that while Baptist Health has installed
of the patient’s breathing patterns translates into sharper** multiple different MRIs throughout the system, never before have
images without breathing motion artifacts.” we gotten so many comments from patients about how good
their MRI experience was,” Dr. Peña adds. “And, the combination
The Institute’s technologists also save time by initiating scans of things like VitalEye, the comfort mattress and sequences
with VitalScreen, the interactive touchscreen on the scanner such as Compressed SENSE and mDIXON have really made our
that provides guidance and insights on the current patient study, patients’ lives and our lives easier in this complex cardiovascular
such as exam duration, coil selection and patient positioning. imaging environment. Ambition truly brings together all the most
“We can verify the patient’s name, scanning orientation and the important aspects of a successful MRI service.”
accuracy of cardiac gating,” Avila says. “In addition to being able
to control the bore lighting and fan, VitalScreen increases our Avila echoes Dr. Peña’s impressions and adds: “Our workflow has
efficiency by enabling us to start acquiring the initial reference become much more efficient by replacing our former system with
images and scouts before we even walk out of the room.” Ambition. We have faster exams, higher quality images, and less
time inside the magnet overall.”
Technologists are also happy with AutoVoice guiding patients
through the MR study. “AutoVoice removes the task of giving COO Carol Melvin concludes: “We’re thrilled to be the first in
breathing instructions from the technologist and thus allows us North America to have Ingenia Ambition. From what we've
to focus on planning the exam,” Avila says. “It’s almost like the seen and demonstrated, Ambition enables us to perform really
study is on auto-pilot – Ambition is doing the work. Plus, high-quality imaging, which is allowing us to take this institute
a diversity of languages is available, which is important in a to a higher level. It also has helped us decrease procedure time,
large metropolitan area like Miami.” which allows us to have slots open for additional patients.” «

**Compared to Philips belt-based signal. Requires an unobstructed line-of-sight.

Cor T2W fatsat Sag T1W Ax PD fatsat


Shoulder with MultiVane
motion reduction
MultiVane was used for motion reduction
in this shoulder examination, providing
excellent detail that is not obscured by
motion artifacts, as happens quite commonly
when no proper motion reduction method is
available. Images from Ingenia Ambition.

Scan time 3:06 min. Scan time 4:10 min. Scan time 4:17 min
Voxels 0.5 x 0.5 x 3 mm, Voxels 0.5 x 0.5 x 3 mm, Voxels 0.5 x 0.5 x 3 mm,
recon 0.4 x 0.4 recon 0.4 x 0.4 recon 0.4 x 0.4

Results from case studies are not predictive of results in other cases. Results in other cases may vary. www.philips.com/fieldstrength 11
User experiences

Switching to Ingenia Elition has created new opportunities


for MS imaging at the University of British Columbia

UBC researchers advance their


multiple sclerosis imaging

One of the main research areas at the MRI Research Centre at the University of British
Columbia (UBC), in Vancouver, Canada, is imaging of multiple sclerosis (MS). The center
runs many studies and trials, and its researchers continually strive to improve and
expand imaging methods to help in visualizing the disease and support diagnosis and
monitoring. In this article, UBC researchers explain how their recently installed 3.0T MRI
system, a Philips Ingenia Elition, helps them advance their MS-related research studies.
At the same time, they feel this scanner makes their lives easier and surprises them
with the impact it has on patients and volunteers.

12 FieldStrength - Issue 57 - 2020


Alex MacKay, DPhil Alex Rauscher, PhD Shannon Kolind, PhD Laura Barlow, RTMR
Professor of Physics, with a joint Associate Professor and physicist Assistant Professor and physicist MRI Technologist Supervisor at the
appointment in the Department at the University of British at the University of British University of British Columbia MRI
of Radiology and the Department Columbia. His research focus is on Columbia, currently working in the Research Centre, 3T facilities. She
of Physics and Astronomy at the quantitative brain MRI and includes Department of Medicine, Division has been working with MRI for a
University of British Columbia, and mapping tissue susceptibility, of Neurology. Her main goal is decade. Her current role focuses
Director of the UBC MRI Research myelin mapping, and studying translating current quantitative- on the field of advanced neuro
Centre. He has been working with the effects of anisotropic tissue and biologicallyspecific MRI research.
MRI since about 1988 with a main orientation on MRI. methods for use in clinical
research focus on neuro. environment, in particular myelin
imaging for MS.

“Switching from our old scanner to Elition is like


jumping from a flip phone to the latest smart phone”

Trends in visualizing and identifying MS lesions Myelin water imaging (MWI) is a breakthrough technique that
with MRI was pioneered at UBC for measuring myelin content in the brain,
At the UBC MRI Research Centre, which is currently staffed by in vivo. “Because the T2 time of water in myelin is much shorter
70 principal investigators, the majority of studies and clinical trials than the T2 of water in the intra- and extracellular spaces, we can
are brain research, with MS-related research as a principle area separate out the myelin water signal.”
of interest. The center installed a 3.0T Ingenia Elition scanner
in December 2018 as a successor of their Achieva 3.0T, with the The techniques for measuring myelin have changed a lot over
intention to use it for all future research studies. the years. “Since we are using the Elition, our myelin water
images are much better. We're now acquiring 1 x 2 x 5 mm voxels
Multiple sclerosis or MS is a neurodegenerative disease that is and displaying at 1 x 1 x 2.5 mm. For a whole brain we can now
characterized by myelin degradation, resulting in cognitive and measure the fraction of water in the myelin component in only
motor deficits. According to Dr. Shannon Kolind, MR imaging about five or six minutes,” Dr. MacKay says.
for diagnosis and monitoring of MS is moving to higher field
strength and using more 3D sequences, as reflected in the “We are actually starting to apply this technique in clinical trials,” says
CMSC guidelines [1-3]. Dr. Kolind. “And I’m really hopeful that this is going to give us more
clues about the underlying disability progression in MS and move us
“In addition to traditional imaging like FLAIR for lesion identification, towards some treatment options for that aspect of the disease.”
we see a real push towards techniques that weren’t normally
required for MS, including good high-resolution 3D T1-weighted Dr. MacKay adds that researchers at UBC are also involved
images to do volumetrics. We’ve also started looking at spinal in trials to examine the effects of MS drug treatments on
cord imaging again, since techniques have improved in terms myelination. “In a way, we’re providing a validation of the
of acquisition and analysis. Another important technique is drug mechanism,” he says. “Some treatments are designed to
susceptibility weighted imaging (SWI), particularly if we are looking promote myelination and unpromote demyelination. We can
for central veins in lesions, which is extremely helpful for diagnosis.” see that some of these drugs are definitely having an effect on
myelin water fraction in the cohorts we’ve been studying,
Boosting myelin imaging capabilities to help and that’s really exciting for us.” »
visualize MS progression
At UBC, a lot of the MS-related work focuses on myelin imaging.
“We're born with very little myelin and that increases as the
brain grows, which is important for nerve signal propagation.
Multiple sclerosis on the other hand, degenerates the myelin “Since we are using the Elition, our
with the opposite effect. So, myelin has a really important role in myelin water images are much better”
brain function, and having a tool that measures myelin can be
extremely useful, we feel,” says Dr. MacKay.

Results from case studies are not predictive of results in other cases. Results in other cases may vary. www.philips.com/fieldstrength 13
User experiences

T1 - weighted Myelin water imaging (echo 1)

Red box is field-of-view

Increasing resolution and coverage. Myelin water imaging With SENSE With Compressed SENSE
These images illustrate that instead of limiting
MWI to the brain, even without the cerebellum, Acquired resolution 1 x 2 x 5 mm 3
1.5 x 2 x 3 mm3
the team can now spend about the same amount Number of echoes 32 or 48 56
of time and scan the whole brain and the cervical
spinal cord, which is a huge boost for them. Echo spacing 10 ms or 8 ms 7 ms

T1 - Weighted Myelin Water Fraction Superimposed


Fast MWI scans with full brain coverage
Dr. Kolind says that Ingenia Elition has opened up a world of
different options and features and it has been tremendously
exciting to discover how these can benefit their protocols.
20%
“Switching from our old scanner to Elition is like jumping from
a flip phone to the latest smart phone,” she adds.

“The biggest jump is being able to turn on Compressed SENSE;


it has definitely made sequences faster, allowing us to fit in
more types of images. However, in most studies one or two
Spinal cord coverage
scans are the main focus, so we can also stick to the time and
apply Compressed SENSE to improve the resolution or even
the coverage. For example, instead of limiting MWI to the brain,
even without the cerebellum, we can now spend about the same
amount of time and scan the whole brain and the cervical spinal
cord, which is a huge boost for us.”

Smaller, more isotropic voxels


Dr. Rauscher says, “For MWI we perform 3D T2 with 32 or more
0% echoes. This used to take a long time, but with Compressed
Myelin Water
Fraction SENSE we can decrease this to ten minutes for the whole
head. Because of the large field of view (FOV) on the readout
direction, we even get information from the brainstem, which we
Excellent detail in previously missed when we were using the GRASE approach.
quantitative maps
Having the whole head scan is nice because it has spatial
Images courtesy of Adam Dvorak, Department of Physics and Astronomy, resolution, orientation and FOV that are comparable to the
University of British Columbia standard 3D clinical MS scans, including the FLAIR and 3D T2,
and a 3D T1 for brain volume.”

Researchers enjoy flexibility in adjusting


sequences, even without pulse programming
The flexibility of the Elition scanner stands out in particular for
Dr. MacKay. “Researchers want broad possibilities for
manipulating pulse sequences, but getting into pulse
programming takes a lot of time and training. Fortunately, the
Elition console allows us to do an amazing number of things
without going into pulse programming. Technologists or scientists
who know the scanner well, can perform scans very quickly, faster

14 FieldStrength - Issue 57 - 2020


“Researchers want broad possibilities to manipulate pulse
sequences. Fortunately, the Elition allows us to do an amazing
number of things without going into pulse programming”

than on either of the other scanners we have.” Technologist Laura Dr. Rauscher says, “With better gradients we can use a shorter
Barlow agrees: “This system is far more intuitive than our Achieva echo spacing on the spin echo, so we get better sampling of
in terms of navigating operator software; it’s much faster.” the rapidly decaying myelin signal, which typically has T2 of
around 10-20 milliseconds at 3 Tesla. If we can reduce echo
Also Dr. Rauscher considers it a huge advantage that he spacing from about 8 to 5-6 milliseconds, we get a much better
can simply try things on the Elition that would require pulse sampling of the short decay component and increase our
programming on different MRI systems, such as their old SNR, which is a big advantage. The same is true for multi-echo
Achieva system. “For example, adding pre-pulses or turning a gradient echo which we use for susceptibility mapping and for
conventional 3D T2 scan into an accelerated GRASE scan with mapping venous vessels in MS.”
multiple echoes have been very easy thanks to the enormous
flexibility with the Elition’s graphic user interface,” he says. In practice, Ingenia Elition allows the team to do things now
that were not possible before: “There are some scans that
“In the past, MWI scans were often limited due to time we didn’t do before, because the scans were taking too long.
constraints,” says Dr. Kolind, “because it was a difficult acquisition With Elition we can combine scans that would have been
and complicated analysis. But with the Elition, we can perform prohibitively long on the old scanner. For instance, we can get
MWI without having to do any programming modifications.” the combined information from looking at advanced diffusion,
multi-shell diffusion combined with myelin water, and then also
Gradient enhancements have a substantial impact add quantitative susceptibility mapping and get a better idea
on myelin imaging of tissue micro structure effects from all three combined. On the
For Dr. Kolind, the Elition excels in advanced neuroimaging for two old scanner we only had time to run maybe one or two of these
main reasons. “It's image quality and access to so many different sequences in addition to the conventional scans,”
imaging parameters. We’re involved in several multi-center studies, says Dr. Rauscher.
and we can always easily identify the images that came from our
Elition scanner, because they are just so beautiful – even though Accelerating scans helps researchers achieve
it seems like we’ve set our parameters similarly to other study their imaging goals
participants. And as a physicist, being able to do many things, for The Elition scanner at UBC has helped researchers decrease
instance to push resolution and save time, is really helpful.” scan times and has paved the way for extended scanning
possibilities. “We can now achieve more of our scanning goals
According to Dr. MacKay, MWI images benefit from Elition’s high in the same time,” says Dr. Rauscher. “Patients can typically
quality gradients. “We need good gradients because we want to stay in the scanner for about 45 minutes. So, with the faster
be able to do multi-echo sequences that have short TE times.” scan times, we can now add more scans into one session. »

“We can now


achieve more of
our scanning goals
in the same time”

Sagittal 3D FLAIR with 0.3 mm3 voxel volume QSM based on a Compressed SENSE
acquired in 5:12 min. using Compressed SENSE multi-echo SWI.
showing a (juxta)cortical MS lesion.

Results from case studies are not predictive of results in other cases. Results in other cases may vary. www.philips.com/fieldstrength 15
User experiences

“The progress bar tells patients how much time is left,


the little clock shows when to do a breath hold. These
may seem little things, but they make a big difference”

Ambient experience in-bore Connect

He says the accelerated scanning is achieved via the use remarked on how comfortable the mattress was. After her scan,
of Compressed SENSE and MultiBand SENSE. “We can use she said it was the best MRI she’d ever had, and she would
Compressed SENSE acceleration factors of about 10 on a 3D definitely come back and volunteer again.”
FLAIR for instance, which is quite remarkable compared with
what we saw with the Achieva. With 3D FLAIR, we can push the Smart features help contribute to a quick workflow
spatial resolution to 0.3 cubic mm and it works. Previously, our for patient preparation and scanning
3D FLAIR scans lasted about 8 minutes, but now with Elition According to Laura Barlow, the addition of the Elition scanner
they are five minutes. The SNR is also visibly better. Our SWI at UBC has resulted in impressive changes in daily workflow.
and QSM scans look fantastic. Also, since a lot of neuroimaging “It’s really easy to operate the scanner,” she says. “Being able to
is EPI based, using the MultiBand SENSE technique can drag-and-drop, having the middle mouse to scroll through the
increase temporal resolution and make it possible to run images, it’s just so much faster than our previous system.”
complicated DTI scans relatively quickly.”
The staff also notices enhancements in patient preparation
Surprised by big impact on patient and prior to scanning. “Bringing patients into the room and
volunteer comfort positioning them on the table is certainly fast now, since we
The great impact of Elition’s patient comfort features was a can move the table without having to landmark with certain
surprise for Dr. Kolind. “In our research projects we are working coils, and having the FlexTrak makes it easier to help patients
with many patients and volunteers. Their universal feedback on and off the table,” Ms. Barlow says.
has really been that it's just such a better experience than
the previous scanner.” Dr. Kolind thinks that the comfortable “The VitalEye wireless gating system makes things much easier,
bed and the Ambient system all contribute to patient comfort. too. We tested it with volunteers who were instructed to move
“Having control over the lighting and environment with the around during scanning, and it still performed very well, which
Ambient Experience seems to really give the patients a feeling was a nice surprise. Being able to set the scan to start as soon
that they have more power during the scanning process.” as we shut the door also improves the flow. The AutoVoice
and progress bar cuts down on the amount of time we need to
According to technologist Laura Barlow, many people are quite communicate with the patient, which also helps accelerate
relaxed when they get off the table. Some explicitly mention the scan time.”
that the comfortable mattress and added features, such as
ability to see the scan’s progress bar, also keep patients feeling An excellent scanner for researchers and their
satisfied with their experiences. study subjects
“Our decision to purchase Ingenia Elition was based on the
“One of our patients admitted to being very uncomfortable image quality and ease of use,” says Dr. MacKay. “We really feel
in previous MRI scans and had actually tried to avoid having that the images we get from the Elition 3.0T scanner are high
clinical MRIs for four years. She had decreased mobility, so we quality and more artifact-free than what we see from other
brought her into the room using the FlexTrak trolley, and she systems. Also, the console of the Elition allows our techs and

16 FieldStrength - Issue 57 - 2020


researchers to do an amazing amount of things without having
to get into pulse programming. Just sitting at the console, you
Summary of experiences with
can do a remarkable number of things with this scanner.”
Ingenia Elition at UBC:
“What we didn’t foresee beforehand was how much patients
• Compressed SENSE and Multiband SENSE
would love the scanner,” says Dr. MacKay. “They find it so much
nicer to be inside the wide bore Elition with its Ambient and In- allow acceleration of virtually every
bore experience. They can see the progress bar that tells them sequence
how far they are in the protocol and how much time is left, or
the little clock when they have to do a breath hold. These may • Shorter scan times allow for additional
seem little things, but they make a big difference, particularly sequences in an examination to provide
because patients participating in trials or research studies often
more information
have to stay quite long in the scanner.” «
• Faster scanning allows for the use of
3D instead of 2D sequences to benefit
References diagnostic confidence
1 Consortium of MS Centers, 2018 MRI guidelines, MRI protocol for the • Comfort features, such as the mattress, the
Diagnosis and Follow-up of MS, www.mscare.org

2 Hu XY, Rajendran L, Lapointe E, Tam R, Li D, Traboulsee A, Rauscher A.


progress bar and Ambient Experience help
Three-dimensional MRI sequences in MS diagnosis and research. Mult patients and study participants have a more
Scler 2019 May 22:1352458519848100. doi: 10.1177/1352458519848100
enjoyable experience
3 Wiggermann V, Hernandez-Torres E, Traboulsee A, Li DKB, Rauscher A.
FLAIR2: A Combination of FLAIR and T2 for Improved MS Lesion • The FlexTrak, VitalEye, and AutoVoice
Detection. AJNR Am J Neuroradiol 37:259–65
features help streamline workflow
4 Kames C, Wiggermann V, Rauscher A Rapid two-step dipole inversion
for susceptibility mapping with sparsity priors. Neuroimage. 2018 Feb
15;167:276-283

“Bringing patients into the room and positioning them


on the table is certainly fast now, since we can move the
table without having to landmark with certain coils”

Results from case studies are not predictive of results in other cases. Results in other cases may vary. www.philips.com/fieldstrength 17
User experiences

Fondation Rothschild creates more time for advanced neuro


exams by faster* scanning, thus boosting diagnostic confidence

Scanning faster* and have


more time for advanced
MRI techniques
When faced with the task of selecting two MRI scanners for a busy neurology clinic,
Dr. Julien Savatovsky and his team looked for a system that could help them meet the
increasing demand for MRI exams, and deal with declining reimbursements in France.
After a balanced assessment of several systems, the quality of the images and the
fast acquisition times of Ingenia Elition 3.0T led to the decision to purchase two Elition
scanners. These have allowed the team to shorten scan times, and that enables
Dr. Savatovsky to include more advanced sequences to boost diagnostic confidence.

The need for flexibility while maintaining a steady From the beginning, the intention was to acquire two of the
workflow same machines. “We like the two MRIs to be interchangeable,
Fondation Rothschild, based in Paris, France, is a tertiary so that we can easily switch a patient to the other device when
care hospital that performs specialized workups for patients we have to accommodate emergencies during the day”, says Dr.
presenting with neurologic, ophthalmologic, and head- Savatovsky. “Another reason is that this allows our technologists
and-neck diseases. They also provide first-line treatment to use both devices in exactly the same way and they only need
for patients, as well as emergency care for acute stroke, to learn one user interface.”
ophthalmologic, and neurologic cases. The radiology
department has been using four MRI scanners, including two Image quality and speed driving the Elition purchase
Ingenia Elition 3.0T machines, since November 2018. The choice for two Elition scanners was not made lightly.
Dr. Savatovsky and his team compared devices from different
According to Dr. Julien Savatovsky, a diagnostic neuroradiologist vendors before making the decision. “Part of this process was
at Fondation Rothschild, the increasing demands for MRI exams, our assessment of the image quality of different devices. We
decreasing reimbursements in France, and the need to perform put together a list of sequences with detailed requirements,
advanced exams for complex patients requires fast, high quality including limited acquisition times, to allow a fair comparison.
scanning and efficient workflow. These challenges drove the We even put the same volunteer in each scanner. Our
decision to buy two Ingenia Elition 3.0T scanners. assessment was that the image quality was better with the

Julien Savatovsky, MD
Diagnostic neuroradiologist at
Fondation Rothschild, Paris, “The main breakthrough for us
since 2006. His clinical interests
include advanced diagnostic was that Compressed SENSE and
imaging in neuro, head and
neck, and ophthalmology.
Multiband SENSE have allowed us
to accelerate our examinations.”

18 FieldStrength - Issue 57 - 2020


Elition scanner. Compressed SENSE or Multiband SENSE was Enriching examinations to boost diagnostic
used for almost every sequence, and I think this helped a lot to confidence
maintain a great image quality in the shorter acquisition time.” “We used to have long examination times for certain types of
patients, a few lasting more than 40 minutes,” says Dr. Savatovsky.
Using speed for shorter exams or more information “What is remarkable, is that now all these examinations are below
in the same acquisition time 30 minutes, which opens up opportunity to add more sequences
According to Dr. Savatovsky, Ingenia Elition has an impact in when needed. It’s really hard to keep a patient for more than 40
virtually all examinations. “We can either make the scanning faster minutes in the scanner, but because we have now cut scan times
compared to our older Ingenia 3.0T, or we save enough time so that by at least 10 minutes, we can add more sequences without
we can add sequences we wouldn’t perform otherwise, or increase making the exam too long. And this is where the new system helps
resolution. So, I think it has benefits for most of our patients.” us make a difference. Examples include our examinations for
informing brain tumor classification or giant cell arteritis workup,
“Some routine exams that we use every day have been shortened or for intracranial wall imaging – so in patients where we need
since we started using Elition. For example, we now use mostly several advanced sequences or high resolution sequences.”
a comprehensive stroke protocol (high b-value diffusion, fast 3D
FLAIR, TOF, supra-aortic vessels angiography, SWIp, T1 post gad) “We added three additional sequences in our brain neoplasm
that lasts 10 to 11 minutes, but our fast stroke protocol takes only classification exam: a 3D SWI sequence, APT and ASL on top
7 minutes. Our routine IAC needs about 10 minutes scan time and of 3D morphologic sequences, an isotropic DSC (dynamic
our comprehensive brain MS examination requires no longer than susceptibility contrast) and multivoxel spectroscopy. I think that
13 minutes of scan time. Our ability to reduce acquisition times of in patients that need a classification for brain mass, for example,
most sequences helps to shorten total examination times, which in we can provide a more detailed and confident diagnosis than
turn helps us to increase the number of patients we scan per day. before, allowing the clinicians to decide for either a medical
workup if no tumor is suspected, or for neurosurgery as soon as
“The main breakthrough for us was that Compressed SENSE and possible if a neoplasm is suspected.”
Multiband SENSE have allowed us to accelerate our examinations.
Alternatively, we can invest the time gained in obtaining higher “In multiple sclerosis patients, we increasingly include a multishot
spatial resolution to see more details, or we can add additional susceptibility sequence [3] in our routine cases, thanks to the
sequences,” says Dr. Savatovsky. “That’s a big improvement from shorter scan times. Our abbreviated MS protocol for brain is »
what we did before.”

Fast MS protocol with


optional sequences
The abbreviated MS protocol for
brain is only around 9 minutes,
so in case of suspected multiple
sclerosis, one or two more
advanced sequences may be
added, such as PSIR (phase
sensitive inversion recovery)
or susceptibility-weighted
sequences to help us make more 3D TFE T1 3D FLAIR DWI 3D T1w TSE Gd 3D PSIR (optional)
confident diagnoses in these 1.0 mm isotropic 1.0 mm isotropic b0, b2000 1.0 mm isotropic 1.0 mm isotropic
inflammatory cases. 2:50 min. 3:00 min. 0:30 min. 2:40 min. 4:20 min.

In this example, the optional


3D multishot susceptibility
weighted sequence with 0.6 mm
isotropic voxels is 2 lesions with
a central vein sign (arrows) and
one lesion with a phase-rim sign
(arrowhead). The total scan time,
including SmartBrain and axial
PD/T2 3mm, is 11:10 min. and
is 18:30 min. with the optional
3D PSIR and 3D SWI multishot
included. 3D SWI (optional)
0.6 mm isotropic
3:30 min.

Results from case studies are not predictive of results in other cases. Results in other cases may vary. www.philips.com/fieldstrength 19
User experiences

around 8 to 9 minutes, so we can ask for one or two additional “The time needed for positioning the patient and the
sequences to visualize the central veins, or to get an additional technologist’s workflow depends on the device. We particularly
contrast to better depict posterior fossa lesions. In cases of white benefit from the lightweight FlexTrak dockable patient transport
matter lesions of unknown significance on FLAIR images, for system for patient preparation outside the MRI room, which we
example when we see high signal hyperintensities in the brain, purchased with the Elition. Currently, patient positioning is quite
we can add on more advanced sequences such as PSIR (phase fast, even for heavy or bedridden patients, because with FlexTrak
sensitive inversion recovery) or susceptibility-weighted sequences the patient and coils can be installed in the preparation room
to help us in distinguishing between MS and nonspecific or and then be brought into the scanner room immediately after the
vascular abnormalities in these inflammatory cases.” previous examination ended.” Other Elition features that support
a fast workflow include the auto-start function that starts the scan
Performing advanced techniques has a direct as soon as the technologist closes the scanner room door.
impact on hospitalizations
So, what is the actual impact of having more information and Accommodating multiple emergencies per day
more diagnostic confidence? According to Dr. Savatovsky, The MRI center at Fondation Rothschild receives several neuro
“One of the indications I’ve seen where using Elition is most and head/neck emergency cases per day. On weekdays, an
impactful is in patients with suspected giant cell arteritis. As an average of 7 unscheduled patients will require scanning, with
ophthalmologic hospital, we see many patients with suspected approximately 4 to 5 patients actually requiring an urgent MRI
giant cell arteritis. Usually we were performing MRI to help us scan, according to Dr. Savatovsky. He notes that the ability
rule out an ischemic stroke, and to verify that the supra aortic to accelerate sequences while maintaining image quality is
vessels are undamaged. With Elition, we still do this, but now particularly important in the emergency setting.
we can add on more detailed high-resolution black-blood
sequences on superficial arteries. This provides us with high “The fast scanning capabilities that came with Elition allow us
confidence levels for diagnosis of giant cell arteritis (GCA) and to do a really quick examination and answer a lot of questions
as a result, some patients are not sent for a biopsy anymore. within a short time. We use every tool available to accelerate
A patient who has a normal MRI will not require a biopsy and image acquisition while maintaining a reasonable image quality.
can be discharged from the hospital in the same day. Before, So, for most of the sequences we use Compressed SENSE, for
such a patient would have to stay for about a week, just to find example, in our 3D FLAIR, in contrast-enhanced and noncontrast
that their biopsy results were negative. We have at least three MR angiography, and for susceptibility-weighted sequences.”
or four patients a week with suspected giant cell arteritis. For
a great deal of these patients we can have a direct impact on Among the emergencies that are routed to the MRI department
their hospital stay.” at Fondation Rothschild, stroke is seen almost daily. “After
arriving, acute stroke patients are immediately brought to the
A good workflow for excellent patient management MRI preparation room and positioned on the FlexTrak table.
Dr. Savatovsky recognizes that throughput in an MRI center not only There, the neurologist examines the patient and the biological
depends on scanning time, but also on the time needed by the workup is performed. Once this is finished, we can immediately
technologist to position the patient and operate the MRI scanner. move the patient with FlexTrak into the MRI and begin the
“Scan time in very short exams will last from 5 to 9 minutes. Our scanning within one or two minutes. So, having the FlexTrak is
goal is to keep our average scan time under 15 minutes.” a big advantage for us.”

Giant cell arteritis


The 3D TSE T1w black blood MSDE
sequence with fat suppression
has an isotropic 0.8 mm voxel size
and sagittal oblique and axial
reformats are made. The images
show superficial temporal artery
thickening and peri-arterial fat
infiltration. The 3D TSE PDw black
blood MSDE with fat suppression
has 0.55 mm isotropic voxels. The
images shows focal involvement of
the frontal branch of the superficial
temporal artery.
3D TSE T1w BB MSDE 3D TSE PDw BB MSDE
0.8 mm isotropic, 4:40 min. 0.55 mm isotropic, 4:30 min.

20 FieldStrength - Issue 57 - 2020


Fast acute stroke protocol
This is an example of acute ischemic stroke with distal occlusion of the right posterior cerebral artery. Note the improved visibility of the ischemic
territory on the diffusion weighted image with high b-value. The 3D FLAIR shows a distal PCA occlusion. The fast SWIp depicts the thrombus on the
isolated second echo image. The total scan time (including SmartBrain, preparations and a fast 3D T1w TSE Gd) is 8:00 minutes.

DWI b1000, b2000, ADC, 0:50 min. 3D FLAIR , 1:30 min.


isotropic 1.15 mm

3D TOF, 1:20 min. SWIp, 0:50 min. CE-MRA, 1:10 min.

Comprehensive stroke MRI within acceptable time Improved diffusion imaging in stroke patients
Dr. Savatovsky appreciates the improvements and flexibility Using MultiBand SENSE allowed the staff to improve their
that Elition with Compressed SENSE and MultiBand SENSE diffusion quality. “Our diffusion sequence was already fast
provides, particularly for stroke patients. “For stroke, it allows before, about 40 seconds. Now with Elition, it still lasts
us to cut about 5 minutes off of our stroke protocol, or to keep 40 seconds, but we improved the spatial resolution by 0.2 mm
the same acquisition time and get more insights.” and use high b-values to be more sensitive to visualize
changes related to acute stroke,” says Dr. Savatovsky.
The ability to perform more sequences can help in making a
swift and confident diagnosis. “For example, our stroke cases “We now also developed a high resolution DTI sequence (1.3 x 1.3 x
usually include the regular sequences that every center does 2 mm) that can be reformatted and takes 2 to 5 minutes depending
(b1000 diffusion, FLAIR, time-of-flight angiography), but we on the coverage. We use it every time we have a doubt, or when
also image supra aortic vessels, and we can replace a gradient we expect the diffusion to be abnormal but don’t see that on the
echo sequence with a fast 50-second susceptibility-weighted fast sequence. We occasionally spot small ischemic infarctions that
sequence, and all of this doesn’t add much time. because all would not have been visible with the regular diffusion sequence.”
the regular sequences are accelerated on Elition.”
Excellent spine and spinal cord imaging
“The time savings with Compressed SENSE and MultiBand Looking for inflammatory lesions of the spinal cord is usually
SENSE make it easier to add sequences to give us additional challenging with MRI, says Dr. Savatovsky. “We solved some of the
insights. Depending on the context and the first results, we challenges by implementing sequences such as 3D PSIR, which
might add a DSC perfusion to assess the ischemic penumbra, allows us to see far more lesions than the usual T2 imaging. We are
an ASL perfusion to help find an alternative cause in case of starting to see cases where the MRI images at 1.5T were normal, but
normal diffusion, or add a high-resolution T1 sequence for a then we do see lesions when performing the PSIR at 3.0T.” [1]
stroke patient, to quickly assess wall imaging in emergency
cases. The additional sequences can help improve patient “Elition also performs very well in imaging of the bony spine,
management, because we can already consider some the discs and degenerative disease, especially now that we can
alternative diagnoses if the morphological MRI is normal.” include at least one 3D sequence in every scan. For example, »

Results from case studies are not predictive of results in other cases. Results in other cases may vary. www.philips.com/fieldstrength 21
User experiences

we perform a lot of 3D spin-echo (TSE) sequences when “The image quality for neurological cases is the most robust we’ve
imaging degenerative lumbar spines. Thanks to Compressed seen. If we compare examination time and image quality of a
SENSE and the 3D SpineVIEW protocols, we have a very high given sequence, like 3D TSE FLAIR, there is no question that the
signal intensity with no flow voids, so the image quality is very Elition performs really well. We are now also capable of performing
good. The possibility to reformat the images in every plane multishot susceptibility and can perform PSIR sequences for
raises the diagnostic confidence, especially in patients who spine and brain, which are not available on all systems. We can
have to undergo surgery.” use Compressed SENSE for every sequence, whereas with other
vendors this might be limited to a few sequences, only.”
Increased patient throughput with higher resolution
Previously, about 30 patients a day were scanned on their Looking back at the economic factors that contributed to his
Ingenia 3.0T, during a 15-hour opening period. With the Elition hospital’s decision to purchase two Elition MRI devices, he notes:
system, the average number of patients scanned per day “Since reimbursement costs are decreasing, we had to calculate
increased by approximately 10%. “On a day where we only scan the number of patients needed to make an economically sound
outpatients, we can scan 35 to 40 patients a day. Also, routine investment. Now we know that also from an economic perspective,
MRI cases, such as IAC, headaches workup, memory impairment, purchasing the Elition MRI machines was a wise decision.” «
acute neurological deficit, and multiple sclerosis, last less than
15 minutes, which is appreciated by patients who prefer short
References
examination times,” says Dr. Savatovsky.
1. Mirafzal S, Goujon A, Deschamps R, Zuber K, Sadik JC, Gout O, Lecler
“Elition really makes a difference. For example, sequences A, Savatovsky J.. 3D PSIR MRI at 3 Tesla improves detection of spinal
cord lesions in multiple sclerosis. J Neurol. 2020 Feb;267(2):406-414. doi:
that lasted 6 minutes a few months ago are now completed 10.1007/s00415-019-09591-8. Epub 2019 Oct 26.
in 3.5 minutes.”
2. Mohammed-Brahim N, Clavel G, Charbonneau F, Duron L, Picard H,
Zuber K, Savatovsky J, Lecler A. Three Tesla 3D High-Resolution Vessel
Purchasing Elition was a wise decision Wall MRI of the Orbit may Differentiate Arteritic From Nonarteritic
In conclusion, Dr. Savatovsky recaps the advances made possible Anterior Ischemic Optic Neuropathy. Invest Radiol. 2019 Jul 16. doi:
10.1097/RLI.0000000000000595. [Epub ahead of print] PMID:31335635
by having the Elition scanners: “Many examinations are shortened,
for more complex cases we can add advanced sequences or switch 3. Sati P, et al; NAIMS Cooperative. The central vein sign and its clinical
to higher resolution for improving diagnostic confidence. Emergency evaluation for the diagnosis of multiple sclerosis: a consensus statement
from the North American Imaging in Multiple Sclerosis Cooperative. Nat
patients in particular benefit from the speed and efficient workflow Rev Neurol. 2016 Dec;12(12):714-722. doi: 10.1038/nrneurol.2016.166. Epub
associated with the FlexTrak patient transport system.” 2016 Nov 11. Review.

Summary of Dr. Savatovsky’s experiences with Ingenia Elition 3.0T:

• Compressed SENSE and Multiband SENSE allow acceleration in virtually every Elition exam

• Scan times of most sequences were reduced with Elition without sacrificing diagnostic confidence*

• Workflow is fast and efficient, particularly in emergency cases

• More patients are scanned per system per day with Elition**

• Shorter scan times allow for additional sequences in an examination to provide more information
and benefit diagnostic confidence

• Faster* scanning allows for the use of 3D instead of 2D sequences to benefit diagnostic
confidence

*Compared to Philips scans without Compressed SENSE


**Compared to the Ingenia 3.0T

22 FieldStrength - Issue 57 - 2020


User experiences

Faster* MRI examinations and


more comfort for patients
Compressed SENSE acceleration helps Ikazia Hospital scan more patients

When their MRI waiting times continued to increase, Ikazia Hospital Rotterdam added
Compressed SENSE software to their existing MRI scanner. This technology can accelerate
MRI scans. It can be used for virtually all anatomical areas and with most sequences and
contrast types. The team at the Ikazia Department of Radiology is delighted with the
significantly shorter examination times, without loss of image quality. The radiology staff
also noticed the impact on their workflow and on their patient’s experience. »

*Compared to examinations without Compressed SENSE.

www.philips.com/fieldstrength 23
User experiences

Mark Stoutjesdijk, MD Wim Boon Marieke van Noort


Has been a radiologist at Ikazia Has worked as MRI technologist at Is Head of the Radiology department at Ikazia.
Hospital Rotterdam for 12 years. Ikazia Hospital for over 19 years. She has been working in radiology for 32 years.

“I believe Compressed SENSE is a must-have for every hospital”


Wim Boon, MRI technologist

Addressing the continuously increasing waiting software to their existing MRI scanner. Compressed SENSE is an
times for MRI acceleration technology that combines ‘compressed sensing’
According to radiologist Mark Stoutjesdijk, the hospital was and ‘sensitivity encoding’. It can reduce scan time for most MRI
facing an enormous capacity challenge for MRI in 2018. sequences and can therefore also shorten examination times.
“We have one MRI scanner and our waiting times continued Although Compressed SENSE can also be used to improve
to increase, which made us quite uncomfortable. We were quality, Mark Stoutjesdijk says that the team jointly made a clear
thinking about adding a second MRI scanner, but such decision to choose for time savings. “We could have exploited
purchase processes typically take at least one year.” the other capabilities of Compressed SENSE, for example
for increasing image quality, but that was already excellent.
However, technologist Wim Boon learned from a Philips We really wanted to increase patient throughput, and we set
application specialist that new scan acceleration software could specific goals for that.”
be installed on their system. “The Compressed SENSE software
is also available for older MRI scanners like our Achieva 1.5T “We first looked for the quick wins, the low-hanging fruit. For
dStream. That would allow us to scan much faster* without us, those were the knee examinations, which we had already
losing our image quality.” clustered in the evenings and on Saturdays,” says Wim Boon.

“We immediately recognized the potential to help us scan more Mark Stoutjesdijk continues: “Together with my fellow radiologists,
patients,” says Marieke van Noort, Head of Radiology at Ikazia. I mainly looked at the quality of the images in relation to the
“During a demo, based on our own protocols, Philips showed us acceleration. It was important that we, as team, reached a
where we could save time, and that was very convincing. consensus on what level of image quality was acceptable.”
I immediately set up a working group, also involving radiologists,
to thoroughly discuss the steps we would take.” Knee exam time halved, more patients scanned
When asked whether the waiting list had disappeared six
A well-planned, step-by-step implementation months after installing Compressed SENSE, the team was
In December 2018, Ikazia Hospital Rotterdam was the first quite amused. Mark Stoutjesdijk explains, “We have more than
hospital in the Netherlands to add Compressed SENSE achieved our goals regarding patient throughput, it’s really
beyond our expectations. Our knee examination times have
been reduced from 30 minutes to only 15 minutes, and other
examinations also take less time. On some Saturdays we scan
“We have more than achieved our goals
as many as 26 to 30 patients. However, apparently increased
regarding patient throughput, it’s really capacity also creates new demand, so our waiting times are still
beyond our expectations.” the same, even though we scan many more patients.”

24 FieldStrength - Issue 57 - 2020


Patients appreciate shorter exams Caring for patients paired with productivity
Although the main aim was to save time, the shorter study duration Despite high pressure on the department to limit waiting times
also benefits patients, according to Wim Boon. “Especially for and increase productivity, the interests of patients remain
patients who are anxious, a shorter time in the scanner is much paramount at Ikazia. “That’s what I like about my job,” says Wim
more comfortable. Patients who have experienced the difference Boon. “It is technical, but the success of an examination largely
between an ’old‘ exam and our current exam with Compressed depends on how we guide patients through it – because they
SENSE indicate that they find it much more pleasant.” are often quite tense.”

Impact is broader than just scan times “Our patients should not notice that we are very busy. When
Installing the acceleration software on the MRI scanner has patients are quite anxious or stressed, we take the time to
also brought about major changes in other areas. According to help them feel comfortable enough to undergo the scan,” says
Marieke van Noort: “All of a sudden we see that patient change Marieke van Noort. Wim Boon adds “The fact that examination
times play a role. In the past, our examination times were so long times are now considerably shorter also helps.”
that the time required for taking the patient on and off the table
didn't matter so much. Now, switching patients needs to happen “I think that in our hospital, we look carefully at how we can
quickly – the entire workflow has changed. We have also deliver good care in an efficient way,” says Mark Stoutjesdijk.
adjusted our patient information brochures accordingly.”
Highly recommended to others
The introduction of Compressed SENSE also encouraged the When asked whether they would recommend the Compressed
radiologists to review the scan protocols, tells Mark Stoutjesdijk. SENSE acceleration software to others, the three interviewees
“We went through our protocols to determine what we really were unanimously enthusiastic. “I have already been consulted
needed to keep, and what we could possibly eliminate, which also by another hospital and I could only confirm that we achieved
resulted in time savings”, he says. “It is also important to involve everything that we expected,” says Marieke van Noort. Wim
the referring clinicians in such a process. After all, they need to be Boon thinks that “It is a must-have for every hospital” and Mark
aware that the examination times have changed, and that they may Stoutjesdijk concludes by saying “The quality of the images is
have to request a different type of examination in some cases.” excellent. And every minute in the MRI room is valuable, so the
less time spent, the better.”«
Wim Boon adds: “It is important to realize that implementing
this application has had a great impact on our patient flow. My
job as a technologist has really changed. If a hospital is buying “We look carefully at how we can
Compressed SENSE, the department should be aware of the deliver good care in an efficient way”
broader influence it can have.”

Results from case studies are not predictive of results in other cases. Results in other cases may vary. www.philips.com/fieldstrength 25
User experiences

Karen Hackling-Searle, Ruth Pearson, Zoe Wray,


Head of MRI Training Facilitator, MRI Radiographer MRI Senior Radiographer

Accelerated MRI examinations helped to increase productivity,


allowing up to 20 additional patients to be scanned each week.

Compressed SENSE
pilot reaps rewards
for Cobalt
In September 2018, Cobalt was the first imaging facility in the UK to
install Compressed SENSE in a clinical setting. Over a three month trial
period, the team has been able to scan an additional 17-20 patients
per week compared to the same period in the previous year, using the
same Ingenia 3.0T scanner. The time gain with Compressed SENSE was
also used to increase spatial resolution in anatomies where this matters,
for instance in breast imaging.

26 FieldStrength - Issue 57 - 2020


Rather than changing all the scanning protocols immediately,
“Cobalt saw its diagnostic several routine body areas were chosen for dedicated
imaging services reduce their MRI Compressed SENSE scanning sessions. Where possible, body
areas were block-booked to reduce set-up time and increase
examination times by up to 30–50%, the throughput.
accommodating up to 20 additional
Dedicated sessions also gave the team time to review the patient
patients per week as a result.” pathway from reception arrival, through preparation to scanning
and patient release. This was to arrive at efficient workflows
to turn patients around in shorter appointment slots, whilst
Cobalt: innovation in imaging continuing to maintain the same level of care and support.
Cobalt is a charity that invests in equipment, research and
education to enable patient access to the best technology Patients were asked to arrive earlier at the clinic and measures
and medical imaging services. Cobalt and Philips have were taken to accommodate additional car parking requirements,
enjoyed a strong collaboration since 1993 when the first 0.5T owing to the increase in patients arriving during the Compressed
MRI scanner in a mobile unit was provided to support patients SENSE sessions. The team recognized a need for additional staff
in Gloucestershire, Herefordshire and Worcestershire. Since to guide the patients through the pathway and arranged for a
then Cobalt and Philips have collaborated on a number of dedicated Imaging Assistant to the Ingenia 3.0T scanner.
memorable firsts, including the UK’s first 1.5T MRI in a mobile
unit, first 1.5T Ingenia mobile, and first 3.0T Achieva TX and A core team was established to set up and optimize scanning
Ingenia MRI mobiles. The team at Cobalt is primarily focused on protocols. This gave them ownership of the task, and authority
medical diagnostic imaging and believes that all patients should to develop the protocol as was necessary, whilst maintaining
have access to the very best equipment while helping doctors high image quality.
to make a clear diagnosis, and an appropriately personalized
treatment plan. The Imaging Centre in Cheltenham remains at When developing protocols, the team had to take care that there
the forefront of diagnostic imaging technology. was no compromise on image quality and that the transition to
new protocols was seamless. In fact, the transition was indeed
Over 75,000 patients are seen each year, both at the Imaging seamless, as the radiologists did not notice the changes made,
Centre in Cheltenham, at the Institute of Translational and continued to report as if nothing has changed.
Medicine (ITM) Imaging Centre in Birmingham and with the
mobile MRI and CT scanners that travel nationally. To meet the “Cobalt strive for innovation and improving the patient
increasing demand for MRI capacity within the clinic, Cobalt pathway. With that in mind, we always have our eye open for
introduced the Philips Compressed SENSE technology on their anything new to achieve this. With Compressed SENSE there
Ingenia 3.0T during September 2018. This made Cobalt the will be a lot of discussions across the whole MR world about
first imaging facility in the UK to use Compressed SENSE in a this technological advance in MRI acceleration technique,”
clinical setting, over a three month period. says Karen Hackling-Searle. »
Adapting to the acceleration software and steps
taken to increase impact
News regarding the Compressed SENSE pilot generated
excitement amongst the team. Karen Hackling-Searle, Head
of MRI, says: “We discussed Compressed SENSE with the
radiographers and highlighted this was something new with
the potential for measurable benefits for our patients. A core
group of radiographers really embraced the trial, in the hope
that we’d see some tangible benefits.”

“In fact, the transition was indeed


seamless, as the radiologists did not
notice the changes made, and continued
to report as if nothing has changed.”

Results from case studies are not predictive of results in other cases. Results in other cases may vary. www.philips.com/fieldstrength 27
User experiences

“Now with the Compressed SENSE technology,


we can get more detail and scan faster”

Growing pressure on imaging services


Over a four-year period, the number of Magnetic
Resonance Imaging (MRI) scans being performed annually
in England has grown by 8.9% (from 2.35 million in2012/13
to 3.36 million in 2016/17)[1]. This is compounding pressures
on radiologists. Figures suggest their workload has
increased by 30% during a similar period (2012–2017) [2].
There is also an ongoing, nationally recognized shortage of
diagnostic radiographers, particularly those specializing in
MRI and CT [3,4].

This increased workload is having detrimental impacts


on the radiology workforce, with radiologists and
radiographers showing signs of stress and burnout,
in part due to longer working hours – a factor in taking
an early retirement or a change in career [5]. The use of
MRI is predicted to increase further, owing to an increase
in chronic conditions and continuous pressures on
healthcare systems [6]. These findings underline a need
for increased efficiencies in imaging services in the UK.

References

1. NHS England, 23 November 2017. Diagnostic Imaging Dataset


Annual Statistical Release 2016/17. Available at: Diagnostic Imaging
Dataset Annual Statistical Release 2016/17

2. BBC, 22 August 2018. Radiologist shortage ‘affecting cancer care’


in the UK. Available at: bbc.com/news/health-45275071 (accessed
2 July 2019)

3. The Society and College of Radiographers, May 2019. UK Workforce


Census 2018 report. Available at: www.sor.org/learning/document-
library/diagnostic-radiography-workforce-uk-census-2018
(accessed 2 July 2019)

4. The Society and College of Radiographers, 6th November 2018.


BBC interview with Society CEO highlights radiographer workforce
shortage. (accessed 2 July 2019)

5. Royal College of Radiologists, April 2019. UK Workforce Census


2018 report.

6. www.businesswire.com/news/home/20190801005481/en/Global-
Magnetic-Resonance-Imaging-Market-Drivers-Restraints The Ingenia 3.0T with Ambient Experience lighting in situ at the
Cobalt centre. The Ingenia 3.0T provides an immersive in-bore
7. Cobalt. Available at: www.cobalthealth.co.uk (accessed 2 July 2019) visual experience.

28 FieldStrength - Issue 57 - 2020


Original Original With Compressed
Compressed SENSE Time saving [%]
Time saving [%]
examination
examination time time time
examination SENSE
Brain
Brain 13:45 min13:45 min 8 min 8 min
5:45 min[42%] 5:45 min [42%]
Shoulder
Shoulder 17 min 17 min 9 min 9 min[47%]
8 min 8 min [47%]
Breast
Breast 6:32 min 6:32 min 3:54 min 3:54 min
2:38 min [40%] 2:38 min [40%]
Lumbar spine
Lumbar spine 21 min 21 min 16 min 16 min
5 min [24%] 5 min [24%]
Knee
Knee 11:42 min 11:42 min 5:57 min 5:57 min
5:45 min [49%] 5:45 min [49%]
Ankle
Ankle 22 min 22 min 13 min 13 min[41%]
9 min 9 min [41%]

Compressed SENSE, scan time 3:54 min, C-SENSE factor 12 SENSE, scan time 6:32 min, SENSE factor 3
Voxels acq 0.8 x 0.72 x 1.8 mm, recon 0.63 x 0.63 x 0.9 mm Voxels acq 0.8 x 0.8 x 1.8 mm, recon 0.63 x 0.63 x 0.9 mm

Increasing productivity and diagnostic confidence if you want more detail on an MRI scan, the scan takes
The team were able to scan an additional 17–20 patients per week, longer. Previously we’ve had to balance between getting the
compared with the same period in the previous year. The increased detail required and how long the patient can lie still. Now
throughput meant that the staff had to be more prepared in terms with the Compressed SENSE technology, we can get more
of moving the patients through the system efficiently. detail and scan faster.”

“I would definitely say that throughput has been helpful to our Enhanced patient experience
breast list. Prior to Compressed SENSE we were scanning up Compressed SENSE in combination with In-bore experience
to seven patients, we’re now able to scan up to nine patients and the Ambient lighting is a combined approach that can
within the same time period,” says Zoe Wray. help relax patients, supporting the high levels of compliance
and a successful scanning to support confident diagnosis.
The time gain with Compressed SENSE was also used to The radiographers feel they did not need to spend so much
increase resolution in order to help radiologists identify the time encouraging anxious patients on and into the scanner
tumor characteristics more confidently which may be used for during set up, which allows a quicker examination, often with
a more personalized treatment. For example, in breast imaging, less movement issues, which helped in keeping the day list
resolution is crucial for visualization of very small lesions. schedule on-track.
Compressed SENSE allows to scan thinner slices, allowing a
3D isotropic sequence which can provide increased diagnostic Zoe Wray, also adds: “It’s better for the patient in that they’re
confidence for the radiologists. not having to stay still as long and they’re not having to stay
in the scanner longer than required either, which can help
“The 3D-THRIVE sequence has proven to be important in improve the experience.” Other groups who are likely to
providing detailed post-processing data to inform on diagnosis benefit include those suffering with pain, and children where
and how we care for the patient,” says Ruth Pearson. “Normally, keeping still for an examination is challenging. «

Results from case studies are not predictive of results in other cases. Results in other cases may vary. www.philips.com/fieldstrength 29
Educational

Understanding how Compressed


SENSE makes MRI faster
Compressed SENSE is the latest Philips MRI acceleration method, based on our industry
leading dStream architecture. Compressed SENSE further expands the performance of dS
SENSE, making MRI scans up to an additional 50% faster*, with virtually identical image quality.
Alternatively, Compressed SENSE can increase the image resolution up to 40% within the same
scan time. Compressed SENSE can be applied to all anatomies and works for both 3D as well
as for 2D MRI acquisitions, making it a powerful asset for almost all clinical MRI exams.

The Compressed SENSE principle in pictures


Basic compressed sensing principle
In this example, only one fifth of the
required MR radiofrequency signals is
recorded. This results in a five times faster
acquisition, with a subsampled k-space
(left) and inherent image artifacts after
standard reconstruction (right).

k-space image

Philips Compressed SENSE


The Compressed SENSE reconstruction
uses iterative, knowledge-based
algorithms to fill in the empty lines in
k-space (left). This removes the artifacts
while keeping the final image fully
consistent with the acquired data (right).

k-space image

*Compared to Philips MR exams without Compressed SENSE

30 FieldStrength - Issue 57 - 2020


Compressed sensing vs other acceleration methods Compressed sensing is not different, but in practice it is often
Compressed sensing is a term from the field of digital signal more forgiving than other acceleration techniques in terms
processing. When a signal is digitally sampled, like it happens in of image distortion and SNR, because it can be designed to
an MRI scanner, the signal is not recorded continuously (like old primarily sample the MR signals that matter most, while leaving
cassette players used to do) but at intervals. A famous theorem out the rest. A unique aspect about compressed sensing is
from digital signal analysis, the Nyquist theorem, states that for that it can bypass the aforementioned Nyquist theorem:
constructing a perfect MR image of 256 x 256 pixels, it is required to although not enough samples are taken for perfect image
sample 256 lines in k-space, each sampled in 256 positions. By reconstruction, a good compressed sensing reconstruction
doing less, the acquisition will be faster, but the reconstructed image can successfully remove the inherent artifacts and produce
will always be distorted one way or another. excellent diagnostic images.

This is exactly what happens with traditional acceleration Philips Compressed SENSE for faster MRI
techniques in MRI, such as halfscan, radial, spiral, increased without sacrificing image quality*
voxel size and parallel imaging. All of these methods skip parts of Compressed SENSE is the Philips implementation of the
k-space during acquisition in order to reduce acquisition time. compressed sensing principle. It combines dS SENSE, our
However, there will always be a penalty: either a reduced signal- industry leading parallel imaging method, with compressed
to-noise ratio (halfscan, parallel imaging), lower image resolution sensing. As a result, it can reduce the scan times by up to 50%
(increased voxel size) or image artifacts (spiral, radial). compared to current examinations without Compressed SENSE.

Philips Compressed SENSE is unique for various reasons:


• C
 ompressed sensing reconstructions can be done in many different ways. Our algorithm uses a priori
information from system calibration data, anatomical knowledge and general MRI principles. All of this
information is carefully balanced to reconstruct the best possible MRI image quality, whilst keeping it
consistent with the measured MRI data.

• T
 raditionally, the time gained with a compressed sensing acquisition is lost again during image reconstruction,
which is typically very long, and requires careful parameter optimization by the user. Not so for Compressed
SENSE, which typically reconstructs under a minute, without the need for complex user interactions, nor
dedicated reconstruction hardware. This pulls it out of the research realm straight into clinical practice.

• T
 hanks to our unique dS SENSE infrastructure we have full k-space sampling flexibility for our
compressed sensing algorithms. This means that Compressed SENSE, unlike other solutions on the
market, has the full freedom to optimize k-space sampling for best SNR and sharpness, without any
restrictions whatsoever.

• A
 s a result of this flexibility, Philips Compressed SENSE can be applied to both 3D and 2D MRI acquisitions,
making it applicable to most clinical routine MRI scans. «

www.philips.com/fieldstrength 31
User experiences

Building MR-simulation
competency in radiotherapy
Starting from scratch, The Christie develops a MR-sim education and
training program for proton beam radiotherapy service

In the development of the National Health Services’ first high energy proton beam therapy
(PBT) center at Manchester’s The Christie Hospital, acquisition of a dedicated MRI system
for PBT planning was essential. MRI can provide exceptional soft tissue visualization for
precise target and organs-at-risk (OAR) delineation for treatment planning and monitoring
on-treatment variation – an imperative for safely delivering proton therapy.

However, integrating MRI in a radiotherapy department presented knew little about the other’s profession, yet the expertise of
a challenge – radiotherapy personnel typically have little or both roles was required for safe, competent pre-treatment
no experience in safely and effectively operating in an MRI imaging. Cross-training was clearly needed.”
environment, while diagnostic radiographers have no or limited
exposure to the needs of pre-treatment radiotherapy. To enable This challenge is further complicated by the fact that although in the
the safe, smooth implementation of an MR-sim Service, the UK there are non-compulsory post-graduate MRI qualifications, the
Christie team developed and executed a training and education approach to educating even diagnostic radiographers in MRI falls
program for all PBT employees. heavily on individual departments to set standards in MRI training
and education. This makes it difficult to know where to start in a
Starting at ground zero with MRI radiotherapy department. “The Society of Radiographers (SCoR)
While The Christie’s Ingenia MR-RT 1.5T system was to be the indicates, for example, that an individual who can scan with MRI is
centerpiece of the new PBT facility’s pre-treatment workflow, ‘An authorized person deemed to have sufficient experience
establishing an imaging staffing model for the department and (knowledge and skills) and appropriate training and is responsible for
training those who would operate the MRI were major hurdles operating the scanner in a safe and appropriate manner,’” he says.
that department administration would need to overcome. “The challenge was, that there was no guidance as to what defines
“The biggest problem was a lack of knowledge, experience that ‘knowledge' during the development of our service. However,
and training,” says Thomas Edwards, Principal Radiographer this is changing, and a working party has been developed by the
at The Christie, who led the team in developing education and Society to publish guidance and an overview of the educational and
training. “Therapeutic and Diagnostic Radiographers in the UK professional requirements for safe, effective use of MRI in radiotherapy
are on completely different educational paths so each group for the purposes of simulation and on-board radiotherapy guidance.”

“The biggest problem in ensuring the safe and


smooth implementation of an MR-sim service was
a lack of knowledge, experience and training”

Thomas Edwards is pre-treatment principal radiographer for protons at the Christie NHS
Foundation Trust. He has worked in radiotherapy for 16 years, specializing in radiotherapy imaging.
He was involved in the development of the Christie Proton service and supported various aspects
of the implementation, including procurement of the service’s Ingenia MR-RT 1.5T system, service
development, recruitment, training and service provision.

32 FieldStrength - Issue 57 - 2020


The Christie NHS Foundation Trust
in Manchester, UK, is the largest
single site cancer centre in Europe,
treating more than 44,000 patients
a year. The centre has access to 15
linear accelerators and offers both
proton beam therapy and MR-
guided therapy.

“Therapeutic and Diagnostic Radiographers in the UK are on completely different


educational paths so each group knew little about the other’s profession”

First steps in building MR-sim competence With the delivery of the Ingenia MR-RT in December 2017, the
A full year before the complete pre-treatment staff were hired clock started for the clinical go-live of the PBT center. “The machine
and ready for training, Edwards became involved in acquiring had to be installed, tested and commissioned and we still had to
the MRI system in a competitive tender process. To facilitate recruit many of the pre-treatment staff members before we could
this process, Edwards recruited Lisa McDaid, a diagnostic start applications training,” Edwards says.“The schedule was very
radiographer with abundant MRI experience to join the standard tight. Our first patient was planned for December 2018, which left
procurement team, which included a physics lead, radiotherapy only nine months to complete training.”
engineer, MR physicist, radiologist and a project manager.
Determining a staffing model
“Since I had very little MRI experience, we needed to hire The Christie proton project team and NHS had worked
someone to help us procure the system,” he says. “Lisa’s together to define the PBT center’s staffing model, including
MR oncology experience and her familiarity with a variety the make-up of the pre-treatment staff who would operate
of MRI systems was invaluable in evaluating modern MRI the MRI system.
scanners.”McDaid also played several other key roles after the
Ingenia acquisition and prior to recruitment of the PBT diagnostic “We decided that we should always have a 50-50 split of
superintendent radiographer and MR responsible person. diagnostic and therapeutic staff,” Edwards says. “And, as we
came to post and started looking at staffing and anticipated
These included ensuring that The Christie was aligned with “MR workload, The Christie team agreed that we needed to have a
local rules” governing regulatory requirements for safety in the mix of both professions, and that ideally each group needed to
PBT department; helping recruit the therapeutic and diagnostic be cross-trained in MRI and radiotherapy to create hybrid MR-
radiographers comprising the permanent PBT pre-treatment RT radiographers. We always assumed that MR scanning would
team; assisting in identifying training needs; safety training; and require a collaborative practice, so at minimum there would be
developing the initial sequences with the Philips applications one diagnostic radiographer and one therapeutic radiographer
training team and other pre-treatment team radiographers. at any time to scan the patients.” »

Timeline of building MR-sim service at The Christie

Oct 2017 Feb 2018 May 2018


Discuss training needs Staff in place First RT patient images
and staff structure Acceptance and handover
with Philips
Dec 2017 Mar 2018 Dec 2018
Delivery Ingenia MR-RT First volunteer images First patient treated

2017 2018

Jan-Nov 2017 Dec 2017-Feb 2018 Mar-Nov 2018


Tender process Installation and commissioning Application training

Results from case studies are not predictive of results in other cases. Results in other cases may vary. www.philips.com/fieldstrength 33
User experiences

“The didactic and hands-on Philips applications View


the extended
training was really well structured” online article for
more detailed
information

MR-RT applications training: the first form of


competence Overview of The Christie hub-and-spoke training
Two months before the delivery of the Ingenia MR-RT, The
model on proton MR-sim pre-treatment.
Christie team met with Philips representatives to confer on staff
structure and training needs for the diagnostic and therapeutic
radiographers.

By February 2018, the Ingenia system was commissioned, fully


MRI
accepted and handed over, and the staff had been recruited and
Safety
hired – a complement of three therapeutic and three diagnostic
radiographers. Philips application training began in March,
MRI
first for the physicists, engineers and dosimetrists, then for the Sequence MRI
Optimization Hardware
permanent pre-treatment staff.

Proton
“The didactic and hands-on Philips applications training was MR-sim
really well structured, with a modular setup in chapters, key Pre-treatment
Hub
stages and key points of the process,” Edwards observes.
MRI MRI
“It was quite comprehensive as well, including everything Examination Daily QA
from safety and basic operations to developing and modifying
protocols. Over a six-week period, they led us through what
MRI
we needed to know about Ingenia MR-RT. And, although the Screening
training was very well aimed at the therapeutic radiographers,
the diagnostic radiographers also benefited because they had
limited understanding of this particular system.

“Since the applications training was the first form of competence, Hub Spoke
Proton Pre-treatment Hub Each spoke includes the
it was extremely important that it was well-documented and includes training for MR-sim additional, specific content for
assessed, to enable us to show evidence of the training – pre-treatment staff and is based the radiographers and consists
especially in lieu of other formal accredited training,” he adds. on MHRA guidelines: of:
• Safety • A competency profile
• Environment • A guide for trainers
“The training was excellent. The Philips applications specialist, • Local rules • A guide for assessors
Lynsey Cameron-Clark, and The Christie team developed • Equipment
a fantastic relationship, which was reassuring. And we felt
comfortable calling on her repeatedly – in fact, we still do.”

Hub-and-spoke model provides tailored training


for different groups We also relied on them to identify their gaps in knowledge.
Following applications training, The Christie MR radiographer For example, for diagnostic radiographers, radiotherapy patient
and Education Team worked together in order to develop positioning is not part of their usual scope of practice, while the
the in-house training of the pre-treatment staff. They therapeutic radiographers – though they were aware of radiation
started by investigating how the Diagnostic Imaging service hazards – had little previous knowledge about the risks of
trains its radiographers and documents this program, and projectiles in a magnetic field or the danger of scanning a patient
then developed the hub-and-spoke training model for that has an implanted medical device. Upskilling both groups
MR simulation. presented a major challenge.”

“We knew what we knew, but we didn’t know what we didn’t know,” The hub-and-spoke model consists of a core module (hub),
Edwards says. “So we also wanted to find out where our gaps in which comprises of the important parts of the UK’s Medicines
knowledge were by relying on the Philips application specialist and Healthcare Products Regulatory Agency (MHRA) MR safety
and our team of therapeutic and diagnostic radiographers. guidelines.

34 FieldStrength - Issue 57 - 2020


Overview of the main learning objectives identified per job role
For diagnostic radiographers For therapeutic radiographers
• Treatment position and coverage for treatment planning • MRI safety
purposes (PBT requires greater accuracy) • Basic MR physics
• Reproducibility and registration requirements • Image acquisition (including parameters and tradeoffs,
• Purpose of images for treatment planning artifact recognition and reduction)
(target v. OAR delineation v. synthetic CT generation) • Image interpretation (e.g., understanding which sequences are
• Differences in requirements of diagnostic and treatment used for target v. OAR delineation, anatomy)
planning imaging (acquired orthogonal to system,
For treatment planners/radiation (clinical)
geometric fidelity, MP imaging on the same isocenter for
oncologists/dosimetrists
better registration accuracy)
• Image interpretation
• Image registration (cross-sectional/cross-modality anatomy)

The spokes represent additional learning modules for specific Safety in an MRI environment
job roles, and include modules on safety, screening, scanning, Integrating MR-sim into a new department was a big change
daily QA and image contrast. for the whole PBT service, necessitating education of more
than just the pre-treatment staff. The most important aspect
“We can choose which training modules are required for any of this training was safety, Edwards adds. “The scanner is
role in the PBT department, and these are mapped out in the surrounded by 150 team members who haven’t necessarily
training needs analysis performed by the education team,” worked adjacent to an MR scanner before,” he says. “We
Edwards says. “The training priorities were safety and instilling developed a general MRI safety program, as part of the training
confidence, with the ultimate goal to have the diagnostic and hub, to teach everyone working in the building about the risks
therapeutic radiographers be equally proficient regardless of associated with a strong magnetic field. Awareness of the
their professional designation. In short, we wanted to create consequences of going through a particular door or taking
hybrid MR-RT radiographers.” certain equipment into the magnet room was felt to be very
important to ensure staff, patient and visitor safety.”
Detailed training guides ensure consistency (See sidebar below on MRI Safety). »
The identified training needs for each group were compiled in
training guides, a guide for the trainer, and an assessor’s guide.
An example of a trainer’s guide is available in the online version
of this article.
Key aspects of MHRA guidelines
“This model ensures that all learners receive the same
MR safety
information, and that it’s delivered and assessed in a consistent
“It’s not just about screening for ferrous material or implants”
manner,” Edwards says. “The training guide contains the
information to be taught, the trainer’s guide instructs how
Noise
to teach the material and the assessor’s guide shows how
• Know acceptable levels and how to limit
to evaluate each learner’s competence. They simply ask an
individual being trained to demonstrate the knowledge and
Specific Absorption Rates (SARs)
hands-on skills that the trainers had presented them. We said:
• Know the effects of high SAR sequences
‘You need to know XYZ and if you say you do, then provide
• Know recommended limitations
evidence that you know XYZ either verbally, in writing or by a
hands-on demonstration.”
Patient positioning and immobilization
devices
• Just because it’s not metal doesn’t mean it’s MRI-safe
• Hidden screws and hinges
“This model ensures that all learners • Heating effects
receive the same information, and
that it’s delivered and assessed in Anti-peristaltic and contrast agents
• Training and awareness
a consistent manner”

Results from case studies are not predictive of results in other cases. Results in other cases may vary. www.philips.com/fieldstrength 35
User experiences

“They are a very competent team of


radiographers working in MR-RT and
they work fairly independently now”

Developing Radiotherapy-specific ExamCards assess the staff again and make sure they know what we have
for PBT Patients asked them to know. It’s a whole process that needs to grow and
The Christie team and the Philips application specialist worked develop, but we are confident they’re a good team of people and
with the center’s radiologists and radiation oncologists to they are where they need to be.”
develop PBT-specific radiotherapy planning imaging protocols
(ExamCards). The process started with soliciting suggestions On the horizon at The Christie is a pilot program set to begin in
from the radiation oncologists regarding their image quality and late 2019 that consolidates educational programs for MR-sim in
contrast requirements for PBT planning. proton therapy, MR-sim in radiotherapy and MR-linac operation
in a single MR in RT hub. “The program is designed to make sure
“We used that input to develop the sequences or ExamCards all Christie radiographers working in MR-sim and MR-linac have
and then test them on a volunteer,” Edwards says. “The primary enhanced skills,” he says. «
radiologist would critique the images and the team would modify
the sequences for more signal, more contrast or a different voxel
size if extra detail was needed. Then we would take new images
References
back to the radiologist for another review. It was an iterative
process, but ultimately we were happy with the results.” 1. Eccles CL, Campbell M. (2019). Keeping Up with the Hybrid Magnetic
Resonance Linear Accelerators: How. Journal of Medical Imaging and
Radiation Sciences, 50(2).
Once the radiation oncologists were satisfied, the center’s
physicists were consulted on the images’ suitability for proton 2. Eccles CL, McNair. HA, Armstrong SEA, Helyer SJ, Scurr ED. (2017).
planning, their geometric accuracy and whether they could be In response to Westbrook - Opening the debate on MRI practioner
education. Radiograph 23: S75-S76.
fused with CT.
3. Eccles CL, NIll S, Herbert T, Scurr E, McNair HA (2019). Blurring the lines
The Christie launches proton therapy service for better visualisation. Radiography 25: 91-93

A journey that began in 2016 with the procurement of Ingenia 4. Paulson, E., Erickson, B., Schultz, C., Li, A., (2016), Comprehensive MRI
MR-RT 1.5T – and continued with the recruitment of the PBT simulation methodology using a dedicated MRI scanner in radiation
oncology for external beam radiation treatment planning. Magnetic
pre-treatment staff and development of a training program to Resonance Physics, Vol 42, pp. 28-39.
transform them into MR-RT radiographers – culminated on
5. Speight R, Schmidt MA, Liney GP, Johnstone R, Eccles CL, Dubec M,
December 31, 2018. On that date, a 15-year-old boy with a brain et al. (2019). IPEM Topical Report: A 2018 IPEM survey of MRI use for
tumor became the PBT service’s first patient, the first of some external beam radiotherapy treatment planning in the UK. Physics in
750 patients The Christie anticipates treating each year. Medicine and Biology.

6. Rai R, Kumar S, Batumalai V, Elwadia D, Ohanessian L, Juresic


According to Edwards, the experience of creating a fully staffed E, Cassapi L, Vinod S, Holloway L, Keall P and Liney, G. (2017). The
integration of MRI in radiation therapy: collaboration of radiographers
PBT service from the ground up was a daunting task, but the and radiation therapists. Journal of Medical Radiation Sciences, 64(1),
result has been quite successful. pp.61-68.

7. The Society and College of Radiographers & and the British Association
“There is still learning to be done, but the pre-treatment team’s of Magnetic Resonance Radiographers (2013). Safety in Magnetic
confidence is growing day by day,” he says. “They are a very Resonance Imaging. London: SCoR & BAMRR
competent team of radiographers working in MR-RT and they
8. Department of Health (2015). Safety Guidelines for Magnetic
work fairly independently now. They ask fewer questions and are Resonance Imaging Equipment in Clinical Use. London: Medicines and
able to make decisions by themselves. The next phase will be to Healthcare Products Regulatory Agency.

36 FieldStrength - Issue 57 - 2020


MR news

Philips maintains its top


ranking in the Dow Jones
Sustainability Indices

In September 2019 Philips has once again been recognized as one of the
top companies for sustainability performance in the global 2019 Dow Jones
Sustainability Indices (DJSI)* list. Philips scored 82 out of 100 points in the
DJSI Health Care Equipment & Services industry group, further improving
on its 2018 score to achieve the #2 ranking in 2019.

Evaluated across the Economic, Environmental and Social With its focus on access to care, the circular economy and climate
dimensions of DJSI’s sustainability review, Philips received best- action, the Philips program Healthy people, Sustainable planet is
in-class scores in several categories, including the innovation already helping the company to deliver on its 2020 commitments
management, climate strategy and contribution to health to become carbon neutral in its operations, to grow its Green
outcome categories. Revenues to 70% of sales, and to have 15% of its revenues
generated through circular economy driven propositions.
Philips continuously strives to make the world healthier and more Philips’ efforts have also received notable recognition in other
sustainable through innovation. Its aim is to improve the lives of sustainability indexes. The company was ranked #1 on Fortune’s
3 billion people a year by 2030, via integrated health technology inaugural Sustainability All Stars list (August 2019), awarded the
solutions that span the health continuum from healthy living and Dutch ‘Crystal Prize’ 2018 for leading change in supply chain
prevention, to diagnosis, treatment and home care. sustainability, and in January 2020 it was included in the CDP
Climate Change A List for the seventh consecutive time. «

* S&P Dow Jones Indices, one of the world's leading index providers, together with SAM, the business unit within
RobecoSAM, which specializes in providing Environmental, Social, and Governance (ESG) data, ratings, and benchmarking,
announced the results of the annual DJSI review on September 13, 2019. The SAM Corporate Sustainability Assessment (CSA)
is one of the longest standing ESG rating methodologies worldwide, dating back to 1999. It assesses companies based on 80
– 120 industry-specific questions across 61 industries focusing on financially material economic, environmental, and social
factors that are relevant to companies’ success, but that are under-researched in conventional financial analysis.

www.philips.com/fieldstrength 37
Research

How a co-research approach


tackles MRI challenges with AI

Artificial Intelligence (AI) brings promising new possibilities to MRI. It may be applied to
many aspects such as automated planning, segmentation and report creation. Also for
scan acceleration it offers new possibilities, as AI enables to acquire less data in an MRI
examination, which can help to reduce the time that a patient needs to be in the scanner.

Top performers in fastMRI image reconstruction Thirty-four teams participated from around the world. All teams
challenge received the largest publicly available data set of de-identified
Last December, it was announced that Philips and the Leiden raw MRI knee measurements that participants could use to
University Medical Center (LUMC) were together the top train an algorithm that was then used to reconstruct hundred
performer in the fastMRI image reconstruction challenge in accelerated MRI scans.
the multi-coil tracks with 8x acceleration category.
To determine the winner, the top five participants with the
A second team in which Philips participated, together with highest scores on a numerical value were first selected. Their
the University of Amsterdam (UvA), the Amsterdam University results were then visually assessed by seven expert radiologists
Medical Center (Amsterdam UMC) and Radboud University, with musculoskeletal sub-specialization, paying attention to
was the top performer in the single-coil track with 4x various aspects: contrast-to-noise ratio, artifacts, sharpness,
acceleration category. diagnostic confidence, and overall image quality. The radiologists
stressed the importance to visually asses the quality of the
The fastMRI challenge is a collaborative research project image, and to not rely blindly on numerical scores.
between Facebook AI Research (FAIR) and NYU Langone
Health. The aim is to investigate the use of AI to make MRI The results were presented at the leading AI conference
scans up to 10 times faster. By producing accurate images from NeurIPS in Vancouver on December 14.
under-sampled data, AI image reconstruction has the potential
to improve the patient’s experience and make MRI exams Teamwork makes the dream work
accessible for more people. Winning the challenge was not the only reason for our
excitement at Philips. The process towards this great
achievement made us also extremely proud. Key to our
success was a multi-disciplinary team including experts
from both Philips and LUMC working fulltime for months on
the AI algorithm, leading to this great success. Of particular
importance was the involvement of radiologists and clinical
scientists who assessed the quality of the reconstructed
images from a clinical point of view.

The team demonstrated that it is possible to deliver


breakthrough solutions via excellent teamwork. The cooperative
working atmosphere and the mutual trust that we now share
will definitely pave the way for other innovative projects,
including the clear focus in bringing this success to the
patients as soon as possible. «

38 FieldStrength - Issue 57 - 2020


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© Royal Philips N.V. 2020
All rights are reserved. Reproduction in whole or in part
is prohibited without the prior written consent of the
copyright holder.

with Philips MRI Philips Healthcare reserves the right to make changes in
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time without notice or obligation and will not be liable
for any consequences resulting from the use of
FieldStrength is a professional magazine for users this publication.

of Philips MR systems. It provides results of MR Printed in Belgium.


studies performed by Philips users. 4522 991 50971

FieldStrength is also available online:


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Don't miss an issue Editor-in-chief


Karen Janssen
Read more articles or register for your personal email
subscription at: www.philips.com/fieldstrength Contributors
Carlos Avila (RT), Laura Barlow (RTMR), Wim Boon,
Megan Breuer (PhD), John Brigly, Jerry Duncan,
Thomas Edwards, Phil Fritz, Karen Hackling-Searle,
Martijn Hartjes, Eltjo Haselhoff (PhD), Frank Hoogenraad
You may also be interested in: (PhD), Karen Janssen, Shannon Kolind (PhD),
Alex MacKay (DPhil), Erin MacMillan, Carol Melvin,
• MR body map to view clinical cases of nearly every
Kim Mulder, Ruth Pearson, Constantino Peña (MD),
anatomy, see www.philips.com/mrbodymap
Alex Rauscher (PhD), Julien Savatovsky (MD, PhD),
• Philips MRI products, see www.philips.com/mri Mark Stoutjesdijk (MD), Alexander Vadnais,
Joyce van der Valk, Marieke van Grootel,
Marieke van Noort, Zoe Wray.

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Notice
FieldStrength is created for users of Philips MRI systems.
It is a professional magazine for users of Philips medical
equipment. It provides the healthcare community with
results of studies performed by colleagues. Some articles
in this magazine may describe research conducted
outside the USA on equipment not yet available for
commercial distribution in the USA. Some products
referenced may not be licensed for sale in Canada.

Results from case studies are not predictive of results


in other cases. Results in other cases may vary. Results
obtained by facilities described in this issue may not be
typical for all facilities. Images that are not part of User
experiences articles and that are not labeled otherwise
are created by Philips.

FieldStrength 39
Ingenia Ambition 1.5T

MR services.
Helium-free.

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techniques to help you excel clinically every day. Based on its new,
revolutionary fully sealed BlueSeal magnet, the solution lets you
experience more productive1 helium-free MR operations.

Get superb image quality even for challenging patients, and perform
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There’s always a way to make life better. Discover more about Ingenia Ambition
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1. Compared to the Ingenia 1.5T ZBO magnet.


2. Compared to Philips scans without Compressed SENSE.

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