BIR UK MRI course

British Institute of Radiology UK MRI Course 8 - 11 October 2013 Aston Conference Centre Birmingham 24 RCR CPD credits

Course programme

Welcome and thank you for coming to the ‘BIR UK MRI course’ organised by the British Institute of Radiology.

This booklet contains the abstracts and biographies for each speaker (where supplied).

This course has been awarded 24 RCR category I CPD credits (6 per day). CPD certificates will be distributed by email within 2 weeks of the course after the online delegate surveys have been completed.

Please complete the online delegate surveys using the below links. We will use your valuable feedback to improve future conferences. https://www.surveymonkey.com/s/MRI_day1 https://www.surveymonkey.com/s/MRI_day2 https://www.surveymonkey.com/s/MRI_day3 https://www.surveymonkey.com/s/MRI_day4

We hope you find the event interesting and enjoyable.

BIR MRI organising committee We are most grateful to

for supporting this conference

Tuesday 8 October 2013 Physics / business 09:00 Registration and refreshments 09:40 Welcome and introduction

09:45 Basic physics refresher

Dr Peter Wright, Sheffield Teaching Hospitals NHS Foundation Trust

10:15 Image contrast

Dr Martin Graves, Cambridge University Hospitals NHS Trust 10:45 Basics of k-space: implications for image quality

Dr Geoff Charles-Edwards, Guy’s & St Thomas’ NHS Foundation Trust 11:15 Refreshments 11: 45 Artefacts

Mrs Sarah Prescott, University Hospital of North Staffordshire 12:15 1.5T versus 3T

Dr Peter Wright, Sheffield Teaching Hospitals NHS Foundation Trust 12:45 Basics of k-space: faster imaging

Dr Geoff Charles-Edwards, Guy’s & St Thomas’ NHS Foundation Trust 13:15 MRI business cases

Mrs Daina Dambitis, Leeds Teaching Hospitals NHS Trust 13:45 Lunch 14:30 Procurement

Mrs Carole Burnett, Leeds Musculoskeletal Biomedical Research Unit 15:00 Installation

Mrs Carole Burnett, Leeds Musculoskeletal Biomedical Research Unit

Dr Martin Graves, Cambridge University Hospitals NHS Trust 15:30 Safety update

Mrs Sarah Prescott, University Hospital of North Staffordshire 16:00 Refreshments 16:15 Dealing with the difficult patient

Ms Celia O’Meara, University College London Hospitals NHS Foundation Trust 16:45 Question and answer 17:15 Close

Speaker profiles (where supplied) Mrs Carole Burnett NIHR Fellow, Leeds Musculoskeletal Biomedical Research Unit I qualified as a Radiographer in 1989 and have specialised in Magnetic Resonance Imaging for the last 16 years. I have had a varied career working within the private sector, industry and National Health service in clinical and managerial positions.

In November 2010 I was awarded a National Institute of Health Research Clinical Doctoral Research Fellowship. This is a 4 year grant to allow me to undertake my PhD investigating ‘Improving the safety and patient experience in the magnetic resonance imaging of arthritis: Magnetic resonance imaging of synovitis without the use of intravenous gadolinium’.

I was appointed the Lead Radiographer for the London Olympic and Paralympic Games in 2012.

Dr Geoff Charles-Edwards Principal Clinical Scientist, Guy’s & St Thomas’ NHS Foundation Trust After training as a clinical physicist, Geoff Charles-Edwards obtained a PhD in Magnetic Resonance from the Institute of Cancer Research, before moving to Guy’s & St Thomas’ hospitals in 2003 where he is now Principal Clinical Scientist. He is also a HEFCE-NIHR Senior Clinical Lecturer and an Honorary Senior Lecturer at King’s College London.

Mrs Daina Dambitis Service manager MRI, Leeds Teaching Hospitals NHS Trust Daina qualified as a radiographer in1980 from Leeds General Infirmary, she then worked as a radiographer in the Middle East in the 1980’s.

Daina returned to Yorkshire working in Nuclear Medicine and CT at St James’s Hospital Leeds.

Daina set up CT service at Harrogate.

Daina trained in MRI at Leeds General Infirmary, worked a split post as a research radiographer.

Daina set up a new MRI service at Cookridge oncology hospital and new oncology wing at St James’s Hospital Leeds.

Daina is now working as Service manager for Leeds Trust MRI. Dr Martin Graves Consultant Clinical Scientist, Cambridge University Hospitals NHS Trust Martin Graves is a Consultant Clinical Scientist at Cambridge University Hospitals NHS Trust and an Affiliated Lecturer in the University of Cambridge Clinical School.

He has nearly 30 years of experience working in clinical and research MRI in both London and Cambridge. He is a fellow of the Institute of Physics and Engineering in Medicine and the Higher Education Academy. He is active on a number of national and international committees including the BIR MR Special Interest Group as well as the ISMRM Education and Annual Meeting Programme Committees. He has coauthored over 130 publications as well as the award winning MRI text book MRI: from Picture to Proton.

He co-edited Carotid Disease: the Role of Imaging in Diagnosis and Management and has recently published Physics MCQs for the Part 1 FRCR. He teaches on a number of MRI courses both nationally and internationally and has received ISMRM Outstanding Teacher awards in 2006 and 2011. His current research interests are in the development of techniques for morphological and functional cardiovascular imaging and interactive MRI. Mrs Sarah Prescott Clinical Scientist, University Hospital of North Staffordshire Sarah started training to be a clinical scientist at University Hospitals Coventry and Warwickshire (UHCW). As part of this training she undertook an MSc in Medical and Radiation Physics at the University of Birmingham. After successfully completing the first part of her training in the areas of MRI, Nuclear Medicine and Radiotherapy, she then went on to complete the second half of her training at University Hospital of North Staffordshire (UHNS) where she specialised in MRI and Nuclear Medicine. She currently works at UHNS as a Clinical Scientist in MRI and Diagnostic Radiology.

Ms Celia O’Meara Superintendent Radiographer - PETMR, University College London Hospitals NHS Foundation Trust Since March 2012, I have been responsible for providing the PET-MR service at UCLH. This is the first simultaneous PET-MR scanner sited in the UK, and the current workload includes oncology, neurology and cardiology. This is an interesting and challenging post as there is both a clinical and research aspect to each working day.

Prior to my current post, I have worked at Guy’s and St Thomas’ NHS Foundation Trust and the Royal Marsden NHS Foundation Trust as a Radiographer. In January 2013, I was awarded best technologist abstract at the annual SCMR conference.

Dr Peter Wright Clinical Scientist, Sheffield Teaching Hospitals NHS Foundation Trust Peter Wright has recently joined Sheffield after previously being at the University Hospital of North Staffordshire where he supported the commissioning of three new Siemens MR systems and subsequent protocol setup and image quality improvement. Prior to UHNS Peter spent 3 years as the in-house physicist at Leeds Musculoskeletal and Biomedical Research Unit (LMBRU), an NIHR funded unit at Leeds NHS Trust. This role included his clinical medical physics training. Prior to this he obtained his PhD at the University of Nottingham in functional MRI and related parameters using 7 T and 3 T MRI systems.

Abstracts (where supplied) Basic physics refresher Dr Peter Wright Education Aims • Origins of the MR Signal • Signal acquisition and spatial encoding • Introduction to longitudinal (T1)and transverse (T2) relaxation mechanisms • Basic pulse sequences – gradient echo and spin echo By the end of the lecture delegates should be familiar with the origins of the MR signal and how it is manipulated to produce an image. This includes the use of magnetic field gradients and radiofrequency (RF) pulses to spatially encode the signal to be acquired. Delegates will be introduced to relaxation techniques, T1 and T2 and the basic spin echo (SE) and gradient echo (GE) sequences in preparation for subsequent lectures.

Image contrast Dr Martin Graves Signal in MRI can arise primarily from three main physical characteristics of the tissue 1. Proton density (): the relative numbers of tissue protons within each voxel 2. T1: the longitudinal relaxation time of tissue within each voxel 3. T2: the transverse relaxation time of tissue within each voxel. Due to tissue magnetic susceptibility (the degree a tissue can become magnetised), combined with the non-uniformity of the static magnetic field, this transverse relaxation time can be shortened and is known as T2*.

The relative contribution of these relaxation times to the contrast in an image is dependent upon the pulse sequence used and the timing/other parameters within that sequence. The contrast in a standard imaging sequence is a mixture of , T1 and T2 or T2* but the imaging parameters are chosen to emphasize one of these over the others, hence the use of the term “weighted” to indicate the primary contrast mechanism.

The aim of this lecture is to provide an overview of the mechanisms and methods that affect contrast in MR images.

At the end of this lecture the participants will be expected to: 1. Describe the physical principles of T1, T2 and T2*relaxation mechanisms 2. Compare spin echo and gradient echo pulse sequences 3. Explain how pulse sequences parameters can be manipulated to produce weighted images demonstrating the desired contrast Further reading McRobbie DW, Moore EA, Graves MJ and Prince MR. MRI: from Picture to Proton 2nd Ed. Cambridge University Press. ISBN 9780521683845

Basics of k-space: implications for image quality Dr Geoff Charles-Edwards Educational aims: A basic understanding of the concept of k-space.

Learning outcomes: An understanding of how k-space relates to the MR acquisition and to the resulting MR image, and how certain areas of k-space contribute differently to image contrast, SNR and spatial resolution.

The concept of k-space and Fourier transforms is often a daunting one, but it is central to MR imaging. A good understanding provides a solid base on which to understand image quality issues and how different acquisition options impact on the final image. This talk will introduce the concept of k-space and describe some of the relationships that exist, both between k-space and the physical state of the magnetisation, and k-space and the resulting image.

Artefacts Mrs Sarah Prescott Learning Outcomes: (1) Recognise MRI artefacts (2) Understand the physics which causes artefacts (3) Suggested methods for overcoming artefacts There are a wide range of artefacts that can be introduced into MRI. Some of these degrade the images so that they are non-diagnostic, whilst others can cause confusion by mimicking pathology. This talk illustrates a range of artefacts to help you identify these in the future. Simple artefacts such as motion and wrap will be discussed, as well as more advanced artefact identification such as cross-talk and in plane flow artefacts. The physics behind these artefacts will be explained, and methods to overcome or reduce these artefacts will be suggested.

1.5T versus 3T Dr Peter Wright Education aims: • Theory behind benefits and disadvantages of higher field strength systems • Real world comparisons of 1.5T and 3T clinical systems • Benefits of higher field strength for advanced techniques • Equipment considerations when procuring a 3 T system The potential benefits of higher field strength systems are well known, but how are they achieved in reality? This lecture will introduce the theory behind the benefits of 3T systems in comparison to 1.5T as well as the trade-offs that may be necessary to achieve those benefits. Real-world examples of 1.5T versus 3T images will be discussed, including reduced scan time and increased resolution examples. However, there are issues to be resolved with 3T systems. Some of these will be identified with suggestions in how to reduce their effect as well as examining extra considerations for 3 T compared to 1.5 T when going through the procurement process.

Basics of k-space: faster imaging Dr Geoff Charles-Edwards Educational aims: A basic understanding of common methods to speed up image acquisition Learning outcomes: An understanding of zero-filling, partial Fourier and parallel imaging: their requirements, pros and cons.

Increasing demands on more time efficient MRI protocols has led to a range of methods that can be used to speed up image acquisition times by missing out portions of k-space. Zero-filling exploits the fact that the outermost areas of k-space contribute least in terms of contrast and SNR to the resulting image and setting these areas to zero prior to Fourier transform rather than spend time acquiring these data often gives satisfactory results with only a slight reduction in spatial resolution.

Partial Fourier techniques generally utilise the symmetry of k-space to miss out up to nearly half of it and calculate what it should have been from the acquired side.

Finally, the additional spatial information that is provided by the use of phased array coils can be exploited to essentially calculate missing lines of k-space. The pros, cons and limitations of each of these methods will be discussed.

MRI business cases Mrs Daina Dambitis Good business planning is essential if we are to deliver a good service to our patients. Small and large hospitals need to ensure their equipment as flexible and versatile as possible. Business cases need to reflect the needs of the service and be matched to finance available. Although many radiographers may not be directly involved in the purchase, scanner replacement or writing of the business case, it is important that everyone understands the value of the taxpayers money and how we spend it.

In this climate there will be a compelling argument to keep equipment running as long as possible and a purchase such as a MRI scanner will leave a huge deficit in any budget.

We need to consider what should be included in a business case. What options are available other than outright purchase, and how to evaluate what the service actually needs.

Procurement Mrs Carole Burnett This talk will cover the basic steps and decisions that are made when buying a MRI scanner. The talk will contain the following subjects: What to buy Who to buy from How to buy Where to place the scanner What to include in the purchase What to look out for in the small print Lesson that I have learnt There will be the opportunity to ask questions at the end of the talk.

The main learning points will be: What to include in procurement package What not to forget to include The basics of procurement Lessons I have learnt Installation Mrs Carole Burnett Dr Martin Graves The installation of an MRI system is a complex project that often falls to members of the Radiology department to specify and in some cases manage. Despite being a relatively mature technology, there are still a number of issues that can occur after the installation of a system that could have been addressed beforehand. This is particularly true if the installation is not “turn-key”. Sites should not necessarily expect that all NHS Estates departments and their contractors have extensive MRI installation knowledge and experience. As with any project, there are always cases where different contractors will blame each other for problems making resolution of the issue very difficult or expensive.

Comprehensive acceptance testing of the system before clinical use is recommended to ensure that the system operates within the vendors performance criteria and to establish appropriate quality control criteria.

The aim of this lecture is to present some “lessons-learnt” from previous installations so that sites may try to avoid the mistakes of others.

At the end of this lecture the participants will be expected to: 1. State a number of “lessons-learnt” from previous installations 2. Identify some potential installation issues 3. Describe the processes involved in acceptance testing and routine quality control Further Reading MHRA. Safety Guidelines for Magnetic Resonance Imaging Equipment in Clinical Use - DB 2007(03) Quality Control in Magnetic Resonance Imaging. The Institute of Physics and Engineering in Medicine. Report No. 80, 1998.

Acceptance Testing and Quality Assurance Procedures for Magnetic Resonance Imaging Facilities. American Association of Physicist in Medicine. Report 100, December 2010

Safety update Mrs Sarah Prescott Learning Outcomes: 1. Update on current safety guidelines 2. Safety implications of 3T 3. How to ensure patients are scanned quickly and safely This talk provides an update on the current safety guidelines associated with MRI. After recapping the key hazards associated with MRI, the focus of this talk switches to patient safety. The three categories of implanted devices are discussed (MR Safe, MR Conditional and MR Unsafe), and examples are given of each. One of the current issues in MRI Safety is that there has been an increase in the number of 3T scanners in clinical service. Some implants which are safe at 1.5T may not be safe at 3T, and this will be discussed in more detail. The talk will end with the answer to the critical question – how do you get your patient through the system safely but quickly?

Dealing with the difficult patient Ms Celia O’Meara The aim of this presentation is to evaluate who can be considered a difficult patient and then to discuss techniques to obtain an optimal MRI scan, whilst ensuring a positive patient experience. There are many patient presentations that fall into this category when undertaking MRI scans. Patients for whom English is not a first language, patients with learning disabilities, paediatric patients, geriatric patients, claustrophobic patients – the list sometimes feels limitless! A prepared and competent operator can gain the confidence and co-operation of the patient and obtain high quality images. This presentation will feature methods that can be implemented in a MRI department effectively.

The learning outcomes of this presentation are: 1. To provide operators with methods to safely screen patients prior to them entering the scan room 2. To increase the awareness of operators of fast imaging techniques currently available from manufacturers 3. To explain techniques available to operators to minimise patient movement 4. To ensure that operators understand that patient experience is also important whilst undertaking scans

Please complete the meeting evaluation survey online at: https://www.surveymonkey.com/s/MRI_day1 Upon collation of your feedback, we will email you your CPD certificate.

Wednesday 9 October 2013 Neuro – spine 08:45 Registration 09:00 Lecture A - Physics of spine imaging

Dr Peter Wright, Sheffield Teaching Hospitals NHS Foundation Trust 09:30 Lecture B - MR imaging of the paediatric spine

Dr Ruth Batty, Royal Hallamshire Hospital 10:00 Lecture C - Spinal infections

Dr Ian Craven, Leeds General Infirmary 10:30 Lecture D - Spinal tumours

Dr Deborah Annesley-Williams, Queen’s Medical Centre, Nottingham 11:00 Refreshments 11:30

Workshop session 1 - topics A&B and C&D

12:15

Workshop session 2 - topics C&D and A&B

13:00

Lunch

14:00

Lecture E - Spinal trauma Dr Curtis Offiah, The Royal London Hospital

14:30

15:00

Lecture F - Myelopathy Dr Fintan Sheerin, Oxford University Hospitals NHS Trust

15:45

Refreshments

16:15

Panel discussion reviewing complex cases

17:00

Close

Workshop session 3 - topics E&F

Speaker profiles (where supplied) Dr Deborah Annesley-Williams Consultant Neuroradiologist, Queen’s Medical Centre, Nottingham I was born and brought up in Ireland and was educated at Alexandra College Dublin.

Following my secondary school education, I moved to Germany and went to medical school at the University of Cologne, qualifying in 1990.

I then held busy clinical jobs in the UK before starting my general radiology training in Stoke-on-Trent. My Neuroradiology training has been through departments in Manchester, Dublin and Newcastle. I was appointed a Consultant at Frenchay Hospital in Bristol in 2000 and obtained an MD from the University of Manchester in 2002. I moved to Queen’s Medical Centre, Nottingham in 2003.

I have established a special interest in the spine, supported by on-going research and regular presentations and publication.

Dr Ruth Batty Consultant Neuroradiologist, Royal Hallamshire Hospital and Sheffield Children’s Hospital Dr Ruth Batty is a Consultant Neuroradiologist at the Royal Hallamshire Hospital, Sheffield and Sheffield Children’s Hospital and Honorary Senior Clinical Lecturer in the Academic Unit of Medical Education at the University of Sheffield.

Ruth graduated from the University of Newcastle Upon Tyne in 1998 with distinction.

She trained in general medicine in the UK and Australia and passed the MRCP in 2001. Following training in Clinical Radiology in Leeds she was a clinical fellow in Neuroradiology in Sheffield. Ruth went on to obtain the European Qualification in Neuroradiology. She has worked as a consultant in Sheffield since 2008.

Ruth is currently involved in research related to open spinal dysraphism. She has published over 50 peer-reviewed articles. She is deputy training programme director for radiology south for Health Education Yorkshire and the Humber. She is a RCR clinical radiology examiner on the Anatomy Working Group.

Dr Ian Craven Consultant Neuroradiologist, Leeds General Infirmary I am a Consultant Neuroradiologist from Leeds General Infirmary with a subspecialist interest in paediatric neuroradiology. I trained in Sheffield where I am still a member of the university, studying for a PhD in imaging normal children. I have a keen interest in education both locally as Specialist Interest Lead in the Leeds Radiology Academy and generally as Co-Founder of the Aunt Minnie Radiology FRCR course. I am currently doing a Post-Graduate Certificate in Medical Education at the University of Cambridge. In my spare time I support Manchester United, coach hockey and play with my 11-month old daughter.

Dr Curtis Offiah Consultant Neuroradiologist, The Royal London Hospital I am a Consultant Neuroradiologist working at Barts Health NHS Trust incorporating the Royal London Hospital and St Bartholomew’s Hospital. I have a number of subspecialty and research interests including neurotrauma. I have lectured nationally and internationally in neurotrauma and have published papers in peer-reviewed radiological journals on neuroradiological aspects of trauma. I also advise Coroner services and police forces on relevant criminal neurotrauma cases.

The Royal London Hospital is a level 1 trauma centre and one of the four delegated major trauma units for London and sees a wealth of varied trauma cases including those pertaining to the head, neck and spine.

Dr Fintan Sheerin Consultant Neuroradiologist, Oxford University Hospitals NHS Trust Dr Sheerin is a Consultant Neuroradiologist at Oxford University Hospitals NHS Trust.

He trained in Cambridge, London and Oxford and is a Scholar of St Catharine’s College Cambridge. His subspecialty interests are in Craniofacial, Stroke, Head and Neck and Spinal imaging.

Dr Peter Wright Clinical Scientist, Sheffield Teaching Hospitals NHS Foundation Trust Peter Wright has recently joined Sheffield after previously being at the University Hospital of North Staffordshire where he supported the commissioning of three new Siemens MR systems and subsequent protocol setup and image quality improvement. Prior to UHNS Peter spent 3 years as the in-house physicist at Leeds Musculoskeletal and Biomedical Research Unit (LMBRU), an NIHR funded unit at Leeds NHS Trust. This role included his clinical medical physics training. Prior to this he obtained his PhD at the University of Nottingham in functional MRI and related parameters using 7 T and 3 T MRI systems.

Abstracts (where supplied) Physics of spine imaging Dr Peter Wright Education Aims 1. Recap relaxation principles and T1 and T2 weighted images 2. Fat and fluid signal nulling techniques 3. Flow compensation techniques 4. Signal saturation techniques

The lecture will start with the principles of relaxation and T1/T2 weighted images followed by examining standard spine protocols. Certain sequences in protocols may require either fat or fluid signal to be nulled to better view possible pathologies.

However, certain artefacts can mimic pathology, such as CSF flow artefact and we will examine the background of flow artefact and flow compensation techniques.

Breathing and cardiac motion can also have a detrimental effect on image quality so will examine techniques to avoid this type of image quality degradation.

MR imaging of the paediatric spine Dr Ruth Batty Aims The lecture aims to cover: 1) When and how to image the paediatric spine

MR imaging protocols

Imaging of the spine in certain intracranial pathologies: Encephalopathy Infection Demyelination

Trauma: non-accidental and accidental head injury Phakomatosis and brain tumours which CSF seed

Techniques for MR imaging in paediatric patients 2) An approach to reporting paediatric MR spine examinations 3) Imaging examples of spinal pathologies. This will mainly concentrate on spinal dysraphisms and congenital malformations of the spine. This will include an overview of open and closed spinal dysraphism with reference to normal embryology with imaging examples.

Learning Outcomes: 1) MR imaging protocols for the paediatric spine for specific indications 2) Be aware of brain pathologies in which the spine should also be imaged 3) Tips for MR imaging the paediatric patient 4) A logical approach to reporting paediatric MR spine examinations 5) A better understanding of spinal dysraphism

Spinal infections Dr Ian Craven This lecture will concentrate on the common findings on MRI in typical and atypical spinal infections. The involvement of different spinal compartments has important consequences for both the patient and clinicians. Specific cases will help illustrate how to differentiate between these whilst trying to highlight the important infection mimics. Interesting cases will then be used to emphasise less common conditions that should remain in the differential. Finally the focus will turn to the complex subject of post-operative spinal infection with practical tips aimed to help those involved with such cases.

By the end of the lecture the learner should be more confident in their approach to protocolling MR imaging in patients who have suspected spinal infection. They should recognise the pertinent findings and be able to exclude important differential diagnoses. Further cases will be presented in the subsequent workshop to help consolidate the lecture material and allow discussion of the more difficult aspects.

Spinal tumours Dr Deborah Annesley-Williams Aim: The aim of this study is to describe the imaging characteristics of spinal tumours, correlated with the operative findings, at Nottingham University Hospitals over the last five years.

Method: A retrospective database search over a period of 5 years between 2008-2013 under a neurosurgeon, with a special interest in spinal tumour surgery. For the purposes of this study, 111 cases were identified. M:F ratio was 1:1. Age range was 13-80 years with a mean of 50.1. Radiology and histological correlation was available in all the cases included in this study.

Results: 22 cases (19.8%) of spinal tumours were intramedullary, 65 cases (58.6%) were intradural, 19 cases (17.1%) both intra and extradural and 5 cases (4.5%) were extradural tumours. Amongst the intramedullary lesions, ependymomas were common in the cervical and lumbar spinal cord, with astrocytomas more often seen in the thoracic cord. Rarer entities encountered included haemangioblastoma, ganglioglioma, metastasis, dermoids, epidermoids and dysraphic cysts.

The most frequently identified intradural extramedullary compartmental tumours were schwannoma (31 cases, 10 involving both ID & ED compartments, with 3 occurring in the ED region alone) and meningioma (28 cases). Schwannomas were most commonly found in the lumbar spine whereas meningiomas were located in the thoracic spine. Rare entities in this region included paragangliomas, bronchogenic cysts, neurenteric cysts and sarcomatous lesions.

Schwannomas were the most frequently encountered extradural tumours in our case series.

Conclusion: This 5 year review of spinal tumours at our tertiary referral centre reveals results that are comparable to internationally published data.

Learning onjectives: The ability to decide whether a spinal tumour is predominantly located in the intramedullary, extramedullary, intradural or extradural compartment and to suggest an appropriate differential for each type of tumour.

Spinal trauma Dr Curtis Offiah Accurate interpretation of magnetic resonance imaging (MRI) of spinal trauma can be very challenging but is central to the appropriate management and prognostication of significantly compromised and frequently obtunded patients as well as paramount in limiting morbidity in surviving patients of significant trauma.

The lecture will provide insight into potential artefacts that may be encountered in MRI of spinal trauma, the technical challenges of MRI in such patients and the limitations of such imaging. Normal anatomy and correlative MRI appearances will be discussed. MRI considerations of blunt and sharp penetrating trauma of the spine will be covered and, where relevant, correlation made with emergency CT imaging which will usually have been performed in the first instance. The slightly more complex normal anatomy, traumatic injury and MRI correlation of the craniocervical junction trauma will also be specifically addressed.

Educational Aims and Learning Outcomes: 1. Understanding the normal anatomy of the craniocervical junction and spine.

2. Understanding the urgency of MRI assessment in the severely injured intubated and ventilated patient with spinal injury.

3. Understanding the concept of “the stable” versus “the unstable” spinal injury.

4. Understanding the fracture and ligamentous injury patterns associated with some of the more typical spinal injuries including high energy mechanism injuries.

5. Understanding prognostic MRI features in cord injury associated with spinal trauma.

Myelopathy Dr Fintan Sheerin Imaging of the spinal cord parenchymal lesions; from traumatic myelopathies to cord tumours.

Phillip Wardle is a Consultant Radiologist and Clinical Director at Cwm T Please complete the meeting evaluation survey online at: https://www.surveymonkey.com/s/MRI_day2 Upon collation of your feedback, we will email you your CPD certificate.

Thursday 10 October 2013 MSK – upper limb 08:45 Registration 09:00 Lecture A - MR Physics for MSK Imaging

Dr Richard Hodgson, University of Manchester 09:30

Lecture B - MRI of the paediatric upper limb Dr Karl Johnson, Birmingham Children’s Hospital

10:00

Lecture C - MRI of the upper limb – Medicolegal aspects Dr David Wilson, Oxford University Hospitals NHS Trust

10:30

Lecture D - Upper limb injuries in the elite athlete Dr Gajan Rajeswaran, Chelsea & Westminster Hospital

11:00

Refreshments

11:30

Workshop session 1 - topics A&B and C&D

12:15

Workshop session 2 - topics C&D and A&B

13:00

Lunch

14:00

Lecture E - A clinical approach to MRI of elbow pain Dr Gina Allen, Oxford University Hospitals NHS Trust

14:30

Lecture F - MRI of cervical lesions that affect the upper limb Dr Asif Saifuddin, The Royal National Orthopaedic Hospital

15:00

Workshop session 3 - topics E&F

15:45

Refreshments

16:15

Panel discussion reviewing complex cases

17:00

Close

Speaker profiles (where supplied) Dr Gina Allen Consultant Musculoskeletal Radiologist Oxford University Hospitals NHS Trust Previously: General Practitioner Fellow in Orthopaedic Radiology at Nuffield Orthopaedic Centre, Oxford Honorary Consultant at Nuffield Orthopaedic Centre, Oxford Consultant Radiologist at the Royal Hospital Haslar, Gosport as a Squadron Leader in Royal Air Force (now retired) Consultant Radiologist at the Royal Orthopaedic Hospital, and University Hospitals, Birmingham Involved in the London Olympic Games 2012 organisation Currently: Consultant Musculoskeletal Radiologist at the Oxford University Hospitals Lead Clinician for Oxford Soft Tissue Injury Clinic Undertaking an MSc in Sports and Exercise Medicine (University of Bath) Teaching Associate and Student Advisor at Green Templeton College, University of Oxford Member of the International Skeletal Society Research into ankle sprains using low dose cone beam Computed Tomography and ultrasound Research into muscle injury (member of International Muscle Research Group) and ultrasound elastography Run MSK US training courses including intervention with St Lukes Radiology Deputy editor European Journal of Radiology Deputy editor Orthopaedic Journal of Sports Medicine

Dr Richard Hodgson Reader in MSK Radiology, University of Manchester I am a Reader in MSK Radiology at the Centre for Imaging Sciences, University of Manchester.

Karl Johnson Consultant Paediatric Radiologist, Birmingham Children’s Hospital I am a Consultant Paediatric Radiologist at Birmingham Children’s Hospital and I was appointed in 1998. I have a special interest in Paediatric Musculoskeletal disorders and trauma.

Dr Gajan Rajeswaran Consultant Musculoskeletal Radiologist, Chelsea & Westminster Hospital He completed his undergraduate medical training at Imperial College London in 2001 and his radiology training at Chelsea & Westminster Hospital.

He has completed two post-CCT fellowships in Musculoskeletal Imaging at Chelsea & Westminster Hospital and the Royal National Orthopaedic Hospital, Stanmore and has worked as a Locum Consultant at Imperial College Healthcare NHS Trust and North West London Hospitals NHS Trust. He was appointed as a Consultant at Chelsea & Westminster Hospital in 2011.

He has several peer reviewed radiological publications and has authored a chapter in a textbook. He lectures regularly at national and international conferences including the European Society of Skeletal Radiology, the British Institute of Radiology, the UK Radiology Congress and the Royal Society of Medicine. He is actively involved in medical education having completed a Postgraduate Certificate in Medical Education and he organizes and teaches on several courses including the Imperial College Graduate Anatomy Programme and the Royal Society of Medicine Radiology for Foundation Doctors Course. He is the joint Training Programme Director for the Chelsea & Westminster Hospital Radiology Scheme and has an active role in radiology training.

Dr Asif Saifuddin Senior Consultant Musculoskeletal Radiologist The Royal National Orthopaedic Hospital Dr Asif Saifuddin is the senior Consultant Musculoskeletal Radiologist at The Royal National Orthopaedic Hospital, Stanmore, UK where he has worked since 1994. His major interests are related to imaging of the spine and musculoskeletal neoplasms.

He is a member of the BSSR, ESSR and ISS and Editoial Board Member of Skeletal Radiology. He has authored many peer reviewed publications, book chapters and also books, including Musculoskeletal MRI published in 2008.

Dr David Wilson Honorary Consultant Radiologist, Oxford University Hospitals NHS Trust Oxford Dr Wilson’s primary interest is in the application of modern imaging techniques to disorders of the locomotor system and spine intervention. He has undertaken original work in the application of diagnostic ultrasound to joint, muscle, and soft tissue disease with particular attention to joint effusion and congenital dysplasia of the hip. He has over 20 years of experience in vertebroplasty and is the author of publications on multicenter controlled trials on the treatment of insufficiency fractures. He has established innovative training courses in the UK in musculoskeletal ultrasound in Oxford and Bath. He teaches internationally and is a leader in the development of ultrasound in musculoskeletal disease and injection techniques in the spine. He has considerable experience in all aspects of musculoskeletal imaging and is the Editor of the principle textbook on MSK imaging. As a former President of the British Society of Skeletal Radiologist and a previous Medical Director of the Nuffield Orthopaedic Centre he has wide clinical and research experience.

Abstracts (where supplied) Dr Richard Hodgson In musculoskeletal MRI as elsewhere, spin echoes and gradient echoes can be used to generate images with different combinations of T1, T2 and T2* weightings.

Intermediate or proton density weighted images are particularly useful for MRI of joints. Fat suppression is very important in the musculoskeletal system and a variety of techniques exist based on chemical shift and T1 differences between fat and water including fat saturation, water excitation, Dixon imaging and STIR. The improvement in SNR by moving to higher field strengths allows higher resolution images to be obtained. Rapid imaging techniques including parallel imaging permit faster and 3-dimensional imaging. A number of artefacts may be important in MSK imaging including chemical shift, fast spin echo blurring, parallel imaging and metal artefacts.

MRI of the paediatric upper limb Dr Karl Johnson The challenge when undertaking any radiological examination in a child, who may be poorly compliant is to achieve good quality diagnostic images. In MR imaging this may be compounded by the relatively small anatomically area of interest.

Consideration also needs to be given to the normal physiological changes that can occur during childhood that can be confused with pathology.

This lecture will review good techniques and procedures that allow good quality images to be obtained regardless of the size and age of the child. A overview of the best sequence choice to increase the sensitivity and specificity of the examination will be detailed, highlighting those particular sequences which are useful in the upper limb. The normal variants that occur during childhood that may be confused with pathology will be illustrated, along with an overview of the clinical applications and pathology encountered in the paediatric upper limb.

MRI of the upper limb – Medicolegal aspects Dr David Wilson MR has become synonymous with high quality and accurate imaging. The DICOM data is permanently available and ready for all to review and reassess. It is hardly surprising that MR images are the centre of many medicolegal cases. They may be the source of the complaint, misinterpretation or inappropriate use. Alternatively they may be the proof that a disease was present and attributable to a particular incident.

There are pitfalls: 1) There may be too high an expectation as to what MR may reveal 2) It is often very hard to use MR to define the time course of a disease 3) The images may be degraded by artifact 4) MR may have been the wrong imaging method for the problem 5) The interpreter may not have sufficient skill in a subspecialty 6) The expert may be using the benefit of hindsight to see the lesion

In the upper limb the areas of common complaint or accusation are: a) A missed rotator cuff tear b) A missed fracture especially around the wrist c) Missed ligament or tendon injuries Of course there are many more problems that ensue, fortunately tumours and infections are rate but they are commonly misinterpreted.

In this presentation we will show cases that have led to litigation and will discuss the issues.

We discuss how routine practice and systematic methods may be used to reduce errors.

Template reporting with standardized caveats will be discussed and the role of imaging protocols will be elaborated.

Upper limb injuries in the elite athlete Dr Gajan Rajeswaran The aim of the presentation is to describe injuries of the upper limb that occur relatively specifically as a result of sporting activity. The following sport related injuries will be discussed: in the shoulder and arm, weightlifting; in the elbow, baseball/softball; in the thumb, skiing; in the finger, rock climbing. Tips to make the diagnosis will be discussed as well as pitfalls in interpretation.

A clinical approach to MRI of elbow pain Dr Gina Allen This lecture will include: 1. Anatomy of the anterior, posterior, medial and lateral elbow including bones, tendons, muscles, ligaments and nerves.

2. Clinical assessment of the patient affecting these areas.

3. Indications for imaging using MRI or other modalities.

4. These topics will be highlighted by cases where MRI has been useful in the diagnosis of disease.

This lecture will be available on our website: http://stlukesradiology.org.uk/stlukes/content/medical-education

MRI of cervical lesions that affect the upper limb Dr Asif Saifuddin, RNOH The motor and sensory nerve supply to the upper limb arises from the ventral rami of the C5-T1 spinal nerves, which combine to form the brachial plexus. Therefore, the upper limb may be affected by lesions of the cervical cord, which may be intramedullary, extramedullary-intradural or extradural in location; or lesions of the C5 to T1 cervical nerves.

Cord compression presents with cervical myelopathy, while nerve root lesions present with radiculopathy; both can be chronic or acute and result in various combinations of pain, weakness and muscle wasting. Acute adult brachial plexus trauma can result in partial or total paralysis of the upper limb.

This talk focuses purely on extradural disorders of the cervical cord and nerves, which are most commonly due to degenerative disc and/or facet disease, but may also result from chronic inflammatory disorders such as rheumatoid arthritis, primary or secondary neoplastic lesions which extend into the epidural space and/or intervertebral foramen, bone or soft tissue infection and acute trauma, either to the spinal column or the intradural plexus.

The aims of the lecture are to cover the basic anatomy of the cervical spine, cord and nerve roots and the patho-anatomy which results in their compression; briefly discuss the MR imaging protocols used in routine practise; summarise the clinical presentations of cord and root lesions; illustrate the abnormal imaging findings of the various disorders seen on cervical spine MRI that will affect the upper limb, concentrating mainly on degenerative disc and facet joint disease.

Please complete the meeting evaluation survey online at: https://www.surveymonkey.com/s/MRI_day3 Upon collation of your feedback, we will email you your CPD certificate.

Friday 11 October 2013 GU - male 08:45 Registration 09:00

Lecture A - MRI pulse sequences for the male GU Dr Dan Wilson, Leeds Teaching Hospitals NHS Trust

09:30

Lecture B - Prostate Dr Clare Allen, University College London Hospitals

10:00

Lecture C - Bladder Dr Nishat Bharwani, Imperial College Healthcare NHS Trust

10:30

Lecture D - Testes/penis Dr Alex Kirkham, University College London Hospitals

11:00 Refreshments 11:30

Workshop session 1 - topics A&B and C&D

12:15 Workshop session 2 - topics C&D and A&B

13:00 Lunch 14:00

Lecture E - MRI adrenal glands Dr Anju Sahdev, Barts Health NHS Trust

14:30

Lecture F - Kidney Dr Narayan Karunanithy, Guy’s & St Thomas’ NHS Foundation Trust

15:00

Workshop session 3 - topics E&F

15:45

Refreshments

16:15

Panel discussion reviewing complex cases

17:00

Close

Speaker profiles (where supplied) Dr Nishat Bharwani Consultant Radiologist, Imperial College Healthcare NHS Trust Dr Nishat Bharwani graduated from Guy’s, King’s & St Thomas’ Schools of Medicine, University of London in 2000. Following this she underwent general medical training and attained Membership of the Royal College of Physicians in 2003.

Nishat undertook general radiology training at St George’s Hospital, London and became a fellow of the Royal College of Radiologists in 2008. She then completed Fellowship training in Body MRI and Oncological Imaging at Barts & The London NHS Trust developing sub-specialty interests in gynaecological, urological and endocrine imaging. Nishat was appointed to her current post as Consultant Radiologist at Imperial College Healthcare NHS Trust in 2011.

Nishat has authored several peer-reviewed journal articles and book chapters. She has made numerous presentations at National and International meetings. Nishat is an experienced educator involved in delivering training on the North West Thames radiology rotation and regularly takes part in several University MSc and other Clinical training courses.

Her current research interests include imaging assessment of nodal metastases in gynaecological cancers and the assessment of metastatic renal cell carcinoma response to treatment with tyrosine kinase inhibitors.

Dr Narayan Karunanithy Consultant Radiologist and Honorary Clinical Lecturer Guy’s & St Thomas’ NHS Foundation Trust Dr Narayan Karunanithy is a Consultant Radiologist and Honorary Clinical Lecturer at Guy’s & St Thomas’ NHS Foundation Trust in London. He is the sub-specialty lead for Renal, Transplant and Vascular Access IR and has introduced the newer NC-MRA techniques of vascular assessment into everyday clinical practice at the Trust. His major research interests are in blood flow computational modeling and quantitative fMRI assessment of early renal transplant dysfunction and rejection.

Dr Anju Sahdev Consultant and Director for Research and Education in imaging, Barts Health NHS Trust Dr Anju Sahdev is Consultant and Director for Research and Education in the department of Imaging, Barts Health, London UK. She is also Senior Lecturer for Queen Mary’s University, London. She graduated from University of London in 1991, and became a member of the Royal College of Physicians in 1995. She completed her radiology training at University College London, becoming a fellow of the Royal College of Radiologists in 1998.

She has authored and co-authored more than 45 peer reviewed publications and has authored 15 chapters in clinical and imaging textbooks and delivered over 50 lecturers at national and international meetings. She has also been part of the national guideline development group in the management of cervical (SIGN guidelines) and renal cancer.

Her main radiological specialties are gynaecological cancer imaging, endocrine and uro-oncology involving ultrasound, CT, MRI including diffusion weighted and dynamic contrast enhanced MRI and PET CT. Dr Dan Wilson Cinical Scientist, Leeds Teaching Hospitals NHS Trust

Don’t forget you can feedback your comments to us by filling in the online evaluation at:

Dr Daniel Wilson has over 15 years experience as a clinical MR Physicist working in a large teaching hospital. He has specialised in MRI in oncology with a particular interest in liver, breast, and prostate MRI. He has a particular interest in diffusion MRI and dynamic contrast enhanced MRI.

https://www.surveymonkey.com/s/17Oct2011

Abstracts (where supplied)

MRI pulse GU Uponsequences collationfor of the yourmale feedback, Dr Dan Wilson

we will email you your CPD

certificate.

Educational aim: To understand the MR physics underpinning a range of advanced imaging sequences that are used in imaging the male GU system.

Learning outcomes: 1. Describe the principles of diffusion weighted MRI. 2. Describe the principles of DCE-MRI. 3. Recognise the appearance of 2 common artefacts associated with advanced MRI techniques.

Registration will be open shortly for the BIR UK MRI Course in 2012.

MRI sequences to imageour the male genitor-urinary undergo at constant Visit website tosystem register

development and revision. MRI involves filling a k-space grid with signal data. This is usually filled in row by row. The simplest acquisitions acquire a single row of k-space per repetition time. To speed up the acquisition multiple rows of k-space can be acquired per TR although this may lead to blurring or artefacts. Fast spin echo acquires multiple spin echoes per TR whilst echo planar imaging acquires multiple gradient echoes. Echo planar imaging is commonly used in diffusion weighted imaging, a technique that is sensitive to self-diffusion of water molecules. The technique has found utility in the detection and characterisation of lesions because the higher cellular densities and more tortuous interstitial spaces of malignant lesions leads to restricted diffusion. DCE-MRI involves the acquisition of multiple imaging volumes at high temporal resolution (typically between 2 and 20 s per volume) before, during and after the injection of a contrast agent. This data can be used to No:sophisticated 215869 analyses can also be generate signal intensity –Registered time curvesCharity and more made to relate these curves to properties of the vasculature such as perfusion. Finally, T2W fast spin echo techniques are now available that collect k-space data radially leading to less motion sensitivity and allowing motion correction processing.

www.bir.org.uk

Bladder MRI Dr Nishat Bharwani Educational aims: 1. To outline the recommended protocol for Bladder MRI and techniques for image optimisation.

2. To illustrate normal MR imaging appearances of the urinary bladder and local pelvic structures.

3. To discuss the role of MRI in the staging of bladder cancer.

4. To review the important differential diagnoses and their MR imaging characteristics.

Learning outcomes: On completion of this workshop session the participant will be able to: 1. Identify and locally stage urothelial bladder carcinoma on MRI. 2. Describe the typical pattern of tumour spread and recognise important review areas for staging.

3. Appreciate the imaging characteristics of inflammatory and other non-neoplastic lesions that can mimic malignancy.

MRI adrenal glands Dr Anju Sahdev MRI has a pivotal role in both detection and characterization of adrenal lesions.

Adrenal lesions are frequently identified in routine clinical practice both as incidental masses and when investigating patients for functional adrenal disease.

Pathognomonic MR imaging features have been established for many of these lesions, including myelolipomas, lipid rich adenomas, haematomas and cysts. The majority of adrenal lesions are benign. However as the adrenal gland is also a frequent site for metastastic disease, distinguishing between benign and malignant masses on imaging is essential when staging patients for the underlying carcinomas.

In functional adrenal disease, clinical and biochemical findings are vital when interpreting the MR imaging findings. The role of imaging is to assess whether the disease is unilateral or bilateral, and where possible, characterise the abnormality and plan surgery.

This presentation describes characteristic imaging features of common adrenal lesions. The use of conventioanl MR sequences, gadolinium enhancement and chemical shift imaging for the characterisation of these lesions will be emphasised.

In addition, the role of quantitative analysis and the application of modern MR techniques in evaluating adrenal masses will be discussed. The presentation also evaluates the place of MRI in context of current international guidelines and other imaging modalities available for adrenal imaging.

Kidney Dr Narayan Karunanithy Educational aims: 1. Describe the established and emerging techniques of renal vascular assessment

by MR angiography 2. Evaluate the role of MR urography for upper renal tract imaging 3. Discuss the potential roles for functional MRI including endogenous techniques of DWI, ASL and BOLD and exogenous technique of dynamic contrast enhanced MRI. Learning outcomes: On completion of the lecture and workshop session the participant will be able to: 1. Understand the applications, limitations and tricks for optimizing contrast enhanced and non contrast MRA techniques for renal vascular assessment 2. Appreciate the applications of static and excretory MRU for upper renal tract assessment 3. Gain familiarity with fMRI techniques that may play an important role in assessing both global and focal renal parenchymal functionality

Please complete the meeting evaluation survey online at: https://www.surveymonkey.com/s/MRI_day4 Upon collation of your feedback, we will email you your CPD certificate.

The BIR itself accepts no legal responsibility for the facts stated or opinions expressed during this 4 day course. It is the responsibility of any attendees to satisfy him/herself as to which part(s) of those facts/opinions should be relied on in any way whatsoever.

Our platinum sponsors

GE Healthcare GE Healthcare provides transformational medical technologies and services to meet the demand for increased access, enhanced quality and more affordable healthcare around the world. GE (NYSE: GE) works on things that matter - great people and technologies taking on tough challenges. From medical imaging, software & IT, patient monitoring and diagnostics to drug discovery, biopharmaceutical manufacturing technologies and performance improvement solutions, GE Healthcare helps medical professionals deliver great healthcare to their patients.

Philips Healthcare Philips is a diversified health and well-being company and a world leader in healthcare, lifestyle and lighting. Our vision is to make the world healthier and more sustainable through meaningful innovation.

We develop innovative healthcare solutions across the continuum of care, in partnership with clinicians and our customers to improve patient outcomes, provide better value, and expand access to care.

As part of this mission we are committed to fuelling a revolution in imaging solutions, designed to deliver greater collaboration and integration, increased patient focus, and improved economic value. We provide advanced imaging technologies you can count on to make confident and informed clinical decisions, while providing more efficient, more personalised care for patients.

Siemens Healthcare The Siemens Healthcare Sector is one of the world’s largest suppliers to the healthcare industry and a trendsetter in medical imaging, laboratory diagnostics, medical information technology and hearing aids. Siemens offers its customers products and solutions for the entire range of patient care from a single source – from prevention and early detection to diagnosis, and on to treatment and aftercare. By optimising clinical workflows for the most common diseases, Siemens also makes healthcare faster, better and more cost-effective. For further information please visit: http://www.siemens.co.uk/healthcare

Upcoming BIR events in 2013/14 Linking orthopaedics and radiology - The plain film revisited 1: The lower limb 17 October 2013

Recent advances in diagnostic imaging 12 November 2013

CT scanning - An educational update 12 November 2013

The journey from research to publication 14 November 2013

Annual trainee meeting 2013: The future of radiology in the NHS - Top topics for interviews 15 November 2013

Stereotactic ablative body radiotherapy: Current status and developments 12 December 2013

Pushing the boundaries of Radiology 13 December 2013

Contrast study day and essential physics for FRCR 23 - 24 January 2014

Radiology errors 31 January 2014

3rd Annual SPECT/CT Symposium: Current status and future directions of SPECT/CT imaging 24 February 2014

Join the BIR today to benefit from reduced delegate rates for our events, membership information can be found online at: http://www.bir.org.uk/join-us/

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For information and updates about BIR activities please visit our website: www.bir.org.uk or follow us on Twitter: @BIR_News