MR Angiography (MRA)
Reprint from RadiologyInfo.org

What is MR Angiography?

Angiography is a minimally invasive medical test that helps physicians diagnose and treat medical conditions. Angiography uses one of three imaging technologies and, in some cases, a contrast material to produce pictures of major blood vessels throughout the body.

Angiography is performed using:

• x-rays with catheters
• computed tomography (CT)
• magnetic resonance imaging (MRI)

In magnetic resonance angiography (MRA), a powerful magnetic field, radio waves and a computer produce the detailed images. MR angiography does not use ionizing radiation (x-rays).

MR angiography may be performed with or without contrast material. If needed, the contrast material is usually injected using a vein in the arm.

What are some common uses of the procedure?

MR angiography is used to examine blood vessels in key areas of the body, including the:

• brain
• kidneys
• pelvis
• legs
• lungs
• heart
• neck
• abdomen

Physicians use the procedure to:

• identify disease and aneurysms in the aorta, both in the chest and abdomen, or in other major blood vessels.
• detect atheroscleosis disease in the carotid artery of the neck, which may limit blood flow to the brain and cause a stroke.
• identify a small aneurysm or arteriovenous malformation inside the brain.
• detect atherosclerotic disease that has narrowed the arteries to the legs and help prepare for endovascular intervention or surgery.
• indicate disease in the arteries to the kidneys or visualize blood flow to help prepare for a kidney transplant.
• guide interventional radiologists and surgeons making repairs to diseased blood vessels, such as implanting stents or evaluating a stent after implantation.
• detect injury to one of more arteries in the neck, chest, abdomen, pelvis or extremities in trauma patients.
• evaluate arteries feeding a tumor prior to surgery or other procedures such as chemoembolization or selective internal radiation therapy.
• identify dissection or splitting in the aorta in the chest or abdomen or its major branches.
• show the extent and severity of atherosclerosis in the coronary arteries and plan for a surgical operation, such as a coronary bypass.
• sample blood from specific veins in the body to detect any endocrine disease.
• examine pulmonary arteries in the lungs to detect pulmonary embolism (blood clots from leg veins).
• screen individuals for arterial disease, especially patients with a family history of arterial disease or disorders.

How should I prepare?

You may be asked to wear a gown during the exam or you may be allowed to wear your own clothing if it is loose-fitting and has no metal fasteners.

Guidelines about eating and drinking before an MRI exam vary at different facilities. Unless you are told otherwise, you may follow your regular daily routine and take medications as usual.   The MR angiogram may require the patient to receive an injection of contrast into the bloodstream. The radiologist or technologist may ask if you have allergies of any kind such as allergy to iodine or x-ray contrast material, drugs, food, the environment, or asthma. However, the contrast material used for an MRI exam, called gadolinim, does not contain iodine and is less likely to cause an allergic reaction than iodine containing contrast used for CT scan.

The radiologist should also know if you have any serious health problems and what surgeries you have undergone. Some conditions, such as severe kidney or liver disease may prevent you from having an MRI with contrast material.

Women should always inform their physician or technologist if there is any possibility that they are pregnant. MRI has been used for scanning patients since the 1980's with no reports of any ill effects on pregnant women or their babies. However, because the baby will be in a strong magnetic field, pregnant women should not have this exam unless the potential benefit from the MRI is assumed to outweigh the potential risks.

If you are breastfeeding at the time of the exam, you should ask your radiologist how to proceed. It may help to pump breast milk ahead of time and keep it on hand for use after contrast material has cleared from your body, about 24 hours after the test. If you have claustrophobia (fear of enclosed spaces) or anxiety, you may want to ask your physician for a prescription for a mild sedative.

Young children should not eat or drink for about four hours if they will receive a sedative.

Jewelry and other accessories should be left at home if possible, or removed prior to the MRI scan. Because they can interfere with the magnetic field of the MRI unit, metal and electronic objects are not allowed in the exam room. These items include:

• jewelry, watches, credit cards and hearing aids, all of which can be damaged.
• pins, hairpins, metal zippers and similar metallic items, which can distort MRI images.
• removable dental work.
• pens, pocketknives and eyeglasses.
• body piercings.

In most cases, an MRI exam is safe for patients with metal implants, except for a few types. People with the following implants cannot be scanned and should not enter the MRI scanning area unless explicitly instructed to do so by a radiologist or technologist who is aware of the presence of any of the following:

• internal (implanted) defibrillator or pacemaker
• cochlear (ear) implant
• some types of clips used on brain aneurysms

You should tell the technologist if you have medical or electronic devices in your body, because they may interfere with the exam or potentially pose a risk, depending on their nature and the strength of the MRI magnet. Examples include but are not limited to:

• artificial heart valves
• implanted drug infusion ports
• implanted electronic device, including a cardiac pacemaker
• artificial limbs or metallic joint prostheses
• implanted nerve stimulators
• metal pins, screws, plates, stents or surgical staples

In general, metal objects used in orthopedic surgery pose no risk during MRI. However, a recently placed artificial joint may require the use of another imaging procedure. If there is any question of their presence, an x-ray may be taken to detect the presence of and identify any metal objects.

Patients who might have metal objects in certain parts of their bodies may also require an x-ray prior to an MRI. Dyes used in tattoos may contain iron and could heat up during MRI, but this is rarely a problem. Tooth fillings and braces usually are not affected by the magnetic field but they may distort images of the facial area or brain, so the radiologist should be aware of them.

What does the equipment look like?

The traditional MRI unit is a large cylinder-shaped tube surrounded by a circular magnet. You will lie on a moveable examination table that slides into the center of the magnet. Some MRI units, called short-bore systems, are designed so that the magnet does not completely surround you; others are open on the sides ("low-strength" open MRI). These units are especially helpful for examining patients who are fearful of being in a closed space and for those who are very obese. Newer open MRI units provide very high quality images for many types of exams; however, open MRI units with older magnets may not provide this same quality. Certain types of exams cannot be performed using open MRI. For more information, consult your doctor.  The computer workstation that processes the imaging information is located in a separate room than the scanner.

How does the procedure work?

Unlike conventional x-ray examinations and computed tomography (CT) scans, MRI does not depend on ionizing radiation. Instead, while in the magnet, radio waves redirect the axes of spinning protons, which are the nuclei of hydrogen atoms, in a strong magnetic field.  The magnetic field is produced by passing an electric current through wire coils in most MRI units. Other coils, located in the machine and in some cases, placed around the part of the body being imaged, send and receive radio waves, producing signals that are detected by the coils.

A computer then processes the signals and generates a series of images each of which shows a thin slice of the body. The images can then be studied from different angles by the interpreting physician.   Overall, the differentiation of abnormal (diseased) tissue from normal tissues is often better with MRI than with other imaging modalities such as x-ray, CT and ultrasound.  Then a contrast material is introduced to the bloodstream during the procedure, it clearly defines the blood vessels being examined by making them appear bright white.

How is it performed?

This examination is usually done on an outpatient basis.  You will be positioned on the moveable examination table. Straps and bolsters may be used to help you stay still and maintain the correct position during imaging.  Small devices that contain coils capable of sending and receiving radio waves may be placed around or adjacent to the area of the body being studied.

If a contrast material will be used in the MRI exam, a nurse or technologist will insert an intravenous (IV) line into a vein in your hand or arm. A saline solution may be used. The solution will drip through the IV to prevent blockage of the IV line until the contrast material is injected.  You will be moved into the magnet of the MRI unit and the radiologist and technologist will leave the room while the MRI examination is performed.

If a contrast material is used during the examination, it will be injected into the intravenous line (IV) after an initial series of scans. Additional series of images will be taken during or following the injection.  When the examination is completed, you may be asked to wait until the technologist or radiologist checks the images in case additional images are needed.  Your intravenous line will be removed. MRI exams generally include multiple runs (sequences), some of which may last several minutes.  The entire examination is usually completed within 30 to 60 minutes.

What will I experience during and after the procedure?

Most MRI exams are painless.  Some patients, however, find it uncomfortable to remain still during MR imaging. Others experience a sense of being closed-in (claustrophobia). Therefore, sedation can be arranged for those patients who anticipate anxiety, but fewer than one in 20 require it.

It is normal for the area of your body being imaged to feel slightly warm, but if it bothers you, notify the radiologist or technologist. It is important that you remain perfectly still while the images are being recorded, which is typically only a few seconds to a few minutes at a time. For some types of exams, you may be asked to hold your breath. You will know when images are being recorded because you will hear tapping or thumping sounds when the coils that generate the radiofrequency pulses are activated. You will be able to relax between imaging sequences, but will be asked to maintain your position as much as possible.

You will usually be alone in the exam room during the MRI procedure. However, the technologist will be able to see, hear and speak with you at all times using a two-way intercom. Many MRI centers allow a friend or parent to stay in the room as long as they are also screened for safety in the magnetic environment.

You may be offered or you may request earplugs to reduce the noise of the MRI scanner, which produces loud thumping and humming noises during imaging. MRI scanners are air-conditioned and well-lit. Some scanners have music to help you pass the time.

When the contrast material is injected, it is normal to feel coolness and a flushing sensation for a minute or two. The intravenous needle may cause you some discomfort when it is inserted and once it is removed, you may experience some bruising. There is also a very small chance of irritation of your skin at the site of the IV tube insertion.

If you have not been sedated, no recovery period is necessary. You may resume your usual activities and normal diet immediately after the exam. A few patients experience side effects from the contrast material, including nausea and local pain. Very rarely, patients are allergic to the contrast material and experience hives, itchy eyes or other reactions. If you experience allergic symptoms, a radiologist or other physician will be available for immediate assistance.  It is recommended that nursing mothers not breastfeed for 36 to 48 hours after an MRI in which a contrast material was given.

Who interprets the results and how do I get them?

A radiologist, a physician specifically trained to supervise and interpret radiology examinations, will analyze the images and send a signed report to your primary care or referring physician, who will share the results with you.

What are the benefits vs. risks?

Benefits

• Angiography may eliminate the need for surgery. If surgery remains necessary, it can be performed more accurately.
• MRI is a noninvasive imaging technique that does not involve exposure to ionizing radiation.
• Detailed images of blood vessels and blood flow are obtained without having to insert a catheter, so that there is no risk of damaging an artery.
• The MR angiography procedure itself may be shorter than a traditional catheter angiogram and requires no recovery period.
• MR angiography is less costly than catheter angiography.
• Even without using contrast material, MR angiography can provide high-quality images of many blood vessels, making it very useful for patients prone to allergic reactions.
• The contrast material used in MRI exams is less likely to produce an allergic reaction than the iodine-based materials used for conventional x-rays and CT scanning.

Risks

• The MRI examination poses almost no risk to the average patient when appropriate safety guidelines are followed.
• If sedation is used there are risks of excessive sedation. The technologist or nurse monitors your vital signs to minimize this risk.
• Although the strong magnetic field is not harmful in itself, implanted medical devices that contain metal may malfunction or cause problems during an MRI exam.
• There is a very slight risk of an allergic reaction if contrast material is injected. Such reactions usually are mild and easily controlled by medication. If you experience allergic symptoms, a radiologist or other physician will be available for immediate assistance.
• Nephrogenic systemic fibrosis is currently a recognized, but rare, complication of MRI believed to be caused by the injection of high doses of MRI contrast material in patients with very poor kidney function.

What are the limitations of MR Angiography?

Unlike CT angiography, MR angiography is not able to see and capture images of calcium deposits.   The clarity of MR angiography images of some arteries does not match those obtained with conventional catheter-based angiography. MRI of small vessels, in particular, may be difficult. Sometimes it may be difficult to separate images of arteries from veins with MR angiography.

Individuals who cannot lie still or who cannot lay on their back may have MR angiography images that are of poor quality. Some tests require patients to hold their breath for 15 to 25 seconds at a time in order to get good MR angiography pictures.  High-quality images are assured only if you are able to remain perfectly still or hold your breath, if requested to do so, while the images are being recorded. If you are anxious, confused or in severe pain, you may find it difficult to lie still during imaging.

A person who is very large may not fit into the opening of a conventional MRI machine.  The presence of an implant or other metallic object sometimes makes it difficult to obtain clear images and patient movement can have the same effect.  Although there is no reason to believe that magnetic resonance imaging harms the fetus, pregnant women usually are advised not to have an MRI exam unless medically necessary.  Contrast injections, especially early in the pregnancy, are usually avoided except when absolutely necessary for medical treatment.