A leap in pediatric MRI confidence at Altona Children’s Hospital

The Pediatric Radiology Department of Altona Children’s Hospital in Hamburg, Germany, performs diagnostic imaging in pediatric patients, from newborns to patients of about 18 years of age, specializing in orthopedic, neurological and gastroenterological imaging.

Dr. Carl-Martin Junge is the Chief Radiologist at the Pediatric Radiology Department. Since November 2019, the department has been using the Philips Ingenia Ambition 1.5T MRI system. Dr. Junge explains that the large range in age and size of pediatric patients requires a broad set of MRI examination protocols. His first priority for an MRI scanner is good and consistent image quality, so that he is able to make confident diagnoses in even the smallest and most difficult pediatric patients. In addition, their way of working requires an MRI scanner that offers a high degree of flexibility to allow tailoring of their imaging on the fly when initial findings give them a reason to do so. From day one of operation, the Ingenia Ambition has impressed Dr. Junge and his team with its powerful performance.

Dr. Junge points out how scanning pediatric patients is more difficult than scanning adults. In addition to the small size, age range and often complex diagnoses, he mentions the challenges with keeping younger patients still in the scanner, during scans that often require 30 minutes or more. “For children from zero to about five years old we use sedation to successfully carry out the examination. For patients from five to about 12-13 years, good coaching and the wonderful Ambient and in-bore features help keep the children calm in the machine and allow for good imaging. It’s a very good advantage compared to other systems, I think. Older children can be treated similar to adults. Of course, motion-robust scan techniques help to address these challenges for all ages.”

Dr. Junge estimates that per day, on average two or three patients out of ten would be scanned with sedation. MRI lead technologist Ms. Meinken adds that she has been happily surprised that the need for sedation was not affected when switching from an open system to a bore system – thanks to the fantastic in-bore and Ambient features.

Another important factor is that many pediatric patients are still undiagnosed at the time of presentation, and the desire is to find a diagnosis immediately in the first exam, in order to limit or avoid the need for follow-up exams. As a consequence, the team needs flexibility and time during the examination.

Both Dr. Junge and Ms. Meinken value the patient-friendly attributes of the Ingenia Ambition. “The in-bore features, including music and videos to entertain the children during the scanning, are very useful,” says Ms. Meinken. “The children really love this, it helps us persuade many of them. Without this, young children often do not want to enter the scanner, but with the films, music and color, they get interested and willing to undergo the scan. And we can take our time with the examinations, because the patients are distracted and at ease. I think, the in-bore features are key to successful examinations, especially for children.”

“And the parents love it too,” says Dr. Junge. “In addition, we can use noise reduction to make the scan more comfortable. Patients with spondylolisthesis or other painful afflictions particularly appreciate the special thick, soft mattress, which helps make their examinations much more comfortable. Many of these patients say it’s fantastic, and they were never lying so comfortably in an MRI system before. I absolutely think that Ambition improves patient satisfaction.”

“These capabilities also help the patients remain motionless inside the scanner, which allows us to obtain images with excellent quality,” says Dr. Junge. “I think the in-bore Connect capability is one of the best highlights of this system.”

Ms. Meinken notes that the Ambient Experience also makes the atmosphere of the scanning room much more pleasant for the staff. “It’s nice for the technologists to work in this friendly-feeling room. It feels much better than working in a dull, colorless room, as we did in the past,” she says.

The MRI staff at Altona Children’s Hospital always make sure there is enough time available to adequately scan each patient. “Throughput is not our priority, we take the time we need for every patient,” says Dr. Junge. “Essential to us are the consistent quality and resolution of the images, for every sequence. Ambition helps us achieve our primary goal of obtaining excellent quality images with high resolution – there is a world of difference with our old system.”

Compressed SENSE is one of the most notable features. “We use this acceleration technology mainly for improving resolution without increasing scan time. We have already incorporated Compressed SENSE into most of our ExamCards,” says Dr. Junge.

Since scan times of 3D scans can be significantly shortened thanks to Compressed SENSE, the MRI team is performing more 3D scans than before. “The advantage of 3D scanning is that we capture one high resolution sequence, but we can reconstruct images in any orientation, even after the scan, when looking at the images for diagnosis. Having this ability to view any cross section we need in high resolution, can make re-scanning unnecessary,” says Dr Junge. “We are currently optimizing our routine head examination to include more 3D scans, including T1- weighted, T2-weighted and FLAIR.”

Two examples of brain examinations. Left: Initial examination of dural sinus malformation (DSM). Right in image below: MRI after three times of coiling and acryl-based embolization.

The ability to perform comprehensive MRI scans tailored to every patient is vitally important for Dr. Junge and his team. The pediatric patients that arrive for an MRI are often not yet diagnosed, and the MRI exam is the first imaging they undergo.

“We may not know exactly what and where we need to scan beforehand,” says Dr. Junge. “During the examination – when seeing the first images – we may realize that we need to scan more anatomies or add different sequences in order to obtain all the relevant information immediately in the first exam. That is why we need flexibility during the exam. We constantly need to adapt our ExamCards as new clinical questions arise. We really appreciate how the Ambition allows us to change scan parameters quickly and easily; this is an extraordinary feature with Ambition, it’s extremely useful, I think.”

Having a collection of dedicated ExamCards is important, as these are the starting points of MRI examinations. “We begin every examination with one of the ExamCards from our collection,” says Dr. Junge. “Then during the examination, as new clinical questions arise based on the initial findings, we adjust and add sequences. This flexible way of working – ExamCards for the routine scans and the possibility to change a parameter with one click – I think that’s a great benefit of Philips MRI scanners.”

“Our application specialist initially helped us make our set of ExamCards for pediatric targets, which we built by adjusting the ExamCards from the standard set of Ambition. Each ExamCard bundles the sequences for a specific examination. Currently, we are still developing more ExamCards for the different age and size categories of our pediatric patients.”

Left in image below: Slipped capital femoral epiphysis after intervention. After intervention with two screws, it is important to check that the circumference is normal and without necrosis. The screws cab cause major metal artifacts, but O-MAR allows to improve visualization of tissue and bone in near vicinity of MR Conditional orthopedic implants*.

*Only for use with MR Safe or MR Conditional implants by strictly following the Instructions for Use

Right in image below: Hydrocephalus post hemorrhagic. Both pictures show a ventriculoperitoneal shunt. With our previous scanner our hydrocephalus protocol needed about 25 min. With Ambition the examination time is about 14 min. including a CSF PCA sequence to show flow in the aqueduct.

The Ingenia Ambition gave Altona Children’s Hospital access to various novel scan techniques that are useful for pediatric imaging. “These modern technologies help us to scan anatomies where we saw challenges in the past, such as in the abdomen and thorax. With Ambition, we can perform high quality abdominal scans. As a result, the number of abdominal scans has increased substantially compared to our practice with our old system,” says Dr. Junge.

“We like to use the VitalEye feature in every abdominal examination. In my opinion it is an excellent trigger feature, and a big improvement from the respiratory belt we were using before,” says Dr. Junge.

“It was also a very pleasant surprise to us that we could get excellent resolution on other anatomies, as well, such as the spine, head and knees, that we didn’t see previously. That is something that helps us tremendously as anatomy of children can be very small.”

Features that provide remarkable benefits to Dr. Junge include Compressed SENSE, which allows to elevate spatial resolution, signal and scan time. MultiVane XD and 3D VANE XD employ radial k-space sampling and help to mitigate motion artifacts and improve robustness for different contrasts and for all age groups. The mDIXON FFE and mDIXON TSE methods nicely address challenges in fat-free imaging and provide multiple contrast types from one single scan. The achievable large field of view (FOV), high resolution and flexible echo times are certainly a huge benefit in examining children.

According to Dr. Junge, the department used to typically scan three or four patients per day with their previous system. However, this number instantly increased when they began using the Ambition. “Without much effort, we almost immediately doubled the number of patients to approximately six or eight per day,” says Dr. Junge. “We have only been using the system for three months and we plan to scan more patients in the future. I think our daily capacity can grow to ten or more patients per day.”

Several factors contributed to the purchase of the Ingenia Ambition system. “Excellent image quality and high resolution have always been the most important criteria for us. It has been amazing for us to see the image resolution and consistent quality that we can obtain with Compressed SENSE throughout the body,” Dr. Junge says. “Also the mDIXON images are fantastic, and 3D VANE and other features as well.”

“Our workflow benefits from the fact that our collection of dedicated ExamCards helps us start a pediatric exam quickly and consistently. At the same time the scanner allows us to modify the parameters and sequences when we discover during the exam that a clinical question requires that. For patient satisfaction, the most impressive feature is the experience in the bore. That’s absolutely the highlight of the machine.”

Dr. Junge also commented on the fully sealed magnet which contains only seven liters of helium. “No helium can escape from the magnet, so no refills are needed, which represents a nice cost saving,” says Dr. Junge. The risk of a quench – with its associated disruptions and cost – is also eliminated.

To conclude, Dr. Junge reiterates that the Ingenia Ambition with its unique magnet technology provides excellent scanning features as well as patient comfort. “Our young patients are surprised and fascinated by the Ambient room and the in-bore experience, which helps them undergo the examination,” he says. “This is key for successful pediatric examinations. However, most outstanding for me are the many features for obtaining high-end pictures with a 1.5T system.”

“For a good diagnosis, we often need to look at multiple anatomies with several diagnostic possibilities and make adjustments during the scan. This can be challenging, but the Ambition provides us with great features, easy operation and high flexibility for obtaining high quality, comprehensive imaging in our pediatric patient population that covers a wide range of age, size and clinical indications. And besides, from day one, we also scan more patients than with our previous system.”

Left in image below: Perthes disease in left hip. The affected area on the upper circumference of the left hip shows contrast uptake in the dynamic scan (on top). The radial scan (on bottom) nicely depicts the hip area, despite the dark shape in the center that is inherent to the radial way of scanning.

Top right in image below: Leukodystrophy in a teenager

Bottom right in image below: Rostral meningitis and arachnoiditis. Both images are from the same 3D T1-weighted post contrast sequence in a newborn, under treatment.

An extensive set of dedicated pediatric ExamCards was developed in a collaboration with some expert users in Germany and based on the guideline from the European Society for Pediatric Oncology Brain Tumor Imaging Group (Nov 2017) and consensus of 11 German Philips MRI users (March 2019). Some highlights are:

Examples of 3.0T neuro-oncology ExamCards (left) and 1.5T body-oncology ExamCards (right) for a selected age group. The list of sequences from the highlighted ExamCard is shown on the right. These ExamCards are part of the Philips DACH Pediatric Reference Scan Protocols.