1. Volume 69, Issue 11, Pages e435-e444 (November 2014)
Contrast-enhanced magnetic resonance lymphography in the assessment of lower limb lymphoedema 
R.D. White, J.R. Weir-McCall, M.J. Budak, S.A. Waugh, D.A. Munnoch, T.A.P. Sudarshan 
Clinical Radiology 
Volume 69, Issue 11, Pages e435-e444 (November 2014)
DOI: /j.crad
Copyright © 2014 The Royal College of Radiologists Terms and Conditions

2. Figure 1
Coronal MIP reformats from MRL showing (a) normal lymphatic anatomy of the calf. The lateral superficial lymphatic vessel (arrow) parallels the course of the short saphenous vein (partially seen due to a small amount of venous contamination), whereas the medial superficial lymphatic vessel (arrowheads) parallels the course of the long saphenous vein. (b) Normal lymphatic anatomy of the thigh. The medial superficial lymphatic vessel (arrow heads) parallels the course of the great saphenous vein and drains into the superficial inguinal nodes (arrow). Note its slight undulating surface.
Clinical Radiology  , e435-e444DOI: ( /j.crad )
Copyright © 2014 The Royal College of Radiologists Terms and Conditions

3. Figure 2
Axial T1-weighted image showing gross oedema throughout the fat, which is hypertrophied, with thickening of the aponeuroses. In comparison, the muscle compartment returns normal signal and is of the same size as the normal contralateral limb.
Clinical Radiology  , e435-e444DOI: ( /j.crad )
Copyright © 2014 The Royal College of Radiologists Terms and Conditions

4. Figure 3
Venous thrombosis. (a) Axial T1-weighted image showing low signal in the left superficial femoral vein with subcutaneous oedema and aponeurosis thickening. The thigh muscles are also oedematous and hypertrophied compared to the other side. Compare this with the appearances in Fig 2. (b) Contrast-enhanced coronal gradient-echo image showing a thrombosed left superficial femoral vein with a filling defect throughout the visualized segment of the vessel.
Clinical Radiology  , e435-e444DOI: ( /j.crad )
Copyright © 2014 The Royal College of Radiologists Terms and Conditions

5. Figure 4
Coronal MIP reformat from MRL showing dilatation of the medial lymphatic trunks: right 6mm, left 7mm. These stop abruptly in the mid-calf with collaterals subsequently carrying the contrast agent superiorly.
Clinical Radiology  , e435-e444DOI: ( /j.crad )
Copyright © 2014 The Royal College of Radiologists Terms and Conditions

6. Figure 5
Coronal MIP reformats from two separate MRL image showing the beaded appearances of the lymphatic vessels. On the left image there is complete absence of the normal medial and lateral lymphatic trunks; this was similar on the contralateral side (not shown), consistent with a primary lymphoedema. Extensive tortuous collateral formation has formed secondary to this. Characteristic beading is best appreciated in the smaller lymphatic vessels (arrows) with this appearance becoming lost as the vessels dilate and become more ectatic. The figure on the right shows a normal medial lymphatic trunk with the slight undulations seen in lymphatic vessels.
Clinical Radiology  , e435-e444DOI: ( /j.crad )
Copyright © 2014 The Royal College of Radiologists Terms and Conditions

7. Figure 6
Coronal MIP reformats from MRL in a patient with primary lymphoedema. (a) Acquisition at 10 min demonstrates normal filling of the right-sided medial and lateral lymphatic vessels, while on the left only the foot and ankle vessels (arrows) enhance. (b). Acquisition at 35 min shows the right lymphatic vessels to now be almost entirely washed out. There has been further enhancement of the left calf vessels although no well-defined medial or lateral trunk is present and this has still not extended beyond the mid-calf (arrows). Diffuse honeycombing of the left calf is also present (arrowheads).
Clinical Radiology  , e435-e444DOI: ( /j.crad )
Copyright © 2014 The Royal College of Radiologists Terms and Conditions

8. Figure 7
Coronal MIP reformats from MRL in a patient with left leg swelling. In (a) there is normal enhancement of the right inguinal nodes at 15 min (arrows), while no nodes are visible in the left groin. In (b), the left nodes are seen to enhance at 65 min.
Clinical Radiology  , e435-e444DOI: ( /j.crad )
Copyright © 2014 The Royal College of Radiologists Terms and Conditions

9. Figure 8
Patient with primary lymphoedema. (a) On this coronal MIP reformat of the calves, a dense blush of contrast obscures the lateral lymphatic vessels in the mid-calf. (b) The axial unsubtracted images through the area of dermal backflow show the contrast to be confined primarily to the dermal tissues (arrow heads) with a dilated lymphatic running deep to this. (c) This can also be seen on the lymphoscintogram. Despite the dermal back flow, nodal enhancement is visualized at 45 min bilaterally, although the uptake on the right (arrow) is less intense than on the left (arrowhead).
Clinical Radiology  , e435-e444DOI: ( /j.crad )
Copyright © 2014 The Royal College of Radiologists Terms and Conditions

10. Figure 9
In this patient with right leg lymphoedema, the right lateral lymphatic vessel is poorly defined while the medial vessel is mildly dilated. Throughout the soft tissues of the calf there is a diffuse “honeycomb” appearance not seen in the normal left calf. On the left the medial and lateral calf lymphatic vessels are well demonstrated. There was a previous history of right leg trauma with large calf and thigh haematoma consistent with a secondary lymphoedema.
Clinical Radiology  , e435-e444DOI: ( /j.crad )
Copyright © 2014 The Royal College of Radiologists Terms and Conditions

11. Figure 10
Patient with prior radiotherapy to groin nodes. (a) Lymphoscintigraphy, with images from left to right taken at: baseline acquisition following both leg injection, 20 min, 1 h, and a magnification of the thigh at 1 h with markers at the right knee and greater trochanter. These show slow movement of the tracer bilaterally, with the tracer on the left reaching the inguinal nodes whereas the tracer on the right has diffused throughout the soft tissues with intense right ankle dermal back flow. The magnified image confirms lack of significant tracer movement beyond the level of the knee. (b) Coronal MIP reformat from MRL demonstrates tortuous collaterals around the right ankle with dermal backflow in this region.
Clinical Radiology  , e435-e444DOI: ( /j.crad )
Copyright © 2014 The Royal College of Radiologists Terms and Conditions