2 JASLOK HOSPITAL AND RESEARCH CENTRE, DR. SONAL GARGJASLOK HOSPITAL AND RESEARCH CENTRE,MUMBAI
3 MRI evaluation of Pelvic floor disorders Urinary and anal incontinence affects a large proportion of the female populationMRI is now the modality of choice for preop planning of pelvic floor repairsSuperior soft tissue evaluation of viscera, pelvic musculature and fascial investmentsGuides detailed evaluation of repair in cases that do not resolve with conservative Rx.MRI has led to a breakthrough in the evaluation of pelvic floor disorders. It accurately identifies the prolapsing organ and unsuspected defects in pelvic floor support.
4 Normal position of the bladder base, vaginal vault and ano- rectal junction at rest Normal position of the bladder base, vaginal vault and ano- rectal junction with Valsalva
5 ANAL SPHINCTER INJURIES Internal and External Sphincter trauma seen in obstetric injuries leads to fecal incontinence.Pelvic floor denervation secondary to vaginal delivery may lead to perineal descent and posterior compartment deficits.
6 MRI of the ANAL SPHINCTERS Recent advances in MRI technologies using the endoanal coil, rapid sequencing, and cinematic display have enabled dynamic defecography.Used to evaluate both muscular and connective tissue supports of the pelvis.Muscular defects along with POP and perineal descent can be assessed.
7 At rest, the bladder base and Cervix is normal. The anal sphincter is open with an abnormally low placed anorectal junctionThe evacuation phase shows a large descending cystocele and Severe descending perineal syndrome
8 Dynamic MRI in Stress Urinary Incontinence Used to asses the functional and anatomic changes that occur during stress incontinenceDynamic MRI guides management options- response with pessary or need for surgery
9 Dynamic MRI A- MRI without pessary B- MRI with pessary (line represents the pubococcygeal line)
10 Fast MRI with and without pessary while performing Valsalva A- Valsalva with pessaryB- Valsalva without pessary(line represents posterior urethro-vesical angle)
11 FETAL MRI- A Developing technique for the Developing patient
12 What does it provide?Offers complete evaluation of the fetus even in difficult situations like oligohydramnios, maternal obesity, limitations of fetal position etc.Overcomes the problems of Calvarial and bone calcification which may obscure detail.Gives more information to guide management and counselling when an abnormality is detected on ultrasound
13 FETAL MRI- Advantages Excellent spatial soft tissue resolution Large field of view-Detailed evaluation of fetal and extra-fetal structures.Three dimensional information with multiplanar imaging.Established safety in second trimesterLimitations of fetal movement has been overcome by using HASTE sequencesFast due to use of HASTE sequences. Maternal or fetal sedation not required
18 FETAL MRI- Applications Central nervous system and spine pathologies:Evaluation of ColpocephalyAgenesis of the Corpus CallosumPosterior fossa anomalies- is there Dandy Walker malformation?Intra-axial and extra-axial mass lesions and fluid collectionsDestructive brain lesions and haemorrhageSpinal dysraphism- delineates the extent and levelSacrococcygeal teratoma- Intrapelvic and abdominal extent of tumor, mass effect on adjacent organsCaudal- low sacral NTD maybe missed on ultrasoundMR imaging plays a critical role in characterizing the contents of the herniated sac and assessing the intracranial anatomy, findings that have a critical role in diagnosis, counseling, management, and prognosis..In cases of encephalocele, MR imaging can show the underlying brain to appear normal (see Fig. 18A) or abnormal (see Fig. 18B). In some cases, because of fetal position, the encephalocele itself may be difficult to visualize with ultrasound, but is better seen with MR imaging (see Fig. 18C). The additional information provided by MR imaging can help identify cases with more favorable prognosis and cases with poor prognosis. Even when ultrasound shows the findings well, MR imaging is helpful for the patients and the neurologists counseling the patients in terms of better visualizing and understanding the anomalies present.
25 CASE 3- PRECIOUS PREGNANCY WITH SUSPECTED ARNOLD CHIARI MALFORMATION
26 FETAL MRI- Applications Intrathoracic lesions:CCAM- cystic nature, differentiates it from Congenital diaphragmatic hrenia containing bowel loopsPulmonary sequestrationCongenital diaphragmatic hernia- extent, severity scores such as lung volumetry
27 FETAL MRI- The future Diffusion tensor imaging and Perfusion studies: Extremely sensitive and specific sequences to detect cerebral ischemiaCan determine the onset of ischemia and detailed extent of neural damage for prognosis and guiding management
28 MRI guided High Intensity Focused Ultrasound- The New Kid on the Block
29 What is HIFU? Thermal ablation technique Sound waves focused to deliver heatResults in tissue necrosis and cell deathDuring the procedure you lie on your stomach on a patient table that fits into a standard MRI scanner. First, the doctor identifies the fibroid(s) on MR images taken of your pelvic region. Then, after detailed planning, high energy focused ultrasound waves heat a small spot in the uterine fibroid to a temperature of up to 85oC. During the pulse or sonication, which lasts about 15 seconds, the doctor monitors the progress and reviews temperature-sensitive images. Since each sonication treats a very small volume, this process will be repeated until the required volume is treated, typically about 50 times. The procedure lasts about 3 hours depending upon the size and number of fibroids treated. Following the treatment the body gradually removes the treated tissue over a period of months, providing symptom relief.
32 What does the MR guidance provide? 3D multiplanar imaging of the fibroidClearly identifies the position and extent of the fibroid, what portion has to be treatedProvides real time information about temperature changes of the treated fibroid to ensure ablation.Clear visualization of the fibroid
33 MrgFUS- What are the advantages? Non-invasive, does not require hospital stayUterus conservingOffers good symptom relief and excellent quality of life
34 MrgFUS- Inclusion Criteria Women between 18 and 59 yearsWeight less than 140 kgUterine size less than 24 weeksSymptomatic fibroids- bleeding, pressure, pain, urinary symptoms etc.
35 MrgFUS- Exclusion Criteria Extensive scarring along the lower abdominal wall or surgical clips in the direct path of the beam.Not yet approved for women seeking fertilityPregnant patients