Tools
Appropriate Magnetic Resonance Imaging Ordering
Introduction
Magnetic resonance imaging (MRI) is a noninvasive diagnostic technique for visualizing organs and soft tissue structures.[1] Historically, its ability to assess structural integrity made it valuable for imaging the neural axis and large joints of the musculoskeletal system. The scope of MRI applications has since expanded to include abdominal, pelvic, and cardiac imaging.
Clinicians commonly order an MRI to characterize brain, soft tissue, and osseous lesions. Specific MRI sequences can provide additional information, such as magnetic resonance elastography, which assists in diagnosing and monitoring hepatic fibrosis, potentially reducing the need for invasive biopsies. Using contrast-enhanced and noncontrast methods, magnetic resonance angiography facilitates the diagnosis of vascular occlusive disease and stenosis. Advances in scan times and gating techniques that reduce cardiac and respiratory motion further support the use of MRI as a useful noninvasive tool for evaluating cardiac structure, function, and myocardial perfusion.[2][3]
MRI offers the advantage of high-resolution images with superior soft-tissue contrast. Images are generated based on the unique magnetic properties of tissues, driven by the spin characteristics of water molecules exposed to magnetic fields of varying strengths.[4] When the field strengths are rapidly pulsed, the alignment of water molecules changes, releasing electromagnetic signals that are detected to form an image. Because this signal is relatively weak, longer acquisition times are required than for radiographs.
Magnetic resonance imaging visualizes water within tissues without the use of potentially harmful ionizing radiation. This feature makes MRI especially useful to evaluate patients at risk from radiation exposure, including pregnant women, young children, and individuals with chronic conditions requiring routine imaging surveillance, such as multiple sclerosis and inflammatory bowel disease.[5]
MRI carries inherent safety risks because the strong magnetic fields can interact with ferromagnetic objects and implanted devices. To mitigate these risks, strict screening parameters are employed to ensure patient safety, including assessments of occupational exposures and surgical implants. However, many new-generation implanted devices are MR-compatible; consultation with the radiologist and technologist is essential before ordering imaging. The magnetic field can affect implanted devices, resulting in loss of function, incorrect positioning, and temperature changes. Additionally, while prosthetic devices such as heart valves, stents, and artificial joints are generally safe in MRI, they may generate signal artifacts that reduce the diagnostic accuracy.[6]
Function
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Function
Traditionally, MRI served as an adjunctive imaging examination following initial evaluation with more accessible and cost-effective modalities, such as radiography, ultrasonography, or computed tomography (CT). The goal of ordering an MRI is to characterize a finding using the specific magnetic properties of tissues and, less commonly, to guide a biopsy. A detailed clinical history is essential when ordering an MRI to ensure the acquisition of appropriate sequences.
Neurologic: The central nervous system is enclosed by dense bone; therefore, CT and MRI are the primary modalities available for evaluation. MRI offers superior spatial and contrast resolution compared with CT, making it the preferred option for detailed evaluation of neurologic structures. While CT remains the first choice due to its rapid image acquisition and availability, noncontrast MRI is also effective in identifying hyperacute ischemic strokes. Diffusion-weighted sequences can detect ischemia based on the diffusion coefficient of water in the brain parenchyma and can demonstrate areas of hyperacute ischemia within the first 6 hours after onset.[7][8] Further perfusion imaging can estimate the extent of the infarct.
Time-of-flight MR angiography is a multidimensional (2-dimensional or 3-dimensional) technique that maps arteries while suppressing the imaging of bony structures and brain parenchyma.[9] The examination is noncontrast and uses flow-related properties during image acquisition.[9] Similarly, the dural venous sinuses can be evaluated with MR venography. These MRI examinations offer alternatives to CT angiography, requiring iodinated contrast. MRI with contrast is preferred for assessing patients with seizures, demyelinating diseases, inflammatory diseases, and suspected neoplasms because it highlights areas of disrupted blood-brain barrier integrity.[10]
Advanced MRI sequences include MR spectroscopy, which identifies tissue metabolites, and functional MRI, which maps critical brain regions, aiding in the characterization and surgical planning for brain tumor cases.[11][12] MRI of the spine is frequently ordered to evaluate neck and low back pain with red flags, as well as trauma, infection, or tumors.[13] CT remains the primary imaging modality for evaluating osseous structures, including the paranasal sinuses and temporal bones, while MRI provides superior soft-tissue contrast for the orbits, sinuses, oral and nasal cavities, and the pharynx.[14]
Breast MRI
Breast MRI is highly sensitive for detecting breast malignancies, but its specificity varies.[15] Breast cancer screening with MRI is indicated in patients with a high risk, defined as patients with the BRCA gene mutation, patients with first-degree relatives with breast cancer, and those with a greater than 20% lifetime risk, in addition to those with a history of radiation to the chest.[16] Dynamic contrast-enhanced breast MRI is used in conjunction with screening mammography in patients at high risk.[17][18] Dynamic contrast-enhanced breast MRI features correspond well with the degree of angiogenesis of invasive breast cancer.[17][18]
Breast MRI requires a specialized breast coil, a large field of view, and standardized sequences. The patient must be informed that the examination is performed in the prone position with the arms extended overhead. Dynamic contrast-enhanced breast MRI is an essential tool to evaluate the extent of breast disease, therapy response, and surveillance of residual or recurrent disease.[16][17] Under the care and direction of a breast imaging specialist, some patients undergo MR-guided biopsy of mammographic or sonographic occult masses. For evaluation of silicone breast implant integrity and localization of free silicone, a noncontrast MRI of the breasts is performed. Breast imaging departments typically have standard protocols for obtaining limited imaging sequences.
Chest and Cardiac MRI
Cardiac MRI provides structural and functional information, but requires patient cooperation with breathholding over approximately 45 minutes.[19] Noncontrast techniques are emerging, but current cardiac MR protocols typically include intravenous contrast agents; patterns of late gadolinium enhancement are critical to identifying scarred tissue.[20] Tissue characterization using extracellular volume fraction and T1 mapping has improved the evaluation of infiltrative cardiomyopathies, often negating the need for invasive endomyocardial biopsies.
Stress cardiac MRI can evaluate ischemia and myocardial viability.[21] MRI with intravenous contrast agents and a customized field of view are appropriate for evaluating chest wall abnormalities that have been definitively diagnosed with other modalities. MRI technologists mark the area of concern with an MRI-visible vitamin E capsule. While contrast-enhanced MRI can characterize mediastinal masses, results from a literature review report that MRI is superior to CT for preoperative planning of posterior mediastinal masses.[22]
Abdominal and Pelvic MRI
Multiphase, postcontrast sequences, and routine noncontrast sequences help characterize abdominal and pelvic lesions and monitor response to therapy. MRI usually follows more cost-effective and widely available initial imaging, such as ultrasound or CT.
- Radiologists can differentiate between a benign and a malignant liver lesion with a high degree of certainty on MRI using T1- and T2-weighted, postcontrast, and diffusion-weighted sequences.[23] Study results indicate that MRI with contrast is superior to ultrasound in diagnosing hepatocellular carcinoma in high-risk populations, resulting in higher detection rates and fewer false positives.[24] MRI can also detect and quantify liver iron and fat deposition and evaluate the degree of fibrosis using MR elastography.[25]
- Pancreaticobiliary diseases, such as biliary duct stones and malignancies, can be evaluated with excellent resolution using the MR cholangiopancreaticography. Extremely fluid-sensitive, this type of MRI evaluates the fluid within these ducts, helping to assess intraluminal pathologies and changes in caliber.[26]
- Multiparametric prostate MRI detects and localizes lesions in patients at risk for prostate cancer. Lesions are given a Prostate Imaging Reporting and Data System (PI-RADS) score based on malignant characteristics. PIRADS 1 and 2 lesions are considered benign, PIRADS 3 is equivocal, and PIRADS 4 and 5 are considered suspicious for prostate cancer.[27] While the prostate-specific antigen level is the primary screening test for prostate cancer, an MRI can provide a target for fusion-guided biopsies to ensure that the most highly suspicious lesions are biopsied. MRI can also be used in addition to serial prostate-specific antigen testing for active surveillance of premalignant lesions or low-grade malignancies. Please see StatPearls' companion resources, "Prostate Cancer Screening", "Prostate Cancer," and "Prostate-Specific Antigen," for more information.
- Renal cysts and masses are commonly detected on CT and ultrasound evaluations of the kidneys. Please see StatPearls' companion resources, "Renal Cystic Disease" and "Simple Renal Cyst," for more information. These lesions can be characterized with a high degree of accuracy for benign or malignant characteristics with MRI. MRI also helps characterize and differentiate the type of renal neoplasm, which can indicate relative aggressiveness and guide further management.[28][29]
- Results from a small study of 81 women with sonographically indeterminate pelvic masses showed that even a limited sequence MR could differentiate between uterine and extrauterine origins of a mass, thereby determining and guiding clinical management.[30]
- MRI plays a critical role in diagnosis, staging, treatment, surgical planning, and surveillance of rectal cancer.[31] MRI is also helpful in the evaluation of penile trauma, carcinoma of the penis, scrotal lesions, and testicular neoplasms, although scrotal ultrasound is the recommended primary imaging modality.[32][33][34][35] MRI examinations are not recommended for cases of possible testicular torsion, because the diagnosis is generally made clinically. Scrotal ultrasonography is more readily available and can be obtained more quickly, minimizing delays in taking the patient to the operating room for exploration. Please see StatPearls' companion resource, "Testicular Torsion," for more information.[36]
- In pregnant individuals, MRI can be performed to detect appendicitis, assess for potential placental invasion into adjacent organs, and demonstrate fetal abnormalities if not characterized on ultrasound.[37][38]
- The radiologist may recommend a follow-up MRI in the appropriate clinical settings.
Musculoskeletal MRI
Radiographs are the primary imaging modality for musculoskeletal structures and significantly contribute to interpreting MRI results. Results from several studies report that MRI is more useful and impacts management when ordered by an experienced clinician or orthopedic specialist.[39][40] Magnetic resonance imaging provides an excellent assessment of the structural integrity of the major peripheral joint support structures, including tendons and ligaments, and any associated inflammatory changes. This evaluation helps guide prognostication and surgical planning. MRI helps differentiate between acute and chronic injuries in sports-related injuries, which can affect management decisions.[41]
While radiographs and CT scans are particularly effective at detecting fractures, MRI is the imaging modality for detecting occult or stress fractures.[42] The presence of such fractures in bones prone to nonunion, such as the navicular bone and femoral neck, helps guide treatment towards immediate intervention.[41] MRI can also help evaluate joint conditions, including infectious, degenerative, and inflammatory causes.[43] MRI effectively identifies cartilage damage, a common feature of early degenerative joint diseases.[44]
MRI and radiographs are also helpful in characterizing bone tumors. MRI examinations can also help in local staging and for follow-up studies. Bone marrow evaluation to detect edema and infiltrative processes can also be performed using MRI, but it is not the standard of care.[45] With the increasing number of joint replacements performed annually in the United States, the issue of paramagnetic joint implants compromising MRI image quality remains a concern. This issue can be overcome by using various imaging techniques to reduce the metallic susceptibility artifacts.[46][47]
Pediatric MRI
MRI has longer acquisition times and requires patients to remain still, which can be challenging for infants and young children. Therefore, MRI should be reserved for cases with insufficient other modalities, with tailored protocols. Pediatric examinations are performed under general anesthesia, which adds another layer of complexity and potential adverse effects.[48] The American College of Radiology has developed guidelines for specific medical conditions, which can be accessed on its website.
Issues of Concern
Issues of concern regarding MRI revolve around the use of nonionizing radiation in vulnerable populations, the safety of contrast agents, and logistical considerations for patients. When ordering an MRI, clinicians should evaluate the clinical question, psychological factors, and examination duration, weighing the risks and benefits.
- Adverse effects of gadolinium-based contrast agents include allergic reactions, nephrogenic systemic fibrosis, and gadolinium deposition.[49] Among these, nephrogenic systemic fibrosis has been particularly interesting since the United States Food and Drug Administration issued a box warning in 2007 for use in patients with decreased renal function (glomerular filtration rate <30 mL/min/1.73 m2). Allergic reactions occur in 0.1% to 0.4% of patients, compared with 0.7% for iodinated contrast agents used in CT scans.[50][51][52]
- The risk of nephrogenic systemic fibrosis for group I and II gadolinium contrast agents is 1.5 per million and 0.008 per million, respectively.
- Per American College of Radiology guidelines, use of group II gadolinium agents (including gadobutrol, gadobenate dimeglumine, gadoteridol, and gadoteric acid) should not be deferred even in the case of renal failure when there is no other diagnostic alternative. [ACR Manual on Contrast Media 2025 ACR Committee on Drugs and Contrast Media, https://edge.sitecorecloud.io/americancoldf5f-acrorgf92a-productioncb02-3650/media/ACR/Files/Clinical/Contrast-Manual/ACR-Manual-on-Contrast-Media.pdf].[38]
- No deleterious effects have been documented from MRI during pregnancy. Therefore, a medically indicated noncontrast MRI can be performed during any trimester. [ACR manual on MR safety. Available at: https://www.acr.org/-/media/ACR/Files/Radiology-Safety/MR-Safety/Manual-on-MR-Safety.pdf] The effect of gadolinium contrast on pregnancy is largely unknown; it should be avoided.[34] Because gadolinium contrast is excreted rapidly, nursing mothers can resume breastfeeding immediately. However, if the mother remains concerned, she can withhold breastfeeding for 12 to 24 hours or express milk before the examination.
- Common patient concerns regarding MRI imaging are claustrophobia and anxiety during the examination. Anxiety attacks occur in as many as 2% of patients undergoing MRIs, with approximately 1% terminating the study early.[4] Techniques for dealing with severe patient anxiety include the following:
- Warm blankets.
- Anxiolytic medications such as benzodiazepines.
- Calming music.
- Panic buttons.
- Relaxation techniques such as grounding, meditation, and deep breathing exercises.
- A supportive companion to help with anxiety.
- An open MRI machine or alternative imaging technique.
- Video preparation and education.[53]
- Proximity to the strong magnetic field poses a potential risk to the patient, and strict stepwise measures ensure that ferromagnetic materials do not enter specific zones surrounding the superconducting magnet. All patients are screened before MR imaging, but special attention should be paid to those with known exposure to sharpnel, bullets, or other metal fragments. Implanted medical devices are susceptible to the magnetic field, resulting in altered function, hardware repositioning, and possible temperature changes.
- Many implanted devices, such as prosthetic heart valves, stents, and artificial joints, are safe for MRI but cause imaging artifacts.[6] Therefore, it is important to consult with the radiologist and MR technologist, who can confirm device compatibility.
Clinical Significance
With its excellent soft-tissue resolution and multiplanar imaging capabilities, MRI has significantly improved patient care by serving as a problem-solving tool in modern medicine. The ability to detect subtle findings early, such as stroke on diffusion-weighted imaging, early metastatic disease, and osteomyelitis in the bone marrow, often guides timely intervention. In addition to diagnosis, MRI is integral to the follow-up of chronic conditions such as multiple sclerosis and inflammatory bowel disease, with the added advantage of avoiding ionizing radiation. The characterization of multiple neoplasms often reduces the need for biopsy and its associated risks, as in liver and brain tumors. However, limitations include greater cost, limited availability, and longer acquisition times.
In summary, the judicious use of MRI by ordering clinicians is crucial for achieving positive patient outcomes, facilitating timely diagnoses, and moderating healthcare costs.
Enhancing Healthcare Team Outcomes
With the continued rise of healthcare costs, increased wait times, and limited resources, judicious ordering of MRI is essential for patient-centered care. Ordering clinicians must integrate clinical findings with established imaging guidelines, such as the American College of Radiology Appropriateness Criteria, to determine the need for an MRI. Evaluating the pretest probability and considering other, more easily accessible imaging modalities before ordering an MRI is crucial. The use of the electronic medical record to search for prior imaging examinations has been shown to reduce the need for further imaging.[54][55]
Nurses play a crucial role in the prescan screening for implanted devices and a prior history of reaction to contrast agents. Radiologists should develop the protocol and tailor the study to address the clinical question. In uncertain situations, proactive consultation with radiologists helps reduce redundancy and optimizes the use of imaging.
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