MRI, Ultrasound and Nuclear Medicine Imaging Dr Dayea Oh OMF Radiologist Dr Dayea Oh OMF Radiologist * **To understand the basic theory of:** * Magnetic Resonance Imaging (MRI) * Ultrasound Imaging / Ultrasonography (US) * Nuclear Medicine Imaging (NMI) * Scintigraphy * Positron Emission Tomography (PET) * Single-Photon Emission Computed Tomography (SPECT) * **To know applications / indications for each of the above advanced imaging modalities** - **To understand the basic theory of:** - Magnetic Resonance Imaging (MRI) - Ultrasound Imaging / Ultrasonography (US) - Nuclear Medicine Imaging (NMI) - Scintigraphy - Positron Emission Tomography (PET) - Single-Photon Emission Computed Tomography (SPECT) - **To know applications / indications for each of the above advanced imaging modalities** **I. Magnetic Resonance Imaging (MRI)** --- **Siemens** Envision Medical Imaging  **I. Magnetic Resonance Imaging (MRI)** Siemens Envision Medical Imaging Clinical photo demonstrating the Magnetic Resonance Imaging (MRI) procedure. A patient is lying supine on the MRI scanner bed with headphones on. A medical professional in a blue uniform stands by the Siemens Envision scanner, appearing to communicate with the patient. Magnetic Resonance Imaging (MRI) - Magnetic field - = “Magnetic” - Radiofrequency waves - = “Resonance” - **NO** ionising radiation - **Soft tissue imaging** - Bore  Magnetic Resonance Imaging (MRI) - Magnetic field - = “Magnetic” - Radiofrequency waves - = “Resonance” - **NO** ionising radiation - **Soft tissue imaging** - Bore Labelled diagram of an MRI scanner cutaway view. The image shows a patient lying on a patient table inside the bore of the scanner. Visible components include the Radio Frequency Coil, Gradient Coils, Magnet, and the main Scanner housing. MRI Scan • Long scanning time • ✅ Claustrophobia • Noisy • Heat in the area being examined • ✅ Ferromagnetic metals  MRI Scan - Long scanning time - ✅ Claustrophobia - Noisy - Heat in the area being examined - ✅ Ferromagnetic metals Clinical photo demonstrating an MRI Scan procedure. A medical professional is assisting a patient lying on the scanner bed, which is being positioned into the bore of a Siemens Envision MRI machine. The image visually supports the text points regarding claustrophobia (the enclosed space) and noise. **Pre-MRI Check** **Pacemaker / Defibrillator (ICD)** **Neurostimulator** **Cochlear Implant** **Stapedectomy (middle ear prosthesis)** **Aneurysm Clip** **Morphine / Insulin Pump** **Glucose Monitor** **Programmable VP Shunt** **Shrapnel** **Retained Metal fragment in eye (eg. from welding / grinding)** <img>MRI machine scan room with empty patient bed <img/>  #### Pre-MRI Check - Pacemaker / Defibrillator (ICD) - Neurostimulator - Cochlear Implant - Stapedectomy (middle ear prosthesis) - Aneurysm Clip - Morphine / Insulin Pump - Glucose Monitor - Programmable VP Shunt - Shrapnel - Retained Metal fragment in eye (eg. from welding / grinding) Clinical photo: An empty MRI scanner room featuring a large magnetic resonance imaging machine on the right and an attached patient bed in the center. The bed is covered with a blue protective sheet. This visual context supports the 'Pre-MRI Check' topic by illustrating the environment where patients with implants or metal fragments must be screened before scanning. MRI – simplified theory Step 1. Magnetisation • STRONG external magnetic field of 1.5T or higher (MRI machine) ▶ 1 T can lift a car! • Hydrogen atoms (in water “H2O” and fat) ▶ Single proton (& 1 electron & zero neutron) ▶ Naturally **spinning** and **wobbling** particles with +ve charge ▶ Charge with motion creates **a magnetic field**  #### Step 1. Magnetisation - STRONG external magnetic field of 1.5T or higher (MRI machine) - 1 T can lift a car! - Hydrogen atoms (in water “H2O” and fat) - Single proton (& 1 electron & zero neutron) - Naturally **spinning** and **wobbling** particles with +ve charge - Charge with motion creates **a magnetic field** Schematic diagram illustrating the MRI magnetization process. It depicts a patient lying inside a U-shaped magnetic field (red and white poles). Blue spheres represent protons within hydrogen atoms, aligned with the Z-axis (B0) indicated by yellow arrows. MRI – simplified theory Magnetisation & z-axis Under external magnetic field (MRI scanner)    #### Magnetisation & z-axis Under external magnetic field (MRI scanner) Labelled diagram: Shows a collection of yellow spheres with blue rings and black arrows pointing in random directions. The label 'No external magnetic field' is positioned above the cluster. Labelled diagram: Shows a grid of yellow spheres with blue rings aligned horizontally. Black arrows point either left or right along parallel horizontal lines representing a magnetic field. The label 'Under external magnetic field (MRI scanner)' is positioned above the grid. Schematic diagram: Depicts a side view of an MRI scanner with a red U-shaped magnet structure enclosing a patient figure lying on a bed. A black arrow labeled 'Z-axis(B₀)' points into the bore of the magnet from the left. Blue dots represent proton spins aligning with the magnetic field inside the scanner. ## MRI – simplified theory Step 2. Resonance; precession, excitation & relaxation * Hydrogen spin & wobble motion = precession * Larmor's equation $\Rightarrow \omega = \gamma B$ * $\omega$ is the **frequency** in MHz, * $\gamma$ is the gyromagnetic ratio in MHz/Tesla, * $B$ is the strength of the magnetic field in Tesla * H protons precess at the rate of **63.87MHz** at 1.5T * Matching radiofrequency (RF) waves create **RESONANCE** * Resonance results in ‘Excitation’ * ‘Relaxation’ releases MR Signals captured by receiver coil * Different body tissues ‘relax’ at different rates * The faster the tissue relaxes, the more the MR signals released in a given time   #### Step 2. Resonance; precession, excitation & relaxation - Hydrogen spin & wobble motion = precession - Larmor's equation $\Rightarrow \omega = \gamma B$ - $\omega$ is the **frequency** in MHz, - $\gamma$ is the gyromagnetic ratio in MHz/Tesla, - $B$ is the strength of the magnetic field in Tesla - H protons precess at the rate of **63.87MHz** at 1.5T - Matching radiofrequency (RF) waves create **RESONANCE** - Resonance results in ‘Excitation’ - ‘Relaxation’ releases MR Signals captured by receiver coil - Different body tissues ‘relax’ at different rates - The faster the tissue relaxes, the more the MR signals released in a given time Labelled diagram showing the concept of precession. It displays a vertical axis labeled 'c' and a horizontal arrow representing an external field. Two sine waves labeled 'RF pulse' point towards red spheres with blue arrows inside them, indicating magnetic moments. Curved dashed lines around the spheres illustrate the wobble motion (precession) induced by the RF pulses. Diagram illustrating the interaction between transmitted and emitted radio waves in an MRI context. It shows a cross-section of a patient lying on a table inside a scanner bore. A zigzag line labeled 'transmitted radio waves' enters from the top left, while another zigzag line labeled 'emitted radio waves' exits towards the top right. An orange arrow at the bottom points to the left, labeled 'magnetic field direction', indicating the orientation of the main magnet. # MRI – simplified theory **Secondary magnetic field IE Gradient** * Distorting / tilting the main magnetic field **to acquire slices from different sections** of **the body** * Different resonance frequencies along the **gradient** * Localisation of different anatomical structures   #### Secondary Magnetic Field (Gradient) - Distorting / tilting the main magnetic field **to acquire slices from different sections** of **the body** - Different resonance frequencies along the **gradient** - Localisation of different anatomical structures Diagram illustrating the gradient effect (Gz) on resonance frequency (f). A yellow silhouette of a human body is shown with a diagonal red line passing through it. The diagram demonstrates how the magnetic field varies across the body to select specific slices. Labelled cutaway diagram of an MRI scanner showing internal components including Radio Frequency Coil, Gradient Coils, Magnet, and Scanner. Labels also identify the Patient lying on the Patient Table inside the Scanner.     Clinical photograph showing a patient lying on the CT scanner table with their head secured in a positioning device. The image demonstrates the setup for a head scan. Clinical photograph showing a medical professional adjusting a leg immobilization device on a patient lying on the CT scanner table. This illustrates the preparation for lower body imaging. Clinical photograph showing a patient positioned on the CT scanner table with a neck support device attached to their head and upper torso. This setup is typical for cervical spine or head imaging procedures. Clinical photograph showing a patient lying on the CT scanner table with an arm immobilization device securing both arms across their chest. This configuration is used for thoracic or abdominal scans to prevent movement artifacts. MRI – simplified theory Step 3. • **MR Signal** received by receiver coil is converted into a digital form and transmitted to computer • The computer processes the data and an image is created  #### Step 3. Signal Acquisition and Processing - **MR Signal** received by receiver coil is converted into a digital form and transmitted to computer - The computer processes the data and an image is created Medical imaging display showing four sagittal MRI scans of a human brain. The images illustrate the anatomy of the cerebrum and cerebellum, consistent with the context of 'MRI simplified theory' presented in the text. # Understanding MRI Signals ### T1 weighted sequence - **(black)**: air, calcium, cortical bone, rapidly flowing blood - **low SI**: fluid, ligaments/muscles/tendons, abdominal organs, cartilage - **intermediate SI**: high-protein tissue (abscess, complex cysts, synovial fluid) - **high SI**: fat, blood, gadolinium (= contrast), melanin, protein ### T2 weighted image - **(black)**: air, calcium, cortical bone, rapidly flowing blood - **low SI**: ligaments, tendons, liver, pancreas, adrenals, cartilage - **intermediate SI**: fat, liver, pancreas, adrenals, muscles, cartilage - **high SI**: fluid, CSF, bladder, bile/gallbladder, kidneys  #### T1 Weighted Sequence - **(black)**: air, calcium, cortical bone, rapidly flowing blood - **low SI**: fluid, ligaments/muscles/tendons, abdominal organs, cartilage - **intermediate SI**: high-protein tissue (abscess, complex cysts, synovial fluid) - **high SI**: fat, blood, gadolinium (= contrast), melanin, protein #### T2 Weighted Image - **(black)**: air, calcium, cortical bone, rapidly flowing blood - **low SI**: ligaments, tendons, liver, pancreas, adrenals, cartilage - **intermediate SI**: fat, liver, pancreas, adrenals, muscles, cartilage - **high SI**: fluid, CSF, bladder, bile/gallbladder, kidneys A composite figure illustrating MRI signal intensities and providing clinical examples. The left section contains two legends: 'T1 weighted sequence' and 'T2 weighted image'. Each legend uses colored circles (black, dark grey, light beige, white) to denote signal intensity levels (low SI, intermediate SI, high SI) and lists corresponding tissues (e.g., air/calcium for black, fluid/CSF for high SI). A red rectangular box highlights the 'high SI' column in both legends. The right section displays two axial brain MRI scans side-by-side: a T1-weighted image on the left showing a hypointense lesion with surrounding edema, and a T2-weighted image on the right showing the same lesion as hyperintense. # MRI Applications in DMFR ## Bullet Points: - **TMJ disorders** - **Tumours and cysts in the head and neck** - Jaw lesions - Salivary gland lesions - Paranasal sinus lesions - **Assessment of IDN** - **Infection / inflammation eg. osteomyelitis** - **Vascular lesions** ## Diagrams: **Mouth Closed** - Glenoid fossa - Disc - Condyle - Bilaminar zone - EAC **Mouth Open** - Articular eminence - A, P (Anterior, Posterior) - ILZ (Interalveolar Ligament Zone - inferred) - Disc MRI scans showing: - **Disc**, **C** (Condyle), **EAC** (External Auditory Canal)    #### Applications - **TMJ disorders** - **Tumours and cysts in the head and neck** - Jaw lesions - Salivary gland lesions - Paranasal sinus lesions - **Assessment of IDN** - **Infection / inflammation eg. osteomyelitis** - **Vascular lesions** #### Diagrams **Mouth Closed** - Glenoid fossa - Disc - Condyle - Bilaminar zone - EAC **Mouth Open** - Articular eminence - A, P (Anterior, Posterior) - ILZ (Interalveolar Ligament Zone - inferred) - Disc MRI scans showing: - **Disc**, **C** (Condyle), **EAC** (External Auditory Canal) Labeled schematic diagram of the temporomandibular joint (TMJ) illustrating anatomical positions in two states. The left panel is titled 'Mouth Closed' and labels the Glenoid fossa, Disc, Condyle, Bilaminar zone, and EAC (External Auditory Canal). The right panel is titled 'Mouth Open' and shows the condyle moving forward to articulate with the Articular eminence, labeling parts A, P, and ILZ. Grayscale MRI scan image showing a sagittal cross-section of the TMJ. Visible structures include the Disc (indicated by an arrow), C (Condyle), and surrounding soft tissue anatomy. Grayscale MRI scan image showing a sagittal cross-section of the TMJ. Visible structures include the Disc (indicated by an arrow), C (Condyle), and EAC (External Auditory Canal).  Clinical photograph demonstrating an ultrasound procedure. A medical professional in a blue scrub top is performing an ultrasound on the patient's arm using a handheld transducer connected to a Siemens ultrasound machine. The monitor displays the resulting sonogram image. # Ultrasound Imaging * **Non-ionising** * Sound waves * Soft tissue imaging * Compact * Inexpensive * Real-time imaging * Technique sensitive   - **Non-ionising** - Sound waves - Soft tissue imaging - Compact - Inexpensive - Real-time imaging - Technique sensitive Clinical photo showing a patient lying supine while a healthcare provider performs an ultrasound scan on the neck area using a handheld transducer. Photo of a portable ultrasound machine with its monitor displaying a real-time grayscale sonogram image. US Explained (V Simply) - Ultrasound (US) = sound wave with high frequency - Diagnostic frequency = 2MHz to 30MHz - Human hearing is 16Hz – 20kHz - Piezoelectric transducer 1. Send US waves into the body 2. Receive reflected waves “echoes” from the body 3. Convert echoes into electric signal 4. Signal sent to computer for image display - US transmission is improved with ultrasound gel “jelly”  Ultrasound (US) = sound wave with high frequency - Diagnostic frequency = 2MHz to 30MHz - Human hearing is 16Hz – 20kHz Piezoelectric transducer: 1. Send US waves into the body 2. Receive reflected waves “echoes” from the body 3. Convert echoes into electric signal 4. Signal sent to computer for image display US transmission is improved with ultrasound gel “jelly” A labelled diagram illustrating the mechanism of ultrasound imaging. It shows a 'Transducer probe Sender/ Reciever' on the left emitting an 'Original wave' (blue arrows) towards a pink circle labeled 'Object'. The wave reflects back as a 'Reflected wave' (pink arrow). Dotted blue lines represent the wave propagation through space. Understanding US Signals **“Echogenecity”** **Echogenicity** | Echogenicity Level | Label | |--------------------|-------------| | Leftmost (light) | hyperechoic | | Light-grey | isoechoic | | Grey | hypoechoic | | Dark grey/black | anechoic | | Tissue/Structure | Classification | |---------------------|----------------| | metal | hyperechoic | | bone | hyperechoic | | soft tissue | isoechoic | | fat | hypoechoic | | air | anechoic |   #### Understanding US Signals “Echogenecity” **Echogenicity** | Echogenicity Level | Label | |--------------------|-------------| | Leftmost (light) | hyperechoic | | Light-grey | isoechoic | | Grey | hypoechoic | | Dark grey/black | anechoic | | Tissue/Structure | Classification | |------------------|----------------| | metal | hyperechoic | | bone | hyperechoic | | soft tissue | isoechoic | | fat | hypoechoic | | air | anechoic | Schematic diagram illustrating the concept of Echogenicity. The top section features a horizontal gradient bar ranging from white to black, with callouts labeling 'hyperechoic' (white), 'isoechoic' (light grey), 'hypoechoic' (dark grey), and 'anechoic' (black). The bottom section maps specific tissues/structures ('metal', 'bone', 'soft tissue', 'fat', 'air') to corresponding positions on this echogenicity scale. Composite ultrasound image panel displaying four distinct examples of echogenicity. From left to right: a bright, reflective circular structure labeled 'ECHOGENTIC'; a dark, shadowed area labeled 'HYPOECHOIC'; a region matching background texture labeled 'ISOECHOIC'; and a completely black void labeled 'ANECHOIC'. ## EUS TERMINOLOGY <table> <tr> <th>'Anechoic' (black)</th> <th>Hypoechoic' (dark)</th> <th>Hyperechoic' (bright)</th> </tr> <tr> <td></td> <td></td> <td></td> </tr> <tr> <td></td> <td></td> <td></td> </tr> <tr> <td>Anything fluid-filled (cyst, blood vessel...)</td> <td>Tumor, lymph node...</td> <td>Fat tissue, stone....</td> </tr> </table>  #### EUS TERMINOLOGY | 'Anechoic' (black) | 'Hypoechoic' (dark) | 'Hyperechoic' (bright) | |----------------------------------------|---------------------|------------------------| | | | | | | | | | Anything fluid-filled (cyst, blood vessel...) | Tumor, lymph node... | Fat tissue, stone.... | A composite medical diagram titled 'EUS TERMINOLOGY' illustrating ultrasound echogenicity. The figure is arranged in a grid of six panels, each demonstrating a specific tissue type or finding. The top row defines the terms: 'Anechoic (black)', 'Hypoechoic (dark)', and 'Hyperechoic (bright)'. The bottom row provides clinical examples for each category: 'Anything fluid-filled (cyst, blood vessel...)' showing a black anechoic structure; 'Tumor, lymph node..' showing a dark hypoechoic mass; and 'Fat tissue, stone....' showing bright hyperechoic structures including one labeled 'STONE'. Labels such as 'SMA', 'CELIAC', and 'G8' are visible on the ultrasound images. # US Applications in DMFR * Salivary gland disease * Soft tissue swelling of the head and neck * Tumours, Cysts, Infection, etc. * Vascular diseases and anomalies of the head and neck * Carotid artery stenosis (blockage or narrowing) * Hematoma (collection of blood in tissues from damaged vessels) * Abnormalities in the blood vessels, lymph node, etc. * Ultrasound-guided procedures * Biopsy (Fine needle aspirational / FNA) * Corticosteroid injection (TM joint) * TMJ Imaging * Real-time imaging (disc-condyle relationship on mouth opening)  - Salivary gland disease - Soft tissue swelling of the head and neck - Tumours, Cysts, Infection, etc. - Vascular diseases and anomalies of the head and neck - Carotid artery stenosis (blockage or narrowing) - Hematoma (collection of blood in tissues from damaged vessels) - Abnormalities in the blood vessels, lymph node, etc. - Ultrasound-guided procedures - Biopsy (Fine needle aspirational / FNA) - Corticosteroid injection (TM joint) - TMJ Imaging - Real-time imaging (disc-condyle relationship on mouth opening) A presentation slide titled 'US Applications in DMFR' listing various clinical uses of ultrasound. The text includes categories such as Salivary gland disease, Soft tissue swelling (Tumours, Cysts, Infection), Vascular diseases (Carotid artery stenosis, Hematoma), Ultrasound-guided procedures (Biopsy/FNA, Corticosteroid injection), and TMJ Imaging (Real-time imaging). III. Nuclear Medicine Imaging (NMI) III. Nuclear Medicine Imaging (NMI) What is Nuclear Medicine Imaging? - Radiology “done inside out” - Radiopharmaceuticals - 99mTc MDP - Technetium99m + Methyl diphosphate - Half life of 6 hrs - “Hot spots” - Three types: - Scintigraphy (2D imaging eg. Bone scan) - Single photon emission computed tomography (SPECT) - Positron emission tomography (PET)   #### What is Nuclear Medicine Imaging? - Radiology “done inside out” - Radiopharmaceuticals - 99mTc MDP - Technetium99m + Methyl diphosphate - Half life of 6 hrs - “Hot spots” - Three types: - Scintigraphy (2D imaging eg. Bone scan) - Single photon emission computed tomography (SPECT) - Positron emission tomography (PET) A bone scan image showing anterior (ANT) and posterior (POST) views of a human skeleton. The image displays 'hot spots' indicating areas of high tracer uptake in the skull, spine, pelvis, and legs. An infographic illustrating the three steps of a bone scan procedure: 1. Radioactive tracer delivered through IV; 2. Wait 2-4 hours for tracer to circulate; 3. Lie still on scanning table while cameras move up and down the body. **SPECT and PET - 3D Nuclear Medicine Imaging** **SPECT** (single photon emission computed tomography) * 3D $\rightarrow$ localisation & estimation of the size & extend of the disease * Single gamma rays * Two receptors **PET** (positron emission tomography) * Like SPECT, but more dimensionally accurate * Paired gamma rays * Multiple receptors     #### SPECT (single photon emission computed tomography) - 3D $\rightarrow$ localisation & estimation of the size & extend of the disease - Single gamma rays - Two receptors #### PET (positron emission tomography) - Like SPECT, but more dimensionally accurate - Paired gamma rays - Multiple receptors Diagram illustrating the PET (Positron Emission Tomography) process. It shows a positron ('sitron') emitting a gamma ray as it travels right, and an electron emitting a gamma ray as it travels left, resulting in two paired gamma rays moving in opposite directions. Diagram illustrating the SPECT (Single Photon Emission Computed Tomography) principle. It depicts a circular array of detectors surrounding a central point where single gamma rays are detected by 'two receptors' to localize the source. Photo showing a patient lying inside a cylindrical scanner labeled 'PET', demonstrating the physical apparatus for Positron Emission Tomography imaging. Photo showing a medical imaging machine with a C-shaped gantry and patient bed, labeled 'SPECT', demonstrating the physical apparatus for Single Photon Emission Computed Tomography imaging.  Medical imaging figure comparing PET, CT, and MRI modalities. The image is arranged in a 2x3 grid showing axial brain slices. Top row: Left (PET) shows a fused metabolic scan with a focal high-intensity uptake (yellow/orange) in the left frontal region; Middle (PET/CT) overlays this on a computed tomography scan showing bone structure; Right (CT) displays the standalone grayscale CT scan. Bottom row: Left (PET) shows a similar metabolic map but with different color distribution; Middle (PET/MRI) fuses the metabolic data onto an MRI background; Right (T2) displays a T2-weighted MRI sequence showing anatomical detail and signal intensity of brain tissue. Nuclear Medicine Imaging in DMFR * Progressive or spontaneous growth of the jaws * Eg. condylar hyperactivity, neoplastic growth * Osteonecrosis of the Jaws * Eg. Medication-related osteonecrosis of the jaws (MRONJ), Osteoradionecrosis of the jaws (ORNJ) * Osteomyelitis * Eg. infectious (secondary) osteomyelitis, primary osteomyelitis * Bone fractures * Bone disorders inc. primary bone tumours * Head and neck cancer $\rightarrow$ **PET** * Eg. oral squamous cell carcinoma (OSCC), lymphoma #### Nuclear Medicine Imaging in DMFR - Progressive or spontaneous growth of the jaws - Eg. condylar hyperactivity, neoplastic growth - Osteonecrosis of the Jaws - Eg. Medication-related osteonecrosis of the jaws (MRONJ), Osteoradionecrosis of the jaws (ORNJ) - Osteomyelitis - Eg. infectious (secondary) osteomyelitis, primary osteomyelitis - Bone fractures - Bone disorders inc. primary bone tumours - Head and neck cancer $\rightarrow$ **PET** - Eg. oral squamous cell carcinoma (OSCC), lymphoma # Further Reading - Whaites E, Drage N. Essentials of Dental Radiography and Radiology, 5th edn. Edinburgh: Churchill Livingstone, 2013. - Lam E, Mallya S. White and Pharoah's Oral Radiology: Principles and Interpretation. 8th edn. St. Louis: Elsevier, 2018.   Book cover image of 'Essentials of Dental Radiography and Radiology' by Whaites E, Drage N., 5th edition. The cover features a white background with black text listing the title, authors, publisher (Churchill Livingstone), and publication year (2013). Book cover image of 'White and Pharoah's Oral Radiology: Principles and Interpretation' by Lam E, Mallya S., 8th edition. The cover features a white background with black text listing the title, authors, publisher (Elsevier), and publication year (2018). 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