Pediatr Radiol (1989) 20:10-19
Radiology
Abdominal magnetic resonance imaging
T. M. Harris and M. D. Cohen
Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA
Abstract. A review of the first five years of experi-
ence with pediatric abdominal Magnetic Resonance
Imaging (MR) is presented. The abdomen is exam-
ined organ by organ with description of normal anat-
omy and pathological processes. Practical clinical
uses of MR are indicated. There is a brief review of
motion artifact supression techniques.
There has been nearly five years of experience with
Magnetic Resonance Imaging (MRI) in the pediatric
population. Comparison of MRI with other imaging
modalities has been made in nearly all organ sys-
tems. Advantages of MRI which have been pro-
posed include lack of ionizing radiation, superior
blood vessel visualization without intravenous con-
trast, improved contrast resolution and multiplanar
imaging. This review attempts to summarize the im-
pact of MRI on abdominal imaging in pediatric pa-
tients.
Pediatric
9 Springer-Verlag 1989
Liver
Vasculature and biliary tree
The normal hepatic vasculature is well seen on MR
without the use of IV contrast. The transverse plane
has been shown to be the most valuable for evalu-
ation of the liver vasculature with greater than 90%
visualization of the IVC; right, middle, and left he-
patic veins; and fight and left portal w~ins [1]. In the
pre-operative evaluation for liver transplantation,
MR can be a useful complementary procedure to
ultrasound in characterizing the portal vein [2]. The
size, position, and patency of the portal vein can be
successfully evaluated prior to transplantation. MRI
can identify cavernomatous transformation of the
portal vein as serpentine vascular structures in the
porta hepatis [3]. Normal bile ducts are poorly visu-
alized with MR but dilated ducts can be seen. Di-
lated ducts are best seen with a combination of both
T1 and T2 weighted SE sequences demonstrating de-
Fig. I a and b. Diagnosis:Choledochal
cyst. a Ultrasound in the sagittal plane
demonstrates dilated common hepatic
duct and common bile duct (arrows). Liver
(L). b SE 30/500. A rounded area of low
signal intensity consistent with bile (B) is
seen below the portal vein (arrows) con-
firming the presence of dilated extraheptic
biliary tree. Aorta (A), Infi~rior Vena Cava
(I)
T_ M. Harris and M. D. Cohen: Abdominal MRI
creased signal compared to surrounding liver on T1
weighted images and increased signal on T2 [4]. All
dilated segments of the intra and extrahepatic bil-
iary tree are well visualized. However, ultrasound
and computed tomography remain the proven non-
11
Fig.2a-e. Diagnosis:Hepatoblasto-
ma. a SE 30/900 and
b SE 20/1500 Axial and coronal im-
ages demonstrate a large homo-
geneous mass (arrows) arising fi'om
the inferior aspect of the liver with
splaying of hepatic vessels (curved
arrow) around the margin of the
mass. Normal, displaced right kid-
ney (K) was clearly identified in
both planes excluding a renal
origin of the mass. c SE 90/1500
T2 weighted image demonstrates
patchy increased signal in the mass
Fig.3a and b. Diagnosis:Neuro-
blastoma with liver metastases.
a and b SE 60/2000 Images show
a left adrenal mass (arrow) with
mixed signal intensity. The liver (L)
has abnormally increased signal
with a diffusely nodular appearance
Fig.4a-c. Diagnosis:Neuroblasto-
ma with extensive liver metastases
in newborn patient, a CT scan with
intravenous contrast demonstrates
massive hepatomegaly (L) with
slightly inhomogeneous texture but
without demonstration of focal le-
sions. In retrospect there is also a
low density lesion without calcifica-
tion in the right adrenal region
(arrow). Stomach (S), Spleen (sp).
b SE 16/550 The liver (L) shows ab-
normally decreased signal com-
pared to spleen (sp) on T1
weighted image indicating a diffuse
process, e SE 80/2000 T2 weighted
image shows markedly abnormal
increased 1"2 signal from liver with
stretching and distortion of vessels
(low signal) much better appreci-
ated than on CT. This finding ~s
consistent with metastatic disease.
Primary tumor was poorly seen
with MR
invasive methods for evaluation of the biliary tree. A
choledochal cyst has been identified with M R as a
mass with characteristics similar to bile (Fig. 1) [5].
However US and nuclear medicine DISIDA studies
are usually adequate for evaluation.
12
Fig.Sa-c. Diagnosis: Cavernous hemangioma, aStrongly T1
weighted image demonstrates well marginated round homogene-
ous areas (H) of low signal intensity in the right lobe of the liver (L).
Stomach (S). bSE30/500 Less T~ weighting makes lesion/liver
FJg.6a-e. Diagnosia: Hemangioendothelioma, a CT with in-
travenous contrast demonstrates large low density liver lesion (H)
with enhancing periphery characteristic of this tumor.
b SE 30/500 and c SE60/1000. A large liver mass is demon-
Tumors
Malignant and benign mass lesions of the pediatric
liver have been evaluated. In general, tumors have
demonstrated T-1 and 3"-2 values longer than normal
liver resulting in hypointense areas on T1 weighted
images and hyperintense lesions on T-2. Lesions
have been more conspicuous on T-2 weighted im-
ages.
Hepatoblastoma (Fig.2), hemangioendothelio-
ma, cystic hamartoma, and numerous metastatic tu-
mors (neuroblastoma (Fig.3), islet cell, Hodgkins
lymphoma) have been imaged and have shown the
above characteristics [6]. Recently at our institution
MR was helpful in characterizing massive hepato-
megally in a neonatal patient. CT showed diffuse
liver enlargement. MR revealed a diffusely nodular
liver with abnormally increased T2 signal consistent
with metastatic disease (Fig.4). Cavernous heman-
gioma, a common liver tumor, has a specific MR ap-
pearance and can be distinguished from liver metas-
tases even though both lesions have prolonged T1
and T2 relaxation times (Fig.5). On strongly T2
weighted images cavernous hemangiomas are ovoid
T.M.Harris and M.D.Cohen: Abdominal MRI
contrast less, but abnormality is still clearly evident (arrow).
c SE 60/2000 T2 weighted image shows characteristic appearance
of cavernous hemartgioma with well defined margins and marked
homogeneous increased signal intensity. Stomach 48),Spleen (sp)
strated with a central area of decreased signal on T1 weighting
which becomes hyperintense on longer TR image. Note the mark-
edly enlarged hepatic artery (arrows) sweeping around the lesion
- a characteristic of hemangioendothelioma in our experience
or spherical with hyperintense homogeneous signal
opposed to metastatic lesions which typically have
less well defined borders and are heterogeneous in
signal. These features in conjunction with higher
contrast/noise ratios in hemangiomas can result in
differentiation of these tumors from metastases with
a 90% accuracy [7]. Although calculated T1 and T2
values have been shown to be of little value in distin-
guishing various liver tumors [8], certain characteris-
tics may be of use in distinguishing between tumor
types. Ferrucci has reported that 25% of metastatic
deposits demonstrate a bright peripheral halo sur-
rounding an isointense or low intensity nodule on T2
weighted images [9]. This finding was not observed
in benign lesions. Histologically, focal nodular
hyperplasia of the liver demonstrates a stellate scar
and this feature has been seen with MR [10]. The fi-
brous pseudocapsnle of hepatoma has a characteris-
tic low intensity peripheral rim on "1"1weighted im-
ages [11]. In our experience, the markedly enlarged
hepatic artery seen feeding an hemangioendothelio-
ma is a characteristic finding of this disease (Fig. 6).
There has been interest in the ability of MR to de-
tect liver metastases [12, 13]. Recent work using a
T. M. Harris and M. D. Cohen: Abdominal MRI
Fig.7a und b. Diagnosis: Hemochromatosis. a SE 30/500 and
b SE 60/2000. Note the homogeneous abnormally decreased sig-
nal from liver (L) on T2 weighted image. Spleen (S)
0.6 T magnet has shown that T1 weighted spin-echo
(SE) imaging (with extensive signal averaging to de-
crease motion artifact) is superior to T2 weighted im-
aging in detection of hepatic metastases. Further
work at this field strength has determined that T1
weighted SE and inversion recovery (IR) sequences
are superior to contrast enhanced computed tomog-
raphy for overall detection of individual metastases.
However, other workers have found that at a field
strength of 1.5 T, there is better focal liver lesion de-
tection with T2 and proton density weighted sequen-
ces (with respiratory compensation) than with T1
weighted images (with signal averaging) [14].
Diffuse processes
Fatty infiltration of the liver has been investigated in
adult patients by proton spectroscopic imaging with
encouraging results. Using a modified SE technique,
"opposed" images can be generated which will dif-
ferentiate fatty infiltration (decreased signal) from
normal liver [15, 16]. Transfusional hemosiderosis
(Fig. 7) has been investigated in children using a SE
technique. Liver and bone marrow demonstrate ab-
normally decreased signal. This is thought to be due
to deposition of paramagnetic hemosiderin in liver
and bone marrow [17]. Estimates of iron content in
liver can be made by MR but cannot yet compete
with the precision of dual-energy CT [18].
Contrast agents
Intravenous MR contrast agents gadolinium-DTPA
and ferrite particles have been studied in liver im-
aging. Contrast agents are used in order to increase
conspicuity of lesions and possibly decrease scan
time. In general, agents decrease both T1 and T2 re-
laxation times. Following intravenous administra-
tion, gd-DTPA is initially distributed in the intravas-
13
cular compartment and then diffuses into the ex-
travascular spaces in both normal and abnormal tis-
sues. Rapid imaging after administration of contrast
with short T E / T R sequences has been necessary in
order to preserve contrast between normal liver and
lesions. Otherwise, delayed diffusion of gd-DTPA
into abnormal tissue results in loss of contrast be-
tween liver and lesion [9]. Ferrite particles are a
promising new agent for liver imaging [19]. The par-
ticles are phagocytized by the reticuloendothelial
system (RES) in liver, spleen and bone marrow. The
presence of ferrite markedly decreases T2 relaxation
times of these tissues resulting in decreased signal on
T2 weighted images. Tissues not containing RES ele-
ments, e.g. metastatic tumor nodules, are unaffected
and continue to produce signal. In animal models,
ferrite has been effective in increasing signal dif-
ferences between normal liver and tumor [20].
At the present time liver MR appears to be most
useful in answering questions concerning vascular
anatomy and in tumor detection. Various character-
istics of focal lesions can be useful in determining the
exact pathology.
Kidneys and adrenal glands
There has been extensive evaluation of the kidneys
with MR. Renal margins can clearly be seen and
renal cortex and medulla differentiated. The ability
of MR to image in multiple planes, particularly coro-
nal, is useful in differentiating renal from extrarenal
processes and demonstrating associated vasculature
(Fig.S).
Congenital anomalies and hereditary disorders
MR is capable of demonstrating congenital renal
anomalies, cystic diseases, and hydronephrosis.
However little added information over ultrasound
(US) or excretory urography (EU) has been found
except in differentiating renal agenesis from abnor-
mal location of the kidney in some cases [21]. MR of
patients with polycystic disease has been able to
demonstrate hemorrhage into cysts. T1 weighted im-
ages show increased signal intensity compared to
14
Fig.8a-c. Diagnosis: Neuroblastoma in ten-year-old female.
a CT with IV contrast demonstrates large complex mass (m) in left
abdomen displacing left kidney (k) posteriorly, b SE 40/900 and
simple cysts [22]. Imaging of patients with sickle-cell
nephropathy has demonstrated decreased cortical
signal on T2 weighted images [23].
Renal transplants
Imaging of renal transplants has been undertaken
[24]. A transplant suffering from acute rejection dem-
onstrates a decrease in corticomedullary differentia-
tion (CMD) and an overall decrease in signal inten-
sity. Complete loss of CMD has been found in
chronic rejection. Acute tubular necrosis shows no
particular pattern varying from good to absent
CMD. Lymphocoeles can be distinguished from he-
matoma by differences in relaxation times although
the utility of this finding is questionable because US
is usually sufficient for examination of peri-trans-
plant fluid collections.
Infection
Acute pyelonephritis in children has been evaluated
with MR but results have been discouraging due to
lack of specific added information [25].
T.M. Harris and M. D. Cohen: Abdominal M RI
e SE 90/2000 show extra-renal origin of mass (arrows) with com-
plex signal characteristics
Fig.9a und b. Diagnosis:Bilateral
adrenal hemorrhage in neonate.
a SE 32/500 and b SE 60/2000
Triangular areas of increased sig-
nal are seen in both suprarenal
locations on both T1 and T2
weighted images indicating sub-
acute hemorrhage in both adrenal
glands (arrowhe~ids). Kidneys (K).
[Reproduced with permission of
Dr. David Cory]
General adrenal disorders
Both normal and abnormal adrenal gl[ands are well
visualized with MR. Adrenal hemorrhage, adenoma,
hyperplasia, metastases and myelolipomas have
been imaged [26]. M R of bilateral adrenal hemor-
rhage has shown areas of increased signal on T1 and
T2 weighted images [27]. Imaging was performed
five days after the onset of symptoms which allowed
the formation of paramagnetic methemoglobin
(Fig.9).
Tumors
Perhaps MRI will find one of its greatest pediatric
abdominal applications in evaluation of renal and
surrounding masses. Diagnosis of Wilms tumor and
neuroblastoma, the two most common extracranial
solid malignant neoplasms in children, typically in-
volves multiple imaging modalities. US is the usual
screening study of an abdominal mass in a pediatric
patient. It can distinguish renal from extrarenal
masses and cystic from solid masses. Cystic masses
T. M. Harris and M. D. Cohen: Abdominal MRt
Fig.10a and b. Diagnosis: Wilm's tumor of the left kidney.
a SE 32/550 Transverse image demonstrates normal right kidney
(K) and well-defined homogeneous mass (M) arising from left
kidney. Note good visualization of normal aorta (small arrow) and
inferior vena cava (large arrow) without IV contrast.
b SE t20/2000 T2 weighted image demonstrates increased signal
of mass (M) as is typical of this tumor. Gallbladder (arrow)
Fig.ll. Diagnosis:Neuroblastoma. SE 30/500. There is extension
of the tumor mass from a primary adrenal location with encase-
ment and displacement of the celiac axis and its branches. Note
exceptional blood vessel delineation without the use of IV con-
trast. Celiac axis (arrow), tumor mass (t), IVC (c), Spleen (s), Liver
03
15
usually require no further evaluation unless they are
renal in origin. Vascular invasion can also be evalu-
ated by US. Computed tomography (CT) is felt to be
a better imaging modality for solid lesions because it
can evaluate the primary tumor for location, calcifi-
cation, nodal or liver metastases, spread across the
midline, paravertebral extension and vascular en-
casement. Both Wilms tumor and neuroblastoma
have been studied with MR [28-31]. Coronal MR has
been found to be most helpful in evaluation renal
versus extrarenal origin of the mass and extension
into surrounding structures. MR can demonstrate all
the features seen by CT except calcification. The in-
ability of MR to identify calcium may well be over-
come by its multiplanar capability with better ability
to identify the origin of a tumor. Belt, et al., were able
to identify the renal origin of all fourteen Wilms tu-
mors that they studied with MR. The tumor demon-
strated signal characteristics consistent with pro-
longed T1 and T2 relaxation times (Fig.10). Most
tumors were inhomogeneous with signal nonunifor-
mity corresponding to areas of necrosis and hemor-
rhage. MR was able to identify hepatic metastases,
enlarged lymph nodes, renal vein/inferior vena cava
invasion and blood vessel displacement.
In seventeen cases of neuroblastoma, Dietrich et
al. [31], were able to identify the site of origin in all.
MR successfully identified vascular involvement,
bone marrow and dural metastases, and intraspinal
and mediastinal spread of tumor. In our experience,
MR better defines vessel encasement by tumor
(Fig.ll) than CT and may prove more accurate at
showing spread into the spinal canal.
So far, the major potential for MR in renal and
surrounding masses is that it might replace the
Fig.12a-c. Diagnosis: Splenic abscess, a C T scan shows two
areas of low attenuation within spleen (A). Stomach (S). b and
e SE 30/500 TI weighted axial and coronal images show two sep-
arate areas of decreased signal intensity in spleen (,4,) consistent
with abnormal fluid collections. On T2 weighted images (not
shown), the abnormal areas had increased signal compared to sur-
rounding splenic parenchyma
16 T.M. Harris and M. D. Cohen: Abdominal M RI

our experience, fatty replacement of the pancreas in

cystic fibrosis is well seen although the clinical value
of this finding is questionable.

Fig.13. Diagnosis:Post-op anal pullthrough with rectum (arrow-
head) positioned outside of levator sling (arrow)
use of multiple other modalities including CT, US
and sulphur colloid scanning. Unfortunately, MR
has yet to consistently provide new and unique in-
formation, e.g. early capsule penetration, dia-
phragm invasion, differentiation of histological sub-
types, etc.
Pancreas
There is little reported information on MRI of the
pediatric pancreas. However, in adult patients, MR
has been shown to be useful in staging pancreatic
neoplasms and the post-operative pancreas [32]. In
Spleen
Splenic evaluation with MR remains limited. T1
weighted images generally demonstrate that the nor-
mal spleen is isointense with liver. The spleen
becomes hyperintense to liver on T2 weighted im-
ages. SE imaging of patients with sickle-cell anemia
has shown decreased intensity of the spleen com-
pared to liver and paraspinal muscles on T2
weighted scans. Calculated T1 and T2 relaxation
times are shorter than in normal spleen [33]. These
findings are presumably due to iron deposition
which causes shortening of T1 and T2 relaxation
times. In a case of Hodgkins disease involving the
spleen, T1 weighted SE images have shown in-
creased intensity of the spleen compared to liver [34].
Splenic abscesses have been imaged demonstrating
prolonged T1 and T2 relaxation times (Fig. 12).
Pelvis
MR has been used successfully to identify unde-
scended testes in both inguinal and intraabdominal
regions [35]. Optimal imaging planes are transaxial

Fig.14a-c. Diagnosis:Blood-filled uterine duplication in a twelve-

year-old female, a Transverse sonogram of pelvis demonstrates
two rounded fluid-filled structures (arrows) posterior to bladder
(b). b and e SE 26/900 Axial and coronal T1 weighted images
show oval blood-filled structures with a central septum
Fig,15a and b. Diagnosis:Wilm's tumor, a SE 32/550 Poor
bowel opacification makes determination of the exact margins of
the fight renal mass (a) difficult on this T1 weighted image.
b SE 120/2000 Increased signal from the tumor mass (a) on T2
weighted image makes delineation of tumor from low signal liver
(L) and unopacified bowel easier. Gallbladder (G)
T. M. Harris and M. D. Cohen: Abdominal MRI 17

Fig. 16a-d. Diagnosis:Multilocular cystic nephroma, a CT s can shows large fluid den-
sity abdominal mass with multiple loculations (arrowheads). b and c SE 40/800 Coro-
nal images demonstrate origin of mass (arrow) from upper pole of left kidney (K). Note
superior bowel (B) opacification (increased signal) in this patient who had ingested
apple juice two hours prior to the scan. d SE 80/2000 T2 weighted image again shows
good bowel delineation (B) and increased signal of well-definedrenal mass (M)

and coronal. Decreased signal on T2 weighted im-
ages and smaller size compared to a coexisting nor-
mal testis may indicate atrophy. Ano-rectal anom-
alies can be demonstrated with M R and multiplanar
imaging has been found to be useful in the preopera-
tive and postoperative evaluation o f the levator sling
(Fig. 13) [36, 37]. Uterine anomalies have been evalu-
ated with successful demonstration of bicornuate,
septate, unicornuate, and didelphys anomalies
(Fig. 14) [381.
Bowel
(Fig. 15). To data oral contrast agents giving repro-
ducible results are not commercially available. Oral
iron solutions were initially thought promising but
success has been limited. A recent report by H a h n
has demonstrated good bowel delineation in rats
with ferrite particles [39]. Oral gd-DTPA is also
undergoing evaluation [40]. In a recent case at our
own institution a child given no oral contrast demon-
strated exquisite bowel opacification (Fig. 16). It was
later discovered that he had consumed apple juice
prior to the examination. Unfortunately, the results
were not reproducible in other humans.

Opacification of the bowel such that it can be distin-

guished from other normal intraabdominal organs
and abdominal pathology remains a problem in M R
Fig. 17. Diagnosis: Respiratory motion artifact and poor bowel
opacification. SE 32/500 Respiratory motion on this upper ab-
dominal image creates ghosting artifact seen as semicircular
bands (arrow) in the phase encoding direction and general blurri-
ness of image. Coupled with poor bowel opacification, separation
of central retroperitoneal structures from bowel is difficult
Technique
One difficulty encountered in MRI o f the a b d o m e n
is that o f artifacts due to motion. The motion arises
from respiration (Fig.17), cardiac pulsation trans-
mitted through the diaphragm, aortic pulsation, and
bowel peristalsis. O f these causes o f motion, the
most important is respiration. There are many differ-
ent methods that have been tried in order to over-
come the effects of respiratory motion. Respiratory
gating has not been found to be very effective, as it
greatly increases scan time. Breath holding is im-
practical, particularly in the pediatric population.
Multiple signal averaging increases total scan time
but will, to some extent, smooth out the effects of
motion. Phase reordering is a complex computer
manipulation and at the present time is available
only for single slice images and therefore not practi-
18
cal. Nonlinear magnetic field gradients greatly help
to overcome motion artifacts. They do however re-
quire the use of long TE and TR times, which means
they are best used for T2 imaging. A simple way of
improving respiratory artifacts is to ensure that the
phase encoding axis is in the side-to side plane. This
helps to decrease the artifact from motion of the
anterior abdominal wall. One of the best methods of
reducing motion artifact is to reduce the scan time.
Using pulse sequences with very short TE (less than
20 msec) and short TR (less than 400 msec) greatly
helps to reduce the effects of motion. Field echo im-
aging which permits even shorter acquisition times
may also, in the future, prove to be helpful in over-
coming motion artifacts.
Conclusion
The abdomen remains a difficult area of the body to
evaluate with MR. Confounding factors include
motion artifact from cardiac pulsation, respiration
and bowel peristalsis which degrade image quality.
Poor ability to precisely delineate bowel and distin-
guish bowel from pathology continues to be a prob-
lem. MR has yet to consistently provide unique infor-
mation which alters patient management and which is
not available by a combination of other imaging
modalities. Although MR has the potential to replace
multiple-modality imaging in certain cases, rarely
does a patient arrive at the scanner without a number
of these less sophisticated radiographic studies. At
this time a cost savings is only theoretical. We must
also remember that we are imaging patients not only
to make a diagnosis but in order to convey diagnostic
points to clinical collegues. Surgeons and pediatri-
cians at our institution seem to be comfortable with
conventional imaging modalities (US, CT, EU), rare-
ly requesting abdominal MR for routine clinical use.
MR is capable of identifying a wide range of patho-
logical processes in the abdomen and image quality is
continually improving. With few exceptions (e.g.
evaluation of levator muscles) MR has not yet been
shown to be the imaging modality of first choice in the
abdomen and pelvis. Further studies with large num-
bers of patients are still needed.
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Received: 22 June 1988; accepted: 1 November 1988
Dr. M. D. Cohen
Director Pediatric Radiology
Indiana University, School of Medicine
702 Barnhill Drive
Indianapolis, IN 46223
USA
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(continued on p.22)