Liver imaging can be performed with sonography, computed tomography (CT) and magnetic resonance imaging (MRI). Ultrasound is, caused by the easy access, still the first-line imaging method of choice; CT and MRI are applied whenever ultrasound imaging yields vague results. Indications are the characterization of metastases and primary liver tumors e.g., benign lesions such as focal nodular hyperplasia (FNH), adenoma, hemangioma and malignant lesions (cancer) such as hepatocellular carcinomas (HCC). The decision, which medical imaging modality is more suitable, MRI or CT, is dependent on the different factors. CT is less costly and more widely available; modern multislice scanners provide high spatial resolution and short scan times but has the disadvantage of radiation exposure.
With the introduction of high performance MR systems and advanced sequences the image quality of MRI for the liver has gained substantially. Fast spin echo or single shot techniques, often combined with fat suppression, are the most common T2 weighted sequences used in liver MRI procedures. Spoiled gradient echo sequences are used as ideal T1 weighted sequences for evaluating of the liver. The repetition time (TR) can be sufficiently long to acquire enough sections covering the entire liver in one pass, and to provide good signal to noise. The TE should be the shortest in phase echo time (TE), which provides strong T1 weighting, minimizes magnetic susceptibility effects, and permits acquisition within one breath hold to cover the whole liver. A flip angle of 80° provides good T1 weighting and less of power deposition and tissue saturation than a larger flip angle that would provide comparable T1 weighting.
Liver MRI is very dependent on the administration of contrast agents, especially when detection and characterization of focal lesions are the issues. Liver MRI combined with MRCP is useful to evaluate patients with hepatic and biliary disease.
Gadolinium chelates are typical non-specific extracellular agents diffusing rapidly to the extravascular space of tissues being cleared by glomerular filtration at the kidney. These characteristics are somewhat problematic when a large organ with a huge interstitial space like the liver is imaged. These agents provide a small temporal imaging window (seconds), after which they begin to diffuse to the interstitial space not only of healthy liver cells but also of lesions, reducing the contrast gradient necessary for easy lesion detection. Dynamic MRI with multiple phases after i.v. contrast media (Gd chelates), with arterial, portal and late phase images (similar to CT) provides additional information.
An additional advantage of MRI is the availability of liver-specific contrast agents (see also Hepatobiliary Contrast Agents). Gd-EOB-DTPA (gadoxetate disodium, Gadolinium ethoxybenzyl dimeglumine, EOVIST Injection, brand name in other countries is Primovist) is a gadolinium-based MRI contrast agent approved by the FDA for the detection and characterization of known or suspected focal liver lesions.
Gd-EOB-DTPA provides dynamic phases after intravenous injection, similarly to non-specific gadolinium chelates, and distributes into the hepatocytes and bile ducts during the hepatobiliary phase. It has up to 50% hepatobiliary excretion in the normal liver.
Since ferumoxides are not eliminated by the kidney, they possess long plasmatic half-lives, allowing circulation for several minutes in the vascular space. The uptake process is dependent on the total size of the particle being quicker for larger particles with a size of the range of 150 nm (called superparamagnetic iron oxide). The smaller ones, possessing a total particle size in the order of 30 nm, are called ultrasmall superparamagnetic iron oxide particles and they suffer a slower uptake by RES cells. Intracellular contrast agents used in liver MRI are primarily targeted to the normal liver parenchyma and not to pathological cells. Currently, iron oxide based MRI contrast agents are not marketed.
Beyond contrast enhanced MRI, the detection of fatty liver disease and iron overload has clinical significance due to the potential for evolution into cirrhosis and hepatocellular carcinoma. Imaging-based liver fat quantification (see also Dixon) provides noninvasively information about fat metabolism; chemical shift imaging or T2*-weighted imaging allow the quantification of hepatic iron concentration.

See also Abdominal Imaging, Primovistâ„¢, Liver Acquisition with Volume Acquisition (LAVA), T1W High Resolution Isotropic Volume Examination (THRIVE) and Bolus Injection.

For Ultrasound Imaging (USI) see Liver Sonography at Medical-Ultrasound-Imaging.com.

Omniscan® is a nonionic chelate complex with low osmolality used as a paramagnetic MRI contrast agent. The efficacy of Omniscan® is similar to that of Gd-DTPA. Omniscan® is given intravenously to enhance images of intracranial and spinal lesions where there is abnormal vascularity or an abnormal blood brain barrier. The complex does not cross an intact blood brain barrier so Omniscan® only accumulates in lesions such as neoplasm's and abscesses.

WARNING: NEPHROGENIC SYSTEMIC FIBROSIS Gadolinium-based contrast agents increase the risk for nephrogenic systemic fibrosis (NSF) in patients with acute or chronic severe renal insufficiency (glomerular filtration rate less than 30 mL/min/1.73m²), or acute renal insufficiency of any severity due to the hepato-renal syndrome or in the perioperative liver transplantation period.

See also Gadodiamide, and Classifications, Characteristics, etc.

Oral administration of this liposomal encapsulated manganese chloride results in a reduction of the T1 relaxation time causing enhanced signal on T1 weighted MR images. Bracco received marketing approval in December 1997 in the United States, but marketing state is still uncertain.

See also Classifications, Characteristics, etc.

Perflubron® is a perfluorochemical for use as an oral contrast agent. Due to its insolubility in water it does not mix with intestinal secretions; thus bowel lumina appear homogeneously dark on MR images when Perflubron® replaces bowel contents. Filled bowel loops appear black with all pulse sequences because the contrast agent lacks mobile protons.
It is commercially available as Imagent GI. Because rapid transit through the gastrointestinal tract it reaches the rectum within 30 to 40 minutes in most patients. MR imaging of the upper abdominal region should begin within 15 minutes and of the pelvic region 15 to 60 minutes after ingestion of perflubron.

See also Classifications, Characteristics, etc.

Perfluorochemicals are fluorinated organic compounds. Perfluorochemicals can be used in gastrointestinal imaging as a negative contrast agent to reduce signal in the intestine. The MRI signal reduction is caused by the absence of mobile protons.
Perfluoroctylbromide (PFOB)(C8F17Br) is suitable for gastrointestinal use in humans; perfluorononane has been tested in animal models. PFOB is commercially available as Perflubron® (Imagent GI, Alliance). Benefits of this type of contrast media are biologically inertia, immiscibility with water, and a fast transit through the small intestine caused by low surface tension.
Fluosol-DA, a perfluorochemical emulsion has been tested in mice as a tumor specific agent for 19F-MRI.

See also Classifications, Characteristics, etc.