MR imaging in the presence of ballistic debris of unknown composition: a review of the literature and practical approach
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REVIEW ARTICLE
MR imaging in the presence of ballistic debris of unknown composition: a review of the literature and practical approach Noah Ditkofsky 1 & Errol Colak 1 & Anish Kirpalani 1 & Shobhit Mathur 1 & Djeven Deva 1 & Dawn Pearce 1 & Aditya Bharatha 1 & Timothy Dowdell 1 Received: 10 February 2020 / Accepted: 16 April 2020 # American Society of Emergency Radiology 2020
Abstract Due to a combination of increasing indications for MR imaging, increased MRI accessibility, and extensive global armed conflict over the last few decades, an increasing number of patients now and in the future will present with retained metallic ballistic debris of unknown composition. To date, there are no guidelines on how to safely image these patients which may result in patients who would benefit from MRI not receiving it. In this article, we review the current literature pertaining to the MRI safety of retained ballistic materials and present the process we use to safely image these patients. Keywords Ballistic debris . GSW . Bullet . MRI . Gunshot wounds . Shotgun wounds
Introduction “The magnet is always on” is a sign commonly posted on the door leading to zone 4 of the MR environment. It is an important reminder that within zone 4 is a magnetic field that is between 10,000 and 100,000 times stronger than the average background magnetic field [17, 27] and that failure to abide by safety protocols may result in injury or death. Therefore, all patients entering the MRI environment are screened and required to change out of street clothes into hospital gowns. One of the common screening questions is “Do you have any retained bullets?”. This is a question to which most patients answer “No.” However, there are a small minority that answers in the affirmative, resulting in much consternation
among the screening technologists and the radiologists who must ultimately decide if the patient is safe to enter the MR environment. The authors expect that this will become an increasingly common problem given increases in violent crime, the global armed conflicts that have been ongoing over the last 20 years, as well as an aging population that includes veterans of prior wars. To date, there is no comprehensive protocol for MR imaging of these patients. In this article, we review the literature surrounding the safety of MRI in the presence of ballistic debris and offer a protocol with which patients who have retained ballistic debris of unknown composition can safely be introduced into the MRI environment.
Background Essentials: • Most, but not all, retained ballistic debris is MRI safe. • Material decomposition dual-energy CT scanning holds future promise in determining whether retained ballistic material has ferromagnetic properties. • Patients with retained ballistic debris of unknown composition adjacent to critical neurovascular structures should be introduced into the magnetic field in an orientation that would result in the metal moving away from the structure of concern should it move. * Noah Ditkofsky [email protected] 1
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