BehindTheMedspeak: Pediatric MRIs will never be the same - thank God almighty!

Few things in anesthesiology are more unsettling than doing pediatric anesthesia in the MRI suite.

One of them is working with an anesthesiology resident who's doing his or her first one.

Because they're so ignorant, they have no idea how scared they should be.

Ignorance really is bliss when you're an anesthesia resident.

You want to take the chief resident down there with you, or at least someone senior who's done them before.

But then, how will people who haven't done one learn unless they at some point do their first?

Doing these kinds of cases is one of the things that finally drove me out of academic anesthesiology.

I got tired of fighting to get at least a minimally experienced resident assigned to do the case with me.

Why is peds anesthesia in the MRI suite so dicey?

Because:

1) Pediatric anesthesia is far more demanding and intolerant of mistakes than the adult version: kids have much less reserve in terms of lung capacity, etc., and can go south in a hurry.

2) Because the MRI suite is ferrous metal-averse, taking anything ferromagnetic into the room risks creating a guided missile that can - and does - kill. These kinds of events, unhappily, continue to occur, always making headlines.

3) The nature of the heavy shielding required results in your watching the patient through a thick, dark window while you're on the outside of the actual MRI room, where the child lies intubated, paralyzed, on a ventilator, surrounded by all your monitors.

Anytime you have to give anesthesia outside the OR - what we call in the business "Third-World Anesthesia" - you're just asking for complications.

You've got no back-up: no spare parts, machines, monitors, or personnel in case the kid crashes.

You're on your own.

Which is OK - up to a point.

But when you've got some first-year resident with you who barely has a clue, and even finds the case "interesting," or "fun," it's just plain scary.

So I was delighted to read, in the January 18 New York Times Science section, that a clever bioengineer in Arizona has created an algorithm to correct for patient movement, thus making sedation or anesthesia, usually necessary for children undergoing an MRI, far less likely to be required.

The MRIs leading this post show, in the top half, a scan from a coughing patient and below, the same scan corrected with the new technology.

I was quite dismayed when I read on and learned that, though the software and hardware upgrades required for MRI machines to create acceptable images with a moving patient have been available for a year, "they are not used in all hospitals and clinics."

It is inconceivable that any institution doing MRIs wouldn't immediately buy these upgrades.

The cost of a medical negligence suit resulting from a dead or brain-damaged child is astronomical, running into the millions of dollars; it dwarfs whatever G.E.'s charging for Version 2.0.

Talk about penny-wise and pound-foolish....

Here's Nicholas Bakalar's story from the Times.

A Sharp Brain Scan, Even With a Squirming Youngster

When Lisa Pelzer's 5-year-old son, Claude Jr., needed a brain scan to rule out a medical reason for his hyperactivity, the boy's pediatric neurologist wrote a prescription for a magnetic resonance imaging scan "with sedation" - the usual way of keeping children still enough to get readable images.

But Ms. Pelzer, who lives in Edison, N.J., was delighted to learn from the radiologist that an advance in M.R.I. technology would make sedation unnecessary.

Damage to the brain can leave a lesion the size of a pencil point, and to find it on an M.R.I. scan, a radiologist needs an extremely high-quality image.

But the procedure requires a patient to remain immobile for as long as 45 minutes.

Even cooperative adult patients can blur a scan by slight movement; as little as a millimeter of movement can be enough to hide important details and make the scan useless as a diagnostic tool.

The problem becomes even more acute in scanning children, elderly patients and people with movement disorders like Parkinson's disease.

The new technique uses an M.R.I. scanner enhanced with new hardware and powerful new software to virtually eliminate the problem of movement, at least for brain scans.

Called Propeller (short for periodically rotated overlapping parallel lines with enhanced reconstruction), the method produces "Rembrandt-quality images" even with a squirming 5-year-old, according to Dr. Lawrence Tanenbaum, a radiologist and professor in the neuroscience department at Seton Hall's Graduate School of Medical Education.

Dr. Tanenbaum has no financial interest in the technology, but gives talks on behalf of General Electric, which makes and markets the scanners.

An M.R.I. machine normally collects a little data every few seconds, eventually gathering enough to create an image.

Propeller works by collecting the data in a new way, creating a blurry image from each set of data.

After the scan is completed, these blurry images are used to track the movement and position of the head from second to second between each data collection.

Then the software corrects for that movement, creating a clear picture of the brain.

Propeller produces huge amounts of information, so more time is required to produce the pictures, but the data can be processed using an ordinary PC.

The scanning method was originally developed by Dr. James Pipe, a bioengineer at the Barrow Neurological Institute of St. Joseph's Hospital in Phoenix.

Dr. Pipe said he held no stock in General Electric, but the company provides research money for his hospital.

The software and hardware upgrades required for M.R.I. machines have been available for about a year, but they are not used in all hospitals and clinics.

"We've had a lot of people ask for help in setting it up," Dr. Pipe said in a telephone interview.

"It's early enough that people are still trying to figure out which situations it is best suited for."

The technique does not work as well for body scans, experts say.

The brain is a single organ that can be moved in only one direction at a time.

In scanning other parts of the body, muscle movement or breathing causes organs and soft tissues to move simultaneously in different directions.

The technique does not yet compensate for that.

Dr. Pipe said he expected that technologies like Propeller would soon be used much more widely in M.R.I.

"We're now getting to the point where computers are fast enough that we can have scanners that are much better than they used to be," Dr. Pipe said.

"For example, a scanner can now detect in the middle of a scan that it has to adjust itself to get a better image. For me, as a researcher, it's a fantastic time."