LI-RADS® v2018

CT/MRI Core

Chapter 12

LI-RADS® Technique

Primary Author

Avinash Kambadakone Massachusetts General Hospital

Contributing Authors

Hersh Chandarana NYU School of Medicine

Victoria Chernyak Montefiore Medical Center
Kathryn J. Fowler UC San Diego
Alice Fung Oregan Health and Science University
Karthik Ganeshan Sir H.N. Reliance Foundation
Rajan Gupta Duke University Medical Center
Alison Harris Vancouver Imaging
Thomas Hope UC San Francisco
Jeanne Horowitz Northwestern University
Hero Hussain American University of Beirut Medical Center
Frank Miller Northwestern University
Sadhna Nandwana Emory University
Dushyant Sahani Massachusetts General Hospital
Claude B. Sirlin UC San Diego
Vahid Yaghmai Northwestern University

Illustrators & figure contributors

Avinash Kambadakone Massachusetts General Hospital

Victoria Chernyak Montefiore Medical Center
Claude B. Sirlin UC San Diego

Editors

Victoria Chernyak Montefiore Medical Center

Claude B. Sirlin UC San Diego
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CT/MRI Core

Table of Contents
Pages
Abbreviations 12-1
Modalities 12-2
Contrast agents and their administration 12-2
Multiphase imaging 12-3
Overview Extracellular agents 12-4
Hepatobiliary agents 12-5
Kinetics and temporal enhancement 12-7
LI-RADS CT/MRI phases 12-8

CT Scanner Required CT scanner configuration 12-13

Configuration CT scanner configuration – detector rows 12-14
MR scanner field strength 12-15
MR scanner
MR coil type 12-16

Contrast media CT 12-17

considerations MRI 12-18
Minimum required phases 12-19
CT protocol
Technical considerations 12-20
Required and optional phases/sequences 12-21
Technical considerations 12-22
MRI protocol
Subtraction imaging 12-24
Diffusion-weighted imaging 12-26
Technical CT 12-28
recommenda-
tions MRI 12-29

References 12-30
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Abbreviations
AP Arterial phase
DP Delayed phase
DWI Diffusion-weighted imaging
ECA Extracellular agent
Gd Gadolinium
HBA Hepatobiliary agent
HBP Hepatobiliary phase
IP In-phase imaging
IV Intravenous
MPR Multiplanar reformations
OPTN Organ Procurement and Transplantation Network
OP Out-of-phase imaging
PVP Portal venous phase
T1WI T1-weighted imaging
T2WI T2-weighted imaging
TP Transitional Phase
3D Three-Dimensional

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LI-RADS® Technique

Modalities

Both CT and MRI may be used for assigning LI-RADS diagnostic categories and/or treatment
response categories.

• Both modalities have advantages and disadvantages, and both permit noninvasive diagnosis of
HCC with high specificity if stringent criteria are applied (i.e., LR-5 criteria).

• LI-RADS does not recommend one modality over another, recognizing that the optimal modality in
a particular patient depends on multiple factors, including institutional or practice preference, and
may require individualized decisions tailored to the patient and the clinical context.

Note that CEUS can be used to assign diagnostic categories but not treatment response categories.
CEUS technique is discussed further in the CEUS Manual. It is not discussed further in this chapter.

Contrast agents and their administration

The use of intravenous (IV) contrast agents is required for assigning LI-RADS diagnostic and/or
treatment response categories. LI-RADS categories cannot be assigned on noncontrast CT or
noncontrast MRI.

• LI-RADS recommends administration of IV contrast agents using a power injector.

• In general, a weight-based dose should be used. The optimal rate of injection depends on the
modality: See page 12-17 for CT and page 12-17 for MRI.

• The bolus should be followed immediately by a saline chaser (30-40 mL) at the same injection
rate to push residual contrast material out of the IV tubing and from the peripheral veins.

Contrast agents for CT

All contrast agents used for LI-RADS categorization with CT are iodine-based low-molecular-weight
(LMW) extracellular contrast agents (ECAs).

Contrast agents for MRI

Two different types of Gd-based contrast agents may be used for LI-RADS categorization with MRI:
extracellular contrast agents (ECAs) and hepatobiliary contrast agents (HBAs).

• Both types have advantages and disadvantages. Both permit noninvasive diagnosis of HCC with
high specificity if stringent criteria are applied (i.e., LR-5 criteria).

• LI-RADS does not recommend one type of agent over another, recognizing that the optimal agent
in a particular patient depends on multiple factors, including institutional or practice preference,
and may require individualized decisions tailored to the patient and the clinical context.
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Overview

Multiphase imaging

Multiphase image acquisition at sequential time ranges (“dynamic phases”) after contrast
administration is required for assigning LI-RADS diagnostic and/or treatment response categories.
LI-RADS categories generally cannot be assigned on single-phase CT or MRI.

The dual vascular supply of liver (75% portal venous and 25% hepatic arterial) results in sequential
opacification of hepatic arteries, portal veins, and hepatic veins after injection of intravenous
contrast, as illustrated in idealized time-intensity curves below.

Note sequential
Aorta and
opacification of
hepatic arteries
vessels

Portal veins
Intensity
or
Attenuation
Hepatic veins

30 sec 1 min 2 min 5 min 10 min 20 min 60 min

Time after injection

Different tissues and structures reach peak enhancement at different times. This allows the
acquisition of images during different time ranges or “dynamic phases” to highlight these differences.

While these phases are a continuum, they are described as distinct time ranges for simplicity and
clinical utility. See page 12-8. As described later, LI-RADS requires certain phases and suggests
others.

The phases are selected to:

• Achieve adequate lesion to background contrast AND

• Permit characterization of major features; some LR-M features; LR-TIV, ancillary imaging
features; and treatment response features.

The exact phases selected depend on the

Modality: CT (page 12-19); MRI (page 12-21) and the type of contrast agent: ECA (page 12-21),
Gadobenate dimeglumine (page 12-21), Gadoxetate disodium (page 12-21).

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Overview – Extracellular Agents

Extracellular agents distribute in the extracellular space.

The extracellular space has two components:

• The vascular space

• The interstitial space

In the liver, the vascular space is composed primarily of sinusoids, while the interstitial space is
composed mainly of the perisinusoidal space (space of Disse).

Extracellular agents are cleared slowly from the extracellular space since there is only one
elimination pathway: excretion by the kidneys via glomerular filtration.

The distribution of ECAs in the extracellular space is illustrated below:

Note gradual clearance

Biliary canaliculus from extracellular space

Hepatocytes

Sinusoidal Peri-sinusoidal
(vascular) (interstitial) space
space

Endothelial
cells

1 min 2 min 4 min 8 min 16 min

Time after injection

Extracellular contrast agent

Extracellular agents do NOT distribute in the intracellular or biliary spaces.

Note absence of contrast agent in hepatocytes and biliary canaliculi at all time points in diagram
above.

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Overview – Hepatobiliary Agents

Hepatobiliary agents (HBAs) distribute initially in the extracellular space and are then taken
up by hepatocytes and excreted into the biliary system.

There are two gadolinium based HBAs:

• Gadoxetate disodium, which has high (~50%) and rapid hepatobiliary uptake and excretion.
• Gadobenate dimeglumine, which has modest (~3-5%) and slow hepatobiliary uptake and
excretion.

HBAs have dual elimination, they are excreted both by the kidneys via glomerular filtration
AND by the liver via the hepatobiliary route.

~50% ~95-97%

Gadoxetate Gadobenate
~50% ~3-5%

For gadobenate dimeglumine:

• The amount and rate of hepatobiliary excretion is too small and slow to noticeably affect the
clearance of contrast from the extracellular space.

• Thus, enhancement of blood vessels and of lesions with large blood spaces (e.g., hemangiomas)
or interstitial spaces (e.g., fibrotic lesions) tends to decline at a similar rate as with ECAs.

For gadoxetate disodium:

• This dual elimination results in rapid clearance from the extracellular space, including the blood
and interstitium.

• Thus, enhancement of blood vessels and of lesions with large extracellular volume—large blood
spaces (e.g., hemangiomas) or interstitial spaces (e.g., fibrotic lesions)---decreases rapidly
compared to ECAs.

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Overview – Hepatobiliary Agents

HBAs may occupy one of four possible spaces, depending on agent and time after injection:

• The vascular space

• The interstitial space
• The hepatocellular space
• The biliary space

The time-dependent distribution of these HBAs in the four spaces is illustrated below:

Modest hepatobiliary uptake & excretion

Gadobenate dimeglumine Biliary canaliculus at ~ 1 hour

1 min 2 min 4 min 8 min ~ 1 hour

Time after injection

Note slow clearance from extracellular space, similar to ECA
Gadobenate dimeglumine

Gadoxetate disodium High hepatobiliary uptake & excretion

Biliary canaliculus at ~ 16 minutes

1 min 2 min 4 min 8 min 16 min

Time after injection

Note rapid clearance from extracellular space

Gadoxetate disodium
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Overview – Kinetics and Temporal Enhancement

Temporal enhancement characteristics are illustrated in the idealized time-intensity curves below

ECAs and gadobenate dimeglumine have similar kinetic properties and produce similar temporal
enhancement characteristics during the first few minutes after injection. For both, vascular
enhancement declines gradually. Due to hepatobiliary uptake, gadobenate dimeglumine causes
substantially greater liver enhancement than ECAs by 1 hour.

Aorta and
hepatic arteries
Liver with ECA or gadobenate:
liver enhancement peaks at around
or just past 1 minute
Intensity
Portal veins
or
Attenuation
Hepatic veins
Liver with gadobenate

Liver

Liver with ECA

30 sec 1 min 2 min 5 min 10 min 20 min 60 min

Time after injection

Gadoxetate disodium has different kinetic properties and produces different temporal enhancement
characteristics than gadobenate dimeglumine or ECAs. Hepatocyte uptake begins during the first
pass, becomes noticeable by about 1-2 minutes, peaks by about 20 minutes, and persists for hours.
Vascular enhancement declines more rapidly due to dual elimination.

Aorta and hepatic arteries Liver with gadoxetate:

liver enhancement continues to increase
after 1 minute, peaking at about 20 minutes

Portal veins
Intensity Liver
Hepatic veins Vascular enhancement with
gadoxetate declines more rapidly
than with ECA or gadobenate

30 sec 1 min 2 min 5 min 10 min 20 min 60 min

Time after injection

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Overview – LI-RADS® CT/MRI Phases

Different tissues and structures reach peak enhancement at different times. This allows the
acquisition of images during different “phases”. The phases represent a continuum with gradual
change overs, but illustrated below as discrete time ranges for simplicity and clinical utility.

Contrast phases with ECAs or gadobenate

Early Late HBP
AP AP PVP Delayed (gadobenate)

Continues
Ao & HAs

Intensity
PVs
or
Attenuation HVs

Liver

30 sec 1 min 2 min 5 min 10 min 20 min 60 min

Time after injection

Contrast phases with gadoxetate

Early Late
AP AP PVP Transitional HBP

Ao & HAs Continues

PVs
Intensity Liver
HVs

30 sec 1 min 2 min 5 min 10 min 20 min 60 min

Time after injection

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Overview – LI-RADS® CT/MRI Phases

Different tissues and structures reach peak enhancement at different times. This allows the
acquisition of images during different “phases”. The phases represent a continuum with gradual
change overs, but illustrated below as discrete time ranges for simplicity and clinical utility.

Contrast phases with ECAs or gadobenate

Early Late HBP
AP AP PVP Delayed (gadobenate)

Ao & HAs Lesion with APHE:

APHE usually peaks in late AP

Intensity
PVs
or
Attenuation HVs

Liver

30 sec 1 min 2 min 5 min 10 min 20 min 60 min

Time after injection

Contrast phases with gadoxetate

Early Late
AP AP PVP Transitional HBP

Ao & HAs Lesion with APHE:

APHE usually peaks in late AP

PVs
Intensity Liver
HVs

30 sec 1 min 2 min 5 min 10 min 20 min 60 min

Time after injection

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Overview – LI-RADS® CT/MRI Phases

Arterial phase In LI-RADS, the arterial phase refers to the hepatic arterial phase unless
(AP) otherwise specified. The arterial phase is a postcontrast time range with the
following characteristics:

• Hepatic artery and branches are fully enhanced.

Early AP Late AP • Hepatic veins not yet enhanced by antegrade flow.

Two subtypes:

• Early AP: Subtype of AP in which portal vein is not yet enhanced.

• Late AP: Subtype of AP in which portal vein is enhanced.

Late AP is strongly preferred for HCC diagnosis and staging, because the
degree of enhancement in HCC usually is higher in the late than in the
early AP. Some HCCs may show hyperenhancement only in the late AP.

Extracellular phase Postcontrast phase in which liver enhancement is attributable mainly to the
(ECP) extracellular distribution of a contrast agent. Operationally, this refers to:

• PVP and DP for ECAs or gadobenate dimeglumine.

• PVP only for gadoxetate disodium.

Portal venous phase Postcontrast time range with the following characteristics:
(PVP)
• Portal veins are fully enhanced.
• Hepatic veins are enhanced by antegrade flow.
• Liver parenchyma is at peak enhancement for ECAs.

Delayed phase Postcontrast phase acquired with ECAs or gadobenate after the portal
(DP) venous phase and with the following characteristics:

• Portal and hepatic veins are enhanced but less than in PVP.
• Liver parenchyma is enhanced but usually less than in PVP.

Typically acquired 2 to 5 minutes after injection.

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Overview – LI-RADS® CT/MRI Phases

Transitional phase Postcontrast phase(s) acquired with gadoxetate disodium after the PVP,
(TP) before the hepatobiliary phase, and with the following characteristics:

• Liver vessels and hepatic parenchyma are of similar signal intensity.

• Both the intracellular and extracellular pools of contrast contribute
substantially to parenchymal enhancement.

Typically acquired 2 to 5 minutes after injection of gadoxetate disodium.

Timing would vary and typically not obtained with gadobenate.

Hepatobiliary phase Postcontrast phase with HBA with the following characteristics:
(HBP)
• Liver parenchyma is hyperintense to hepatic blood vessels.
• There may be excretion of contrast into biliary system.

Typically acquired about 20 minutes after injection for gadoxetate disodium.

If obtained with gadobenate dimeglumine, a delay of 1-3 hours is needed.

HBP is suboptimal if liver is not more intense than hepatic blood vessels.

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Overview – LI-RADS® CT/MRI Phases

CT or MRI with ECA and MRI with gadobenate dimeglumine

Pre Late AP PVP Delayed

CT

MRI

MRI with gadoxetate disodium

Pre Late AP PVP TP HBP

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CT Scanner Configuration

Required CT Scanner Configuration

LI-RADS requires use of multidetector CT scanners to enable accurate HCC diagnosis and staging.
Single-slice CT cannot be used for LI-RADS diagnosis and staging.

✘ ✓

Single-slice CT Multidetector CT

Rationale

Rapid acquisitions are required to capture multiphase images.

Single-slice CT is adequate for portal venous phase imaging but, due to slow scan speed and long
acquisition time, has limited ability to scan the liver in multiple phases as required by LI-RADS.

Multidetector CT offers several advantages over single slice CT:

• Reduced gantry rotation time

• Reduced scan duration
• Ability to obtain thinner sections resulting in higher z-axis spatial resolution.

Reduced scan duration enables whole-liver coverage during a short, comfortable breath hold;
volumetric acquisitions can be repeated to enable multiphase imaging. Reduced scan duration also
decreases motion artifact, particularly in patients with ascites.

Thinner, submillimeter sections diminish partial volume averaging artifacts, which improves
sensitivity for small lesions, and allows multiplanar reformation.

Evidence

Evidence is indirect, relying on historical data.

• Studies have shown that single-slice CT has low sensitivity for detecting HCC, especially for
lesions < 2 cm.
• The advent of multi-detector technology has improved tumor detection rates.
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CT Scanner Detector Rows

Minimum number of detector rows

LI-RADS requires a minimum of 8 detector rows. Scanners with 4 or fewer rows cannot be used for
LI-RADS diagnosis and staging.

✘ ✓

≤ 4-detector row CT ≥ 8-detector row CT

Rationale

Thin slices are required for adequate sensitivity for detecting observations and characterizing major
features. As summarized below, 8-row multidetector CT has higher per-lesion sensitivity for HCC
than 4-row multidetector HCC.

Additionally, increasing the number of rows from 4 to 8 to 16 to 64 or more allows whole-liver

coverage with progressively thinner sections along the z-axis, facilitating generation of isotropic data
with sub-millimeter spatial resolution. Isotropic data allow multiplanar reformations in any plane
(axial, coronal, sagittal, or arbitrary). In general, the minimum number of rows for acquiring isotropic
data is 16, although 8-row multidetector CT can produce high-quality multiplanar reformations.

Evidence

4-row multidetector CT has a reported sensitivity of 73% for detecting HCC overall.

8-row multi-detector CT has a reported sensitivity of 87% for detecting HCC overall.

Additionally, 8-row multidetector CT has a positive predictive value of 96% for detecting HCC in
patients with explant pathology reference standard.

The PPV for 4-row MDCT for HCC with explant pathology is 84.7%.

No studies have compared per-lesion sensitivity of 64-row or 16-row multidetector CT vs. 8-row
multidetector CT for detecting HCC.

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MR Scanner Field Strength

Required MR Scanner Field Strength

LI-RADS requires use of MR scanners with field strength ≥ 1.5T to enable accurate HCC diagnosis
and staging. Scanners with field strength ≤ 1.0T cannot be used for LI-RADS diagnosis and staging.

✘ ✓

≤ 1.0 Tesla ≥ 1.5 Tesla

Rationale

MRI of the liver for diagnosis and staging of HCC is typically performed on higher field strength
scanners (1.5 or 3 Tesla), which is considered an acceptable minimal standard of care.

Such scanners provide

• Adequate temporal resolution for multiphase imaging AND

• Sufficient spatial and contrast resolution for evaluation of small hepatic lesions.

Generally, liver MRI performed at lower field strengths (≤ 1.0 Tesla) has lower signal-to-noise ratio
and inferior image quality.

Evidence

The recommendation for 1.5 or 3 Tesla over ≤ 1 Tesla scanners reflects widespread clinical practice
patterns and is based on the universal adoption of 1.5 and 3 Tesla scanners as standard of care for
liver imaging.

There are no comparative studies on the diagnostic performance of ≤ 1.0 Tesla vs. ≥ 1.5 Tesla
scanners for HCC diagnosis.

The accuracy for diagnosis and staging of HCC is comparable at 1.5 Tesla and 3 Tesla, although 3
Tesla provides higher lesion-to-liver contrast on dynamic contrast-enhanced images.

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MR Coil Type

Required Coil Type

LI-RADS requires use of multichannel, phased array coils. If available, a torso coil should be used in
most cases. A cardiac coil can be used if a torso coil in not available. Scans acquired with the built-in
body coil alone cannot be used for LI-RADS diagnosis and staging.

Rationale

Phased array coils have multiple coil elements designed for volumetric imaging.

Compared to body coils, multichannel phased array coils

• provide higher signal-to-noise ratio and spatial resolution at similar field of view.
• provide better image quality and higher contrast-to-noise ratio, while achieving faster acquisition
time, for detecting liver lesions at 1.5 Tesla.

Phased array coils with specific coil element configurations also permit parallel imaging, which can
reduce scan time and improve temporal resolution.

In general, coils with more receiver channels enable higher acceleration factors for parallel imaging
and provide improved signal-to-noise ratio (SNR). Most state-of-the art MRI torso phased array coils
have at least 8 channels, with some having 32 or more channels.

Evidence

The recommendation for using multichannel, phased array coils reflects widespread clinical practice
patterns and is based on the universal adoption of such coils as standard of care for liver imaging.

There are no comparative studies on the diagnostic performance of MRI using the body coil versus
using a torso phased array coil for HCC diagnosis, but due to the many advantages of multichannel
phased array coils as well as their widespread acceptance as standard of care, it is doubtful that
such a study will be performed.

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Contrast Media Considerations - CT

Technical Suggestion

For CT, LI-RADS suggests use of iodinated contrast medium with:

• Concentration: 300mgI/mL or higher

• Dose: 1.5-2mL/kg body weight
• Contrast injection rate: 3mL/sec or higher

LI-RADS also suggests a saline chaser bolus (30-40 mL) at the same injection rate to follow the
contrast bolus. The saline chaser pushes residual contrast in the injection tubing and peripheral
veins.

Rationale/Evidence

Important factors that impact image quality: concentration, dose and injection rate of iodinated
contrast as well as use of a saline chaser.

Arterial enhancement and detection of APHE depend mainly on injection rate.

Hepatic parenchymal enhancement depends mainly on total iodine dose.

Concentration: Iodinated contrast medium concentrations range widely: 240-400 mgI/mL.

Concentrations ≥ 300 mgI/mL yield better HCC detection and image quality.

Patient co-morbidities decrease liver perfusion. Patients with the following conditions may benefit
from higher concentrations: reduced cardiac output, obesity, advanced cirrhosis, portal vein
thrombosis.. In cirrhosis, higher iodine concentration improves lesion to liver contrast and achieves
higher portal venous phase hepatic parenchymal attenuation.

Dose: Weight-based dosing is suggested. Larger patients with larger blood volume may have more
dilution of contrast material and lower target organ enhancement than smaller patients.

Optimal dose for liver imaging is 1.5-2 mL/kg body weight. This is equivalent to about 525-600
mgI/kg:

• 350 mgI/mL * 1.5 mL/kg = 525 mgI/Kg

• 300 mgI/mL * 2 mL/kg = 600 mgI/kg

This dose yields an absolute parenchymal enhancement of > 50 HU.

Injection rate: Injection rates > 3 mL/s improve sensitivity for detection of hypervascular HCC,
especially for small lesions.

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Contrast Media Considerations - MRI

Types of MR contrast agents

Two different types of Gd-based MR contrast agents can be used for LI-RADS categorization:

• Extracellular contrast agents (ECAs)

• Hepatobiliary contrast agents (HBAs)

Both types of agents have advantages and disadvantages, and both permit noninvasive diagnosis of
HCC with high specificity if stringent criteria are applied (i.e., LR-5 criteria).

HBAs, like ECA, yield similar enhancement characteristics on arterial and portal venous phases, but
also provide hepatobiliary phase (HBP) information. This combination of information can improve
detection of HCC..

LI-RADS does not recommend one type of agent over another, recognizing that the optimal agent
selection depends on patient, radiologist, institutional practice and other factors.

Types of MR HBAs

There are two clinically available HBAs:

• Gadoxetate disodium
• Gadobenate dimeglumine

Both agents have relatively high relaxivity compared to ECAs, which potentially permits detection of
smaller lesions.

Both agents are taken up and excreted by hepatocytes, but they differ in the degree of hepatobiliary
excretion.

• Gadoxetate disodium ~ 50%

• Gadobenate dimeglumine ~ 3-5%

Please see Chapter 13 for more information on gadoxetate and gadobenate.

Contrast agent dose and injection rate

Dose: please see package insert for manufacturer recommended dose

Contrast injection rate: 1-2 mL/sec

LI-RADS also suggests a saline chaser bolus (30-40 mL) at same injection rate to follow the contrast
bolus. The saline chaser pushes residual contrast in the injection tubing and peripheral veins.

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CT Protocol

Minimum required phases with CT

• Arterial phase (late arterial phase strongly preferred)

• Portal venous phase
• Delayed phase (typically acquired 2 to 5 minutes after injection)

Precontrast imaging is suggested if patient has had locoregional treatment; it is optional otherwise.

Rationale for selected phases

The required phases are selected to

• accentuate lesion to background enhancement and

• permit characterization of LI-RADS major features as well as LR-M, LR-TIV, and ancillary
features.

Precontrast imaging is optional for CT in treatment-naïve patients, because it adds radiation

exposure with low incremental benefit.

Precontrast imaging is suggested in treated patients to differentiate tumor enhancement versus

intrinsic posttreatment hyperdensity from blood, proteinaceous material, or iodized oil.

AP and PVP are required for characterization of APHE, WO and enhancing “capsule”.

DP improves HCC detection and characterization, particularly for small lesions, and is more
sensitive for detection of WO and enhancing “capsule” than PVP.

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CT Protocol

Technical considerations

All multiphase
Slice thickness ≤ 5 mm
acquisitions

Bolus tracking or fixed time delay is suggested

Bolus tracking:

• Aortic triggering is performed at L1 level, celiac axis, or

diaphragmatic hiatus.
Arterial phase • After threshold aortic enhancement of 100-150 HU is
reached, a scan delay of 15-30 s is suggested for late
AP acquisition.
Timing of
multiphase Fixed time delay:
sequences
• 35-45 s after starting injection with rate of 3-5 mL/s

60-75 s after starting injection at 3-5 mL/s, regardless of

Portal venous phase
how the arterial phase is timed

Delayed phase 2-5 min

Multiplanar reformats are recommended in the coronal and sagittal planes for
Multiplanar arterial and portal venous phase images.
reformats
Multiplanar reformats are optional for delayed phase images

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MRI Protocol

Minimum required phases with MRI

For MRI with all contrast agents:

• Precontrast imaging
• Arterial phase (late arterial phase strongly preferred)
• Portal venous phase

For MRI with ECA or gadobenate

• Delayed phase (typically acquired 2 to 5 minutes after injection)

For MRI with gadoxetate

• Transitional phase (TP) (typically acquired 2 to 5 minutes after injection)

• Hepatobiliary phase (HBP) (typically acquired 20 minutes after injection)

Other required sequences

• T1-weighted out-of-phase (OP) and in-phase (IP) imaging (precontrast)

• T2-weighted imaging (pre or postcontrast) (fat suppression is optional)

Optional phases/sequences

• Diffusion-weighted imaging (DWI) (pre or postcontrast)

• HBP with gadobenate (typically acquired 1-3 hours after injection)

Rationale for required phases

The rationale for the required phases is similar to CT (see page 12-19) with the following differences:

• Precontrast images establish the intrinsic T1 intensity of observations, provide a baseline against
which contrast enhancement can be identified, and allow for subtraction imaging. These are
required since there is no additional exposure to ionizing radiation.

• TP aids in lesion detection and diagnostic confidence, as HCCs, LGDN and HGDN often are
hypointense in TP.

• HBP imaging improves sensitivity and specificity for HCC diagnosis (see Chapter 13).

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MRI Protocol

Rationale for other required sequences

T1-weighted OP and IP imaging (precontrast) allows for the detection of intralesional fat/iron and fat
and iron sparing, which are LI-RADS ancillary features (see Chapter 16).

T2-weighted imaging is necessary for characterization of some ancillary features (see Chapter 16);
provides information about the presence of fluid, fibrosis and iron; allows distinction between solid
and nonsolid lesions; can increase diagnostic confidence.

Rationale for optional phases/sequences

DWI improves detection of hepatic observations, and is necessary for characterization of some LR-M
and ancillary features (see Chapter 16). DWI is optional, not required, due to its inconsistent image
quality. DWI is prone to artifact/image degradation.

HBP with gadobenate is optional due to the slow and modest uptake of this agent, which requires a
long (~1-3 hour) delay and makes HBP imaging impractical.

Technical considerations

Weighting T1 weighted

Acquisition type 3D is strongly recommended

Fat suppression Strongly recommended

All multiphase
sequences Slice thickness ≤ 5 mm

Postcontrast acquisition parameters should match

precontrast parameters to facilitate subtraction.
Comment
Optionally, the flip angle can be increased in the HBP to
enhance T1 weighting.

• Bolus tracking is recommended.

Arterial phase
• Multiarterial acquisition can have a fixed delay.

Portal venous phase 60-80 s after the start of injection at 3-5 mL/s
Timing of
multiphase Delayed phase 2-5 min
sequences
Transitional phase 2-5 min

~ 20 min (with gadoxetate)

Hepatobiliary phase
~1-3 hrs (with gadobenate)
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MRI Protocol

Technical considerations (Cont’d)

• 2D single shot (SSFSE/HASTE) OR

Acquisition type
• 2D fast spin echo techniques (FSE/TSE)

T2-weighted Fat suppression Optional

imaging
Slice thickness ≤ 8 mm, slice gap, ≤ 2 mm

Other Acquisition in coronal and axial planes is recommended.

• Dual-phase acquisition is strongly recommended.

• OP should be acquired as the first echo.
Acquisition type • Both 2D and 3D acquisitions are acceptable.
T1-weighted
• IP and OP images can be generated as part of Dixon
out-of-phase
acquisition.
(OP) and in-
phase (IP)
Fat suppression None
imaging
• If 2D: ≤ 8 mm, slice gap ≤ 2 mm
Slice thickness
• If 3D: ≤ 6 mm

• Single shot echoplanar imaging (SS-EPI) with > 2 b-

values (including b=0-50 and b=400-1000 s/mm2.
Acquisition type • Can be acquired using breath-hold, free-breathing,
respiratory-gated techniques or multiple signal
averages.

Fat suppression N/A

Diffusion-
weighted
Slice thickness ≤ 8 mm slice gap, ≤ 2 mm
imaging
• Higher b-values can improve specificity for HCC, but
have lower SNR.
• Free breathing sequences allow for more b-values,
Other
higher SNR and thinner sections vs breath-hold, but are
longer to acquire and more artifact prone.
• Parallel imaging is recommended to reduce artifacts.

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Subtraction Imaging

Definition

Subtraction imaging refers to post processed images generated from subtraction of precontrast from
postcontrast images.

Technical Recommendation

Subtraction imaging is suggested for liver MRI to characterize APHE and/or “washout” appearance
of intrinsically T1 hyperintense observations.

• Subtracting the precontrast from the arterial phase T1-weighted images can be used to
characterize APHE (see Chapter 16, page 26)

• Subtracting the precontrast from the portal venous or, if an ECA or gadobenate is used, delayed
phase T1-weighted images can be used to characterize washout appearance (see Chapter 16,
page 104)

Radiologists and institutions can determine whether to generate subtractions routinely or only in
select cases when needed.

Subtraction images can usually be obtained at the scanner console by automatic subtraction of the
precontrast T1-weighted images from the postcontrast T1-weighted images.

For subtractions to be valid, precontrast and postcontrast phases must be acquired with identical
technique – including the same sequence and image-weighting parameters (e.g., TR, TE, flip angle,
and calibration settings) and be properly registered.

Coregistration can be facilitated by patient education prior to scanning and acquiring breathhold
images at relaxed end expiration.

Rationale for suggesting subtraction imaging:

• Subtraction imaging can enable characterization of APHE and washout appearance for
intrinsically T1 hyperintense lesions.

• Subtraction improves accuracy and reader confidence for assessment of tumor necrosis following
locoregional therapies by improving detection of APHE related to residual/recurrent tumor.

Rationale for not requiring subtraction imaging:

• They cannot be automatically produced on all scanners, require additional workflow steps, and
add to the number of images being transferred and stored.

• Misregistration between unenhanced and enhanced images can be a source of artifact and result
in false-positive characterization, particularly for observations at the periphery or dome of liver.

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Subtraction Imaging

• Example: Subtractions

Pre AP PVP DP

High signal on pre Assessment of APHE and WO is confounded by intrisically high T1 signal

Sub AP Sub PVP Sub DP

Subtractions confirm presence of APHE and DP WO

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Diffusion Weighted Imaging

Definition

Diffusion-weighted imaging refers to images in which contrast is generated mainly or largely by

differences in diffusivity between tissues.

Since the echo times required to generate diffusion-weighted images are generally intermediate to
long (i.e., ≥ 40 ms), the images are also T2 weighted.

Technical Recommendation

Diffusion-weighted imaging is suggested for liver MRI to

• improve sensitivity for HCC by detecting lesions that may be difficult to see on other sequences
• increase diagnostic confidence, and
• permit characterization of
• one ancillary feature favoring malignancy (diffusion restriction) and
• two LR-M features (targetoid appearance at DWI, marked diffusion restriction).

DWI is highly sensitive to artifacts (susceptibility, motion artifacts, etc.). Artifacts can be greatest in
the left lobe (cardiac and diaphragm motion, air in the stomach, upper and lower GI tract).
Techniques to lessen artifacts include (but are not limited to): respiratory gating, parallel imaging,
using relatively low imaging matrix.

DWI quality is similar pre- and post-contrast. Consider acquiring DWI post contrast if that would
reduce overall scanner time and/or reduce the risk of patient fatigue during dynamic contrast-
enhanced imaging.

Rationale for suggesting diffusion weighted imaging:

• Diffusion-weighted imaging can improve sensitivity for HCC and reader confidence, and it can
permit characterization of some ancillary and LR-M features.

Rationale for not requiring diffusion-weighted imaging:

• High-quality diffusion-weighted imaging cannot be achieved consistently on all MR scanners.

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Advanced and Emerging Techniques

Dual energy/multispectral imaging

Insufficient evidence for LI-RADS to recommend for or against the use of dual energy/multispectral
imaging.

Multiarterial phase MRI

Insufficient evidence for LI-RADS to recommend for or against the use of multiarterial phase imaging

Susceptibility-weighted MRI

Insufficient evidence for LI-RADS to recommend for or against the use of susceptibility-weighted
imaging.

Quantitative imaging techniques

Insufficient evidence for LI-RADS to recommend for or against the use of quantitative imaging
techniques/biomarkers for LI-RADS categorization.

Examples of these techniques/biomarkers include:

• Confounder-corrected chemical shift encoded MRI to quantify proton density frat fraction (PDFF)
– a measure of tissue lipid content
• Multi-echo or confounder-corrected chemical shift encoded MRI to quantify R2* – a marker of iron
content
• Magnetic resonance elastography to quantify stiffness – a marker of fibrosis
• Other:
• Perfusion analysis to quantify perfusion parameters, texture analysist to quantify texture
features, DWI volumetric analysis to quantify volumetric ADC

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Technical Recommendations for CT at a Glance

Scanner configuration Multidetector row scanner

Detector rows ≥ 8 detector rows

Multiplanar reformations Suggested

Slice thickness (for axial

≤ 5 mm required
reconstructions and, if obtained,
(2.5 – 3 mm suggested for multiplanar reformations)
multiplanar reformations)

• Suggested for patients treated with locoregional therapy

Precontrast imaging
• Optional otherwise

The following are the minimum required phases for both

treatment-naïve and treated patients:

Contrast-enhanced phases • Arterial phase

• Late arterial phase strongly preferred
• Portal venous phase
• Delayed phase (2-5 minutes after initial injection of contrast)

Timing of arterial phase Bolus tracking or fixed-time delay is suggested

• ≥ 300mgI/mL for a dose of 1.5-2.5 mL/kg body weight

• Injection rate of ≥ 3 mL/sec
Contrast considerations
• Saline chaser bolus (30-40 mL) with same injection rate
• Power injector

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Technical Recommendations for MRI at a Glance

MR Scanner 1.5 or 3T

Coil type Phased array multichannel torso coil

Multiphase 3D T1WI is required with the following phases:

• Precontrast
• Arterial phase
• Late arterial phase strongly preferred
• Multiarterial phase imaging is optional if available
Multiphase
• Portal venous phase
Required • Delayed phase (2-5 minutes) if using ECA or gadobenate
imaging • Transitional phase (2-5 minutes) if using gadoxetate
• Hepatobiliary phase (~20 minutes) if using gadoxetate

Fat suppression is suggested

• Unenhanced T1-weighted OP and IP imaging

Other
• T2-weighted imaging (fat suppression optional)

• DWI
Suggested imaging
• Multiplanar acquisition(s)

• Hepatobiliary phase (~1-3 hours) if using gadobenate

Optional imaging
• Quantitative imaging techniques, if available, are optional

Timing of arterial phase Bolus tracking is suggested

Slice thickness See pages corresponding to each phase or sequence

• ECA or gadobenate or gadoxetate

• Weight-adjusted dose
Contrast considerations • Injection rate of 1-2 mL/sec
• Saline chaser bolus (30-40 mL) with same injection rate
• Power injector

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