How radiographers help translate advanced MRI technology into safe, efficient, and patient-centered clinical practice
A new generation of MRI is making the once-impossible routine — sharper images, faster scans, a deeper look inside the body than ever before. But with that power comes a quieter truth: the smarter the machine, the more it depends on the person operating it.
Drawing on months of hands-on work with one of the most powerful scanners available today, Davide Fierro reflects on what really changes when the technology leaps forward: and why the future of medical imaging will be shaped not by hardware alone, but by the skill, judgment, and care of the people who use it.
By Davide Fierro, MRI Radiographer, Policlinico Universitario “Umberto I” of Rome, Vice President of AITERM.
Part of the Fourier Crew, Everything MRI.
There is a particular moment when you stand in front of a new generation MRI scanner for the first time and realize: this is not just another system upgrade. It feels like the beginning of a new chapter.
Higher field strength, stronger gradients, faster sequences, and AI-powered reconstruction are changing what is possible in MRI. Examinations that once seemed too long, too complex, or too sensitive to motion are becoming more accessible. Diffusion imaging can go deeper. Functional imaging can become more precise. 4D Flow, whole-body MRI, and quantitative techniques are opening new ways to look at anatomy, physiology, and disease.
But with this new level of performance comes a new level of responsibility.
High-performance MRI does not only challenge the scanner. It also challenges the people operating it. Greater technical power requires greater awareness: of SAR, peripheral nerve stimulation, acoustic noise, patient comfort, and the risks that can arise when a patient is too close to the bore. The more advanced the technology becomes, the more important it is to understand not only what it can do, but also what it demands from the clinical team.
This article shares a first practical perspective on working with high-performance gradient MRI. It looks at what has changed, what new clinical possibilities are emerging, and which safety considerations become especially relevant in daily practice. Above all, it highlights the role of the radiographer: the person who translates technical potential into a safe, calm, and successful patient experience.
Because the future of MRI is not defined by hardware alone. It is defined by how confidently, responsibly, and thoughtfully we use it.
One of the most powerful and high-performance MRI scanners on the market was recently introduced and purchased at our site.
For those unfamiliar with it, MAGNETOM Cima.X, developed by Siemens Healthineers, not only combines cutting-edge software technology like Deep Resolve and a series of recently introduced sequences like Grasp-Vibe and similar, but also boasts the most vibrant hardware innovations.
State-of-the-art coils, the ability to automatically trigger with the patient's breathing using Biomatrix technology, and Beat Sensor technology to perform cardiac MRI scans without ECG positioning.
Finally, the high-performance Gemini Gradients provide unprecedented gradient capabilities, allowing us to use the system’s “Performance” mode in selected diagnostic and research contexts and achieve results that were previously difficult or impossible to obtain in routine clinical practice.
Figure 1: Davide Fierro next to a Siemens Healthineers MAGNETOM Cima.X MRI scanner. Image courtesy of Davide Fierro (Author).
High-performance gradient systems are essential for advanced MRI techniques such as diffusion MRI (Setsompop et al., 2013).
This article was born from the need to share a preliminary assessment of the experience we are gaining with a 3T system equipped with a gradient system capable of a gradient amplitude of 200 mT/m and a slew rate of 200 T/m/s, particularly in terms of patient safety and the clinical and research applications enabled by this level of performance, including echo-planar imaging.
We have noticed in our experience that the use of such high-performance Magnetic Resonance scanners can open up various clinical and research scenarios, in particular renewing the evaluation and classical conception of specific applications that have always represented the pillars of clinical study protocols such as Diffusion (quantitative evaluation of the Brownian motions of water molecules), functional Magnetic Resonance (performed to precisely evaluate the areas of brain activation following specific stimuli administered to the patient) and quantitative angiographic studies such as 4D Flow (where the fourth dimension is represented by time and which allows quantitative evaluations of the flow) which benefit greatly from the use of such high-performance scanners.
But let's give a technical overview of the specific clinical applications that can greatly benefit from using this system.
Let's give a technical overview of the specific clinical applications that can greatly benefit from using this system.
Diffusion MRI measures the microscopic motion of water molecules within tissues. Because water diffusion is influenced by cellular structures, diffusion MRI provides indirect information about tissue microstructure. (Basser et al., 1994; Jones, 2010)
Diffusion weighting is controlled by the b-value, which depends on gradient amplitude, duration, and spacing.
High gradient strengths allow:
larger diffusion weighting
Using high gradient intensity systems it is possible to reach very high b values, in the order of 2000 or more, and by using gradients in "Performance" mode it is possible to perform these acquisitions with clinical temporal resolutions and standard times. (Jones, 2010; Setsompop et al., 2013)
Diffusion-based acquisitions such as IVIM (Intravoxel Incoherent Motion) or Kurtosis can be performed without problems and in acceptable clinical times.
Figure 2: Example of a liver examination performed on a 3T MAGNETOM Cima.X, including an axial T2-weighted fat-suppressed image and an axial IVIM diffusion acquisition with 11 b-values, both using Siemens Healthineers Deep Resolve, as well as liver segmentation with quantitative T2* and R2* assessment. Images courtesy of Davide Fierro (Author).
Even in terms of b-value, high-intensity gradient systems, being fundamental elements in the use of echoplanar sequences, allow values exceeding b-values of 2000 to be achieved, potentially opening up previously unpredictable diagnostic scenarios.
In our daily experience, we are also using diffusion to perform assessments on tissue composition, such as a sort of virtual elastography, to be possibly compared with ultrasound data. This represents one of the most exciting scenarios for the use of such high-performance machinery, the possibility of exploring and implementing applications that were not previously possible.
Functional MRI (fMRI) detects brain activity by measuring changes in blood oxygenation as the BOLD signal (Ogawa et al., 1990).
Fast imaging sequences such as Echo Planar Imaging (EPI) are required to capture these dynamic signals (Feinberg & Setsompop, 2013).
High-performance gradients enable:
faster acquisition
This type of machinery allows for the experimentation of new tasks or models of stimulus and signal acquisition that allow for the experimentation and comparison of data that would not have been possible to acquire before.
4D Flow MRI is an advanced cardiovascular MRI technique that measures the blood velocity field in 3D over time.
The name "4D" stands for:
The technique is derived from Phase-Contrast MRI, but extends velocity measurement to the entire volume and in all directions. Blood flow velocity is encoded in the "phase of the MRI signal" using velocity gradients (VENC). By acquiring the volume during the cardiac cycle (ECG gating), a 3D velocity map is obtained for each time step.
Figure 3: 4D Flow MRI makes complex cardiovascular flow visible and measurable across three spatial dimensions and the cardiac cycle. Image courtesy of Davide Fierro (Author).
The dataset can reconstruct:
Streamlines (streamlines)
Wall shear stress
Volumetric flow
Blood kinetic energy
This information is difficult or impossible to obtain with traditional MRI. Main application of 4D Flow can be done in Cardiology in particular study of valvular heart disease, congenital Heart Disease.
One of advantages of 4D Flow application is that Any vessel can be analyzed after acquisition (without planning 2D planes).
Main Disadvantages:
long acquisition times (5–20 min), but with parallel imaging, like compress sensing can be limited. (Lustig et al., 2007)
lower spatial resolution.
need for complex post-processing.
sensitivity to velocity aliasing (VENC), which must be minimized with VENC-scout sequences.
One of the advantages of using synergistically high magnetic field strength and powerful gradient systems has enabled major advances in neuroimaging, cardio imaging, prostate imaging, Liver imaging and whole body (especially in terms of time that you need to acquire it).
Figure 4: Examples of high-performance MRI applications, including sagittal 3D FLAIR with 0.8 mm voxel size, axial PSIR real images, 2-chamber cine steady-state free precession imaging, T2 HASTE, and coronal whole-body T1 VIBE fat-suppressed reconstruction. Images courtesy of Davide Fierro (Author).
Major benefits include:
Figure 5: Quantitative liver evaluation highlights how advanced MRI can move beyond morphology toward measurable tissue characterization. Image courtesy of Davide Fierro (Author).
Having gained, over the course of my experience as a radiographer dedicated to MRI, especially 3T body imaging, in addition to the enthusiasm for working on such a high-performance machine, the first considerations I had to face related not so much to imaging as to patient safety.
Anyone who works dedicatedly in MRI knows how important safety is to prevent accidents, which unfortunately occur all too frequently and can cause significant damage not only to the scanner but also to the patient's health, requiring risky maneuvers such as the "Quench," which can lead to the deactivation of the static magnetic field B0, and costly helium refilling operations by radiology centers.
In addition to these considerations, another major safety concern relates to SAR and the use of gradients in "Performance" mode, which theoretically exploit the maximum available amplitude and can lead to peripheral nerve stimulation, which we will explore in greater detail later in this section.
Another important consideration concerns the bore size of these machines. MAGNETOM Cima.X features a 60 cm bore, which requires particular attention to patient comfort and positioning. In some patients, the relatively confined space may increase feelings of claustrophobia, potentially limiting tolerance of the examination and making optimal cooperation more difficult.
The patient size should not be excessive, to ensure optimal patient positioning without touching the internal walls of the bore. This approach, in addition to significantly improving exam performance, helps prevent potential thermal injuries that could occur and allow safe operation.
Magnetic field gradients, the cornerstones of the components of a Magnetic Resonance Tomography scanner, induce rapid linear energy variations of a few milliteslas and a few milliseconds, which can induce electrical currents in the human body, potentially stimulating peripheral nerves.
For this reason, when working with small bore sizes, it is essential to be extremely precise and careful when positioning patients. This is because patient comfort can be limited, as can their compliance. When positioning the patient, we must also use pads, especially laterally along the right-left application axis, to avoid contact between the patient's surface and the internal surface of the scanner, which could lead to thermal accidents and non-uniform and correct heat dispersion.
Figure 6: MR Safety Angel Pad prepared ahead of the MRI examination on a Siemens Healthineers MAGNETOM Lumina system. It helps reduce the risk of conductive loops and direct contact with the bore, especially in small-bore systems or when positioning larger patients. Shown here with PearlFit Wedge for added patient comfort. Image courtesy of Pearl Technology.
Since it's a high-performance device, it's essential to spend a few extra minutes explaining how the exam will be structured (will the patient have to cooperate with their breathing? Will they be asked to hold their breath during inhalation or expiratory breaths? Will they be notified when contrast is due to be administered? If so, what sensations might they feel?) as well as positioning it correctly to minimize claustrophobia and ensure the patient has a better memory of the exam, which is crucial when dealing with patients, especially cancer patients, who must undergo exams several times over time.
The acoustic limitations of using a magnetic resonance imaging scanner are related to the strong noise produced by magnetic gradients during image acquisition. This noise can reach high levels and must be managed according to specific safety regulations.
Generally, during an MRI scan, the emitted and perceived noise can vary between 80 and 120 dB, but in some rapid sequences, such as echo-planar sequences, typical of diffusion imaging and consistent with a research scanner that uses various diffusion applications and methodologies, it can even exceed 130 dB.
Compared to the noises we hear in our daily lives, for those unaware of the noises emitted by MRI, these levels can be compared to:
heavy traffic (~85 dB)
rock concert (~110–120 dB)
For this reason, hearing protection is mandatory, using earmuffs that reduce the patient's perception of noise.
There are various national and international reference standards. We will not directly address the individual national standards, but we will mention the international technical standard, International Electrotechnical Commission standard IEC 60601-2-33 (2022), which:
The radio frequency used in MRI to perturb the system and create magnetization on the transverse plane deposits energy that is absorbed by the patient's body during an MRI scan.
It is measured using a specific parameter called SAR (Specific Absorption Rate), which indicates how much power is absorbed per unit of mass. Its unit of measurement is W/kg.
When we move from a Low-Middle Field system to a High-Field-High-Gradient system, the SAR increases. This is because the Larmor frequency increases, as more radio frequency energy is required to excite the protons in a single layer. This increases the SAR.
The main risk is actual thermal heating of the tissues. Therefore, when we first began working on this type of scanner, I always advised patients to notify us if they noticed an increase in local heat perception. Possible effects included:
Increased body temperature
Possible local burns, which occur more frequently in: severely overweight patients, the presence of metal, and skin-to-skin contact.
Even in this case, there are national and international regulations, and we will focus in particular this time
on the International Electrotechnical Commission – IEC 60601-2-33 standard, which defines the main regulatory modes:
But how is SAR controlled in practice and what specific actions can be used in modern MRI systems? They automatically calculate the SAR, limit RF power, block dangerous sequences using pop-ups, and create alternatives to limit energy deposition.
Among the most commonly used technical strategies are: reducing the flip angle, increasing the repetition time (TR), and using less energy-intensive sequences.
The continued development of high-field MRI and high-performance gradient systems will significantly expand the capabilities of biomedical imaging. Future systems may achieve cellular-level resolution in vivo, enabling new insights into brain connectivity, neurodegenerative diseases, and personalized medicine. (Uğurbil, 2018)
Integration with advanced computational reconstruction techniques and artificial intelligence will further accelerate MRI acquisition and improve image quality.
Figure 7: The next chapter of MRI will be shaped not only by stronger hardware, but also by smarter reconstruction and computational workflows. Image courtesy of Davide Fierro (Author).
The journey has just begun, but already in these few months I have been able to experience a small taste of the future of our profession by working with this scanner: the speed of acquisition and post-processing processes, the possibility of high-impact quantitative imaging increasingly focused on microscopic structures, and the experimentation with different diffusion possibilities are opening up previously unthinkable scenarios.
The integration of all this hardware and software advancement will help us achieve even greater performance.
Our mission is to ensure we are prepared, to continue to train and not be overwhelmed by the advent of technology. Only then will we be able to fully exploit its immense potential, produce the best possible images for patients, and offer a high-quality diagnostic service.
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International Electrotechnical Commission. (2022). IEC 60601-2-33:2022: Medical electrical equipment – Part 2-33: Particular requirements for the basic safety and essential performance of magnetic resonance equipment for medical diagnosis. International Electrotechnical Commission. https://webstore.iec.ch/en/publication/67211
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