Postgadolinium with fat suppression sequence

Gadolinium concentrates in areas of inflammation and results in a hyperintense signal on Tl images. As fat is hyperintense on Tl sequence, images are acquired using a fat suppression technique. Normal marrow in the foot is predominantly composed of fat. Thus it is hypointense on the fat-suppressed images. Any bright or high signal after injection of gadolinium with fat suppression technique applied represents a focus of inflammation.

The main MRI finding in osteomyelitis is an abnormal marrow signal which is dark on Tl images and bright on STIR images. After injection of gadolinium the abnormal marrow enhances as shown by a bright focus on the fat suppressed Tl images. Further signs of osteomyelitis include cortical disruption and periosteal reaction. An MRI which is negative excludes osteomyelitis.

An abscess presents as a focal low Tl signal but a high STIR lesion. Following the injection of gadolinium on fat suppressed Tl images there is a low signal in the centre of the abscess.

However, MRI has notable limitations. MRI of the septic diabetic foot can show a number of false positive diagnoses. An abnormal marrow signal can be seen with Charcot's osteoarthropathy and fractures. The acute phase of Charcot's osteoarthropathy may show the same enhancing marrow oedema that is impossible to separate from osteomyelitis.

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