It will come as no surprise that magnetic resonance imaging (MRI) is a widespread diagnostic tool, one that has proliferated since its introduction into hospitals a few decades ago. The MRI equipment is critical in medical diagnosis, disease staging, and follow-up. It is the choice of tool in order to perform investigation for neurological cancers. Higher resolution and better visualization technique make it the most preferred tool. MRI scanners are considered superior to other imaging modalities like X-rays and CT scanners. The MRI scans stand out as the obvious choice for many disease conditions such as dementia, epilepsy, and other infectious diseases; and now are being increasingly used in radiation therapy.
One of the potentially game changing fields in MRI is cardiac MRI. Cardiac MRI is widely used as complementary to other imaging techniques. It is extremely helpful in the assessment of serious heart ailments such as congenital heart disease and cardiomyopathies, etc. Simplification of advanced cardiac MR with automated image acquisition, visualization, free breathing exams, artificial intelligence, and machine learning speed cardiac MRI exam reviews and automatically identifies the anatomy and creates standard views.
Amongst the many advantages of MRI, nonionizing radiation foundation, superior contrast resolution, imaging in any plane, and tremendous potential for newer ways to image are the main reasons behind the upsurge in MRI usage. Vendors are also offering MRI sequences, which are lower on noise. Also, the recent advances in MRI can also be seen on the software side and are mainly directed toward decreasing scan time, reducing different types of artifacts, and enhancing the resolution of images obtained. Newer software delivers eight contrasts in a single acquisition that too in a fraction of time compared to conventional MRI. So one can generate multiple image contrasts in a single MR scan.
Despite several applications in human health, the recent figures suggest that the number of MRI scanners deployed across the world is lower than one might expect. Within Asia, Japan has the largest number. Though India has ten times the population of Japan, the number of MRI scanners in the country is ten times less. MRI, in other words, remains an elite and very expensive technology in the country. Demand is growing across India for improved medical care, fueled by rising incomes, increased insurance penetration, upsurges in chronic disease, and an aging population. And these shifts have led to a particularly strong demand for more and better imaging to diagnose and treat illness.
What is more, the growing access to imaging is uneven in the country. While many high-end private hospitals are actively integrating state-of-the-art equipment, the cost is still out of reach for most public hospitals, as well as many private hospitals in smaller cities. But some of that disparity is starting to flatten out. More hospitals are opting for the high-end equipment, even in Tier II and Tier III cities. Another problem is that most of the products developed in the west are not designed for India, and the country’s average patient population has a strong genetic predisposition for cardiovascular diseases (CVDs). CVD is the leading cause of death in India, and is becoming increasingly common among younger age groups. Myocarditis is another large health problem in the country, and requires cardiac MRIs for accurate diagnosis and treatment. The whole field has shifted toward diagnosis and treatment based on imaging.
MRI scanners of different magnet strengths are commercially available in India, ranging from 0.2T to 3.0T. Lower-field scanners (less than 1 T) have the advantages of easier installations and lower costs, and are used in specific situations, but these systems suffer in broader clinical applications due to lower signal strengths and longer scan time. So for routine clinical use, 1.5T or 3.0T MRI scanners are preferred. Needless to say that as the magnet field strength increases, the signal increases and the costs go high as well. However, as the healthcare system undergoes significant reform, the emphasis is now shifting from treatment to prevention, which in turn improves the efficiency of diseases and care management. Greater awareness and technological innovation are enabling people to take charge of their health and focus on disease prevention. As India’s population booms, the country needs a very efficient imaging technology to screen and diagnose patients. The requirement of proper teleradiology setup, the digitization tool, and the right infrastructure is humungous.
Indian Market Dynamics
The Indian market for MRI equipment seems to be converging toward the 1.5T and 3T systems, with the refurbished and 0.2T-0.5T diminishing in their relevance. The buyers are upgrading themselves to the next category.
In 2017, it is estimated as ₹1750 crore, with 1.5T continuing to dominate the market.
The imaging centers are increasingly overcoming the previous challenges of image distortion, shadowing with the multi drive RF transmit technology with silent scans. The conventional 3.0T MRI systems acquired the patient data with coils and transmitted them to an electronics room through copper cables. In the digital versions, the signals are digitized in the machine room itself and then transmitted to the electronics room via broadband optical fiber cable technology, thus minimizing signal loss and improving the image quality for better diagnostic confidence. The technologically superior 3T machines overcome tissue heating by automatically customizing and delivering the optimal magnetic waves as per the size and shape of the patient, through its personalized patient management system. They offer clinical benefits across spectrum of medical specialties by using advanced applications in neuro, spine, vascular, abdomen, whole-body, breast, cardiac, musculoskeletal, ortho etc. and have espoused the new horizons in diagnostic capabilities and have the potential to change the course of treatment.
However, since GST implementation, some medical facilities located in Tier III cities and smaller towns are compromising and foregoing the automated sequencers in-built in the better machines.
In 2018, 18 district hospitals in Uttar Pradesh are set to get MRI units. The Patna high court had also directed the health department to ensure that MRI machines are installed in all government medical colleges and hospitals in the state.
India is currently facing a shortage of trained medical imaging professionals, largely because imaging has become so crucial to dealing with most illnesses. Telemedicine could address some of the imaging shortages. Rural and other hospitals that lack enough radiologists are starting to turn to this technology in the hopes that they can farm out some of their imaging needs to better-staffed hospitals. Many major healthcare systems in India, including Fortis Healthcare, Apollo Hospitals, and Narayana Hrudayalaya, have already invested heavily in telemedicine services to try to meet that demand.
Unique Broadband Systems Ltd (UBS) of Canada and Kaynes Technology of India, have been awarded funding by the Global Innovation and Technology Alliance (GITA) of India and Global Affairs Canada, for the co-development and co-marketing of high power RF amplifiers for low-field MRI applications.The project is expected to be completed by 2019. This joint venture will introduce a breakthrough technology in RF based power amplification of MRI or any image processing devices. It enables portability, less heat dissipation, and easier cooling through normal air coolers for MRI scanners. This in turn, will make MRI scanning machines more affordable and will also be suitable for rural applications.
The global MRI market is projected to rise from a valuation of USD 6611 million in 2017 to reach USD 9120.8 million by end of 2022, reflecting a CAGR of 6.6 percent, predicts Transparency Market Research. Recent advances in scanning technology used in MRI and substantial advancements made in imaging contrast agents with respect to biologic tolerance and contrast capability are key developments expected to accentuate the market. In addition, the notable flexibility in the use of these agents is also a significant factor bolstering their demand among patient populations. For instance, paramagnetic contrast agent is preferred for obtaining an accurate and precise diagnosis.
The rise of novel applications areas of MRI modality such as in diagnosing multiple sclerosis and breast cancer is a notable trend boosting the market. Furthermore, the growing application of MRI-guided radiotherapy for brain tumors and in neurosurgical planning is a crucial factor accentuating the market. However, the high cost of MRI system, along with problems in serviceability, and the low reimbursement rates for MRI procedures in various developing countries are key aspects likely to hinder the growth of the market. Nevertheless, the advent of cardiac pacemaker-compatible MRI modality is a significant product innovation opening up exciting opportunities for market players.
The closed MRI systems segment accounted for the major market shares and dominated the market in the past. Though the growing popularity of open MRI equipment will result in decreasing this segment’s revenue shares, advantages such as high image quality and high magnetic field strength will aid in their adoption in the coming years. Moreover, the low-field strength MRI systems segment accounted for the major shares and dominated the market in the past owing to the various advantages of low-field strength MRI systems such as low device cost, open scanners, low operational cost, lower fringe field, and lower exposure to radiofrequency pulses. Of all the product types of MRI, the 1.5T MRI currently is the dominant segment and is predicted to hold a share of 49.5 percent by the end of 2022.
Geographically, North America is the leading market and is predicted to hold the major revenue share till 2022 and is estimated to contribute revenue of USD 3212.1 million by 2022 end. The dominance is attributed to the vast commercial demand for technologically advanced MRI modality, mainly for a timely diagnosis of various chronic disorders among populations.
Several players are focused on launching a wide portfolio of advanced MRI equipment and are focusing on geographic expansion in a move to consolidate their shares over the years. Additionally, the market also has the presence of software providers which further intensifies the level of competition in the market.
Emerging Market Trends
According to Technavio, there are three emerging trends that will drive the global MRI systems market.
Strategic initiatives. Vendors in the global MRI systems market are adopting strategic initiatives to survive in the highly competitive market space. Complementary players are involved in strategic collaborations and mergers and acquisitions to improve their geographical presence and enhance their expertise. This will help in the development and launch of new products. Additionally, end-users will have a wide range of treatment options based on the complexity of the disease. Thus, strategic initiatives will give a boost to the vendors in the market by providing an added advantage to the vendors involved.
Growing focus on development of PET/MRI hybrid imaging systems. The market is witnessing the emergence of PET/MRI hybrid imaging systems, which combine the anatomical imaging and functional imaging data, bringing excellent soft tissue characterization and imaging provided by MRI scans without ionizing radiation. Also, PET/MRI hybrid systems have major applications in breast and prostate cancer. Vendors such as Philips, Aspect Imaging, and MR Solutions have all launched indigenous PET/MRI hybrid systems. Such initiatives are expected to provide a boost to the market over the years.
Growing importance of tele-imaging. Tele-imaging is key to provide quality healthcare in remote areas where necessary technology is not easily available. The introduction of fully automated, versatile, and easy to use imaging systems has led to the significant expansion of teleradiology and tele-imaging in remote areas. Currently, researchers are focused on developing a low-cost tele-imaging platform by using inexpensive and readily available technology/equipment to further increase the adoption of tele-imaging in low and middle-income countries. This has driven the demand for digital imaging both in developed and developing countries such as the US, Germany, Japan, India, Brazil, and China, thereby driving market growth.
The technological developments during recent years have been dramatic. Recent technological innovations in MRI, such as the next wave in parallel imaging and motion correction techniques, have further reduced scan times and improved imaging quality. There has also been a re-imaging of the ambient environment of the imaging suite. Further with the magnetic flux level increasing from 1.5T to 3.0T or 7T, the accuracy of detection increases through better imaging quality.
Another improvement is a lessening of the noise level during a procedure. Some scans involved a series of hammering sounds, which could also be frightening. Depending on the type of test, the noise level in a newer machine can be as quiet as the running of a home dishwasher. Also, with the more obese patients, having the current wider bore scanners is important. Just getting a patient in and out of a scanner can be a challenge with certain body types. Having wider bore scanners does facilitate that quite a bit. Thus, the changes in scanner technology have been significant.
Increased magnetic flux. The market has witnessed the transformation of 3T imaging from niche to mainstream. Initially, buyers were not sure if it would be worth the investment. The initial expectation was that 3 T would be great for neuroimaging, MR angiography, MR spectroscopy, and advanced fMRI and DTI applications. However, the technology has matured, 3T pulse sequences have been improved, motion correction has been introduced, and the range of applications has started to ramp up. What 3T has brought to these areas is nothing short of unbelievable. The detail one sees now on wrist exams, elbow exams, ankle exams at 3T is stunning.
Parallel imaging. A milestone in the advancement of MRI came with parallel imaging. The sensitivity encoding (SENSE) parallel imaging technique enables a reduction in scan times by a factor of two or more. Since its original implementation, continuous improvement of the technique has increased its performance and now the new advances allow greatly increased speed in the routine clinical setting. Faster image acquisition can also help decrease breath-hold times, resulting in reduction of motion artifacts and fewer motion-corrupted images.
Propeller imaging. Parallel imaging is not the only improvement that has pushed the boundaries, aiming to further shorten scan times without trade-off in terms of image quality. Another important innovation is development of propeller imaging. Now many vendors have a propeller type of method. The method is based on constructing parts of images at a time, and running the scan so quickly that the second time one runs it they acquire another part of the exam, and third time another part of the exam. So it looks like one is acquiring a single picture – a full picture at one moment in time. And it reduces the amount of time exposure for each part of the image. It almost looks like freezing human motion.
Increased efficiency and throughput. Technological advances in the modern imaging suite have also led to efficiency gains. With the conversion to PACS-based radiology departments, there has been a dramatic increase in the volume of scans that one can read in a day. Just by not having to physically hang a film but simply clicking on the next one saves time; having the prior studies immediately available saves time and helps to deliver quality in radiology care. Coupling these changes with communication tools to enhance critical results reporting, image sharing for second opinions on the fly, and regular peer reviews have all raised the bar in radiology. Likewise MRI scanners have allowed for improved throughput by enabling to perform scans in a shorter period of time.
MRI linear accelerator. The major technological advance in the field of radiotherapy is the merger of MRI and linear accelerators to create a hybrid machine – MRI Linac. The MRI Linac will push the technology of image guided radiotherapy to a completely new level. MRI gives much better soft tissue contrast when compared to CT scans. This allows a better assessment of the target at the moment of treatment over traditional CT scans. There is not a huge radiation dose delivered per CT scan, but a patient will normally undergo anywhere up to 38 radiotherapy treatments. There will be no dose associated with MRI Linac pretreatment imaging.
From the start MRI has constantly been in development in order to improve image quality and the set of scans for different purposes. Images of higher quality are very helpful to improve the accuracy of diagnosis and for the improvement to treat various complications. These days much research is still being done to broaden the use of magnetic resonance. 7T MRI scanners are the most interesting systems to do research because they recognize more detail and the scan times are shorter. With recent FDA clearance of the first 7T MRI system in October 2017, the future 7T scanners might become the new clinical standard.
However, the challenge is to bring down the costs for these systems. The development of low-cost, compact MRI will make affordable diagnostic imaging more widely available at the healthcare facilities, and also in remote or rural communities and smaller medical units that do not have ready access to these technologies.
Multiple initiatives are taking effort at this moment to build lower cost MRI systems with state-of-the-art technology. In recent years, changes in healthcare systems and the constantly shifting economic situation of the country have increased the emphasis on healthcare costs and have influenced purchasing and operating models in MRI.
There are more than 800 medical-device manufacturers in India, and many of them are aiming products at the country’s medical-imaging market that is expected to hit USD 2.3 billion by 2020, according to a Deloitte report. Despite achieving considerable growth, the country still depends heavily on imported devices for addressing domestic demand. More than 70 percent of medical equipment sold in the country is imported.
Through Make in India, the government is looking to build manufacturing hubs to address the issue. Also, the Medical Devices Rules 2017 is expected to push domestic manufacturing and provide big opportunities for players. All in all, the rapidly expanding sector presents immense growth opportunities.
Technology Trends in MRI
Rakesh K Gupta
Director and Head of Radiology and Imaging,
Fortis Memorial Research Institute
At present, MRI is the most versatile diagnostic imaging modality that has the ability to demonstrate a wide range of imaging contrasts in humans with exquisite spatial resolution. In brief, the current technology trends in MRI are:
State-of-the-art MR hardware: multi-transmits enabled dual RF amplifiers with digital multi-channel acquisition at 3.0 T as the optimal MRI system to improve the speed of data acquisition while maintaining the high-resolution imaging in routine clinical set-up.
A number of MR methods are being employed in MR scanners recently to improve the speed of MR data acquisition and to decrease the total MRI scan time duration for each patient using techniques like compressed-SENSE, spiral MR acquisition without compromising diagnostic information and resolution.
The current trend is to develop MR technique/sequences without the use of an external contrast agent like arterial spin labelling (ASL) and BOLD fMRI to study tissue perfusion, amide proton transfer (APT) imaging to study the molecular mechanisms in tumors
There is a big push toward noninvasive accurate quantification of the fat and iron content in the liver at a stage when it can be reversed. Currently, fat quant and iron quant techniques that are available at MRI machines will have an impact on maintaining liver health and thus prevent the development of cirrhosis and its related complications.
Development of ultrashort TE-based sequences have resulted in imaging of the bone cortex, and lung imaging with exquisite details which will be the boon especially for children where CT should be avoided due to harmful effects of radiation.
Though the 7 T MRI is a research tool in the US of America and Europe, it has been recently approved by FDA for human clinical use. It has a great potential by further improving the resolution of imaging especially in neuroscience where we can attain a resolution of 50–60 microns in vivo. However, it is hampered by the cost of the machine and its commercial viability besides its stability in the current form. It may have a huge potential in future with improvement in RF technology, pulse sequence design, and its use in whole body imaging.
In addition, in the near future, we may also observe MRI’s new expansions in various so-far non-traditional applications like MR-guided radio-therapy using hybrid systems like MR-Linac
Caution: The Magnet is Always ON
Dr Mona Bhatia
Director and Head of Department
Department of Radiodiagnosis and Imaging
Fortis Escorts Heart Institute
Recent unfortunate accidents and the events that have ensued have forced many organizations to do a self-introspection and audit of the on-ground MRI safety guidelines, SOPs, and standards being followed to ensure patient and personnel safety. Meticulous training is key to prevent any future accidents and hence many organizations need to revisit their MRI safety protocols and add multifold layered safety precautions besides implementation of strict protocols.
Needless to emphasize that the MRI magnet is always on, irrespective of whether a patient is being scanned or not. The MRI magnet generates an extremely strong magnetic field which extends in all directions from the center of the magnet. Unfortunately this field cannot be seen or felt. A 1.5T magnet has 15,000 times the strength of the earth’s magnetic field; a 3T magnet has 30,000 times the strength. Ferromagnetic objects are strongly attracted to the magnetic field and have the capability of creating a missile phenomenon. Hence patients, personnel, and attendants need to be made fully aware of the risks including the wheeling in of patients, their oxygen source, any devices and implants etc. It is of paramount importance that unauthorized/non-trained/uninformed persons should never be allowed to assist/accompany a patient into the MRI suite. The MRI suite must necessarily have a double layer of protection from random people straying into the premises, particularly at night, in addition to adequate signage and warnings in English and in the local language.
Implants and devices are not always an absolute contraindication for MRI. Implanted devices are classified as MR safe if the item poses no known hazard; MR conditional items demonstrate safety within defined conditions and MR unsafe items pose unacceptable risks to the patient, medical staff, or other persons within the MR environment. Utmost precautions are a must to verify the implants and their category with adequate preliminary steps to ensure only patients with MR safe and MR conditional implants enter the MRI. In the event of patients with pacemakers, the MR conditional pacemaker is switched in an MR-compatible mode in order to perform a risk-free examination eliminating possible hazards in the MRI environment.
A safety training schedule must be mandatory for all personnel and new joinees for diagnostic centers and hospitals to train staff who are responsible for patient transfer to and from the MRI suite especially when the patient is a child. Screening and projection of MRI safety training videos and loops in the MRI waiting area, ensure both patients and relatives are alert and informed regarding the safety rules associated with an MRI scanner. Although doctors and technicians are usually well aware that unauthorized entry into the MRI field can cause potential hazards to personnel, relatives and/or, patients. Further, new staff training and written assessment on safety protocols is a must.
It is now imperative that all MRI suites do internal and external audits to ensure safety of patients, relatives, and personnel in a professional manner and take heed of the signage, Caution: The Magnet is Always ON.