Value Add

Which MRI to Buy— Superconducting or Permanent?

In conversation with Som Panicker, Vice president, MRI Division, Sanrad Medical Systems

Som Panicker Vice president, MRI Division, Sanrad Medical Systems

Buying any capital medical equipment is a big decision, and most of the individual or institutional customers will have to go through this question on what kind of MRI they should purchase, and we have found out that many customers are confused with this basic step of identifying the right type of equipment suitable for them. In the process of unfolding this most important start up question we have decided to talk to few experts from both Superconducting and permanent type MR equipment segment and share their expertise.

In this first series of articles we have spent some quality time with Som Panicker, Vice President of MRI Division with Sanrad Medical Systems who spent more than 17 years of experience in MR equipment industry. He has rich project and product management experience both with superconducting as well as permanent MRI including Philips Medical Systems and Hitachi medical systems before taking over MRI business of Sanrad representing MDT, USA. He was involved with many MR sales processes and always advised customers on merits and demerits of various types of MRIs.

Let us start with a basic question what is the basic difference between different types of MRIs available in the market.

In order to understand this basic concept let me put this in a small table which is very helpful for you. (See table 1).

When a customer starts planning an MRI, what are the factors he/ she should consider to decide on what type of magnet?

Every customer should consider a few aspects before finalising a MR type. They are:

• What will be the patient load? How many patients per day?
• Is this site a private diagnostic centre, hospital, referral or research centre?
• What is their budget for initial purchase and annual service cost?
• What is the geographical area this MR will serve and its population?
• How many MRIs are already in this area?
• How many physicians, neurologists, neurosurgeons, orthopaedic surgeons are based in this area?
• How and who will invest? Financed by a bank /financial institutions or own funds/donation/charity/public fund?

I can make a logical recommendation going through these answers and most probably they can get convinced on that logical conclusion.

You have worked on superconducting MRI for many years, how do you compare the quality between these two systems?

Frankly speaking we should not compare superconducting MRIs with permanent systems as they are two segments of customer choice and we should help the customer to make a right choice depending on his needs and capability. I have great respect for superconducting MRI and I am also closely following the developments with 3T and updating myself with some experimental systems like 7T and 9T MRI. These are ultimate in MR research and are very useful for new experiments in clinical diagnosis.

Permanent MRIs were developed around 25 years back but became popular only in the last 10 years due to tremendous improvements in system design, image quality and new pulse sequences at par with high tesla systems.

I remember when I was working with superconducting MRs abroad in 90s, in our training courses they used to teach about MRI and they used to say the so-called permanent magnets are very low tesla magnets not good for clinical diagnosis. Today, most of the MR manufactures are making permanent magnets and are very successful in making good business globally.

But there is a wide spread campaign that permanent magnets are compromise systems offering low image quality. How do you tackle this issue?

It is true that permanent MRI are cost-effective systems offering image quality acceptable to routine clinical diagnostic standards and keeping in mind the investment required.

This is like a situation you are looking for a good car which you can afford to buy. There are many models of car which can satisfy all your quality expectation and offering extremely high specification. But basic question is how much you can afford to spend on a car and is it satisfying your requirements to a large extent.

In fact, a 1.5T system is also a compromise system compared to 3T systems and a 3T system is superior in specifications and quality and I whole-heartedly recommend a 3T MR system for any customer who says investment is not an issue and he want the last word in MRI.

How do you react when a customer says only Supercon MRI will be good for him?

Unfortunately, many individual customers reach their conclusion without applying their mind logically and buy a brand new, refurbished or used supercon MRI and then land up in never-ending financial difficulties and viability problems.

If they start working on a base point like how many patients they want to do and most of the time an answer to this question will give their first lead to this confusing question. I have asked many neurosurgeons and neurologists working with permanent MR systems and most of them said in less than two per cent cases they find permanent MR image quality is not enough for making their diagnosis and referred such patients to higher tesla systems. This is very important aspect and we can say the same thing can happen with 1.5T compared to 3T image information.

Can you tell us how permanent MRIs have become very popular in India and many countries in recent years?

Permanent MRI became popular first in Japan mainly due to less space for installation and low initial cost as well as running cost. Japanese medical equipment gained acceptance all over the world due to its low cost, high reliability and high image quality. Japanese-made permanent MRs also entered other markets like India and Far East. Permanent MRs are sold in USA mainly as secondary units or interventional units with their popularity and acceptance multiplied all over the world. Today, other than Japan and USA, maximum number of permanent MRs are installed in India and the growth and success of permanent MR market in India was phenomenal. With the soaring dollar prices, it becomes no longer viable for an individual buyer to invest in 1.5T or 3T superconducting as patients can only be charged equally irrespective of supercon or permanent MR systems in a private diagnostic centre.

Are permanent MR Systems bought only because they are cheap?

Definitely not. Permanent MR Systems are acceptable today like any other superconducting MRI and many times preferred over a refurbished 1.5T MR system and I can give many examples of customers opted for permanent MRI despite they have resources for buying any 1.5T or even a 3T MRI. They bought the system after getting fully convinced that they can do 90 per cent of their MR requirements using a good quality permanent MR system compared to a high field MR system. Of course most of the customer keeps in mind what investment they need to make for an MR system and how fast they can get their return on investment. But that is not the only reason for making their choice but the acceptance of permanent MRI image quality by most of the clinicians.

What is the benchmark for an MRI image quality and how far this is achieved by permanent MRs?

When you are talking about quality with permanent MRI, unfortunately not all the permanent MR systems available today are of the same quality standard. There are some brands which are acceptable worldwide due to its high specifications and image quality. I would like to compare only those systems with a radiologist's expectation from an MR image.

A very quality conscious radiologist or clinician looks for at least the following basic factors in any MR image:

• How good is the spatial and contrast resolution of the image?
• How good or better is the Signal to Noise Ratio (SNR)?
• How less artefact in the image?
• Am I getting the information I am looking for diagnosis?

Permanent MRI images are improved in all these aspects over the last 10 years and some factors like artefact reduction they are better off than high field magnets. In fact, I have shown a puzzle of mixed MRI images to more than 10 of my radiologist friends and more than 80 per cent permanent magnet images are mixed with 1.5T as well as 3T images. Except for angio, most of the radiologists could not separate permanent magnet images from this set. It is a fact if you know in advance that these images are from a permanent MRI, you may look them with a different mindset assuming that they cannot better than 1.5T. Unfortunately, sometimes some bad quality images are printed from high tesla systems due to various reasons like poor installation, reconditioned systems, bad environment, bad operator skills to get good images.

The radiologist will look at the MRI picture shown at the right side and try to co-relate the text book image he has in mind and then how good he can match with it the better he will appreciate the image. Now, if I ask him can you make out which MR is used here, is it supercon or permanent? In fact, if we can satisfy his requirements he will not care if the magnet is A, B or Open. And permanent magnet manufactures have been working for many years to match this quality expectation.

You mean to say permanent MR quality is as good as Supercon?

Not exactly, as I have explained in the beginning, permanent MRI are acceptable as a cost-effective solution having a tread off between price and quality and can be used for 90 per cent of the routine examination. When you talk about limitations higher field systems like 1.5T or 3T systems also have certain limitations and some time refer the same patient to an Open system. A typical example is joint motion studies (kinematic studies).

I have one funny experience when a marketing guy explained to a referring doctor that a 1.5T system will have five times better quality as 1.5/ .3= 5 , this is a ridiculous judgment as the quality is not five times less for permanent and supercon is not five times greater. Once we understand this quality aspect it is much easier to make a conclusion on what MRI you should buy.

Is field strength of the magnet or Tesla a major criterion?

Of course. But field strength of the magnet is not the only criterion for image quality. Other than magnet technology there is also the entire signal chain and the respective software. In the latest permanent MR systems there are several new techniques developed to improve the filtering out of movement and noise artefacts.

The second important argument for MRI examinations with an open system is patient comfort. Many patients are still too nervous about undergoing MRI examinations— a problem significantly alleviated by the use of open systems. Most of the open systems offer a free view around the patient, making it suitable for groups of patients with particular problems like children or obese patients.

Also, there is a major advantage in open systems for the examining doctors. Examination times can be shortened significantly, and the open system makes certain interventions, like in catheterisation or biopsies, possible. Additionally, MRI imaging is now of interest for further indications. For example, orthopaedic specialists who want to study a musculoskeletal organ or a joint dynamically. Radiation exposure in CT examinations has been continually reduced, but still has to be considered and the effects of exposure to radiation should be viewed cumulatively. In this, MRI examinations are superior to CT scans.

Thanks to the higher dollar exchange rates, lot of refurbished or used MRIs, both supercon as well as permanent MRIs, are quite popular. What is your advice for people looking for such cost-saving solution?

I am very happy, you have asked me this question when we talked about cost-effective solutions. Unlike CT, an MR installation is a complex process and lot of factors like transport of the magnet, shielding room, environment, equipment history, damage while offloading, coil damage or poor performance etc will result in poor image quality coming out of a second hand or refurbished MR system. Adding to the mystery, most of the time installations or adjustments of a used MRI will be done by people who have not trained on the system.

As a result, more than 95 per cent of the used MR customers are unhappy. Risk of buying a refurbished supercon system is very high as spare parts can be very expensive as well as maintaining a supercon system will be much more than maintaining a new supercon system. Also, while transporting a used permanent MR system, shimming or the homogeneity of the magnet can go partly or completely bad and if it cannot be corrected will end-up in very bad image quality. Installing a used MRI will never be the same like installing a factory shipped new MRI. I have seen plenty of used MR customers struggling with no escape route due to a bad image quality and expensive running costs with used MRI system.

Many of the MR systems or components like coils are made in China today, but are they reliable?

It is true that most of the MR magnets as well as coils irrespective of the origin of the MRI company are now made in China. Every raw material required for making magnets or MR components are easily available in China making it one of the hot destinations for all MR vendors. That is the reason nine out of 10 MR manufactures have set-up their main factory or accessory units in China today.

These products are manufactured or assembled in China do not make any degradation or deviation in quality as these high-end medical imaging equipment are manufactured as per strict quality control norms and are highly reliable. Unfortunately, there is a general impression that anything coming from China are inferior. Japanese products were facing a similar situation 25 years back from the US and Europe. China is one country that has made tremendous progress in science and technology or space travel in recent years and they have developed some of the most advanced scientific equipment on par with any advanced country in the world. In my opinion, China will be a superpower in next 10 years and even the US will have to struggle to catch with China then.

Finally what is Sanrad and MDT doing with permanent MRI and what is your vision on the future of permanent MRI in India?

Sanrad is the company built on customer trust and unlimited service support thanks to the ideology of our founder and mentor Ratish Nair. Every product we introduced in the market was after carefully evaluating the pros and cons and keeping enough number of spares. There is a wide-spread belief among our customers that anything they buy from Sanrad will never let them down. In fact this very same feeling make us very responsible company while growing big. Before entering into permanent MRI segment Sanrad evaluated at least five different MR vendors and finally reached an agreement with MDT, US to represent them in the Indian subcontinent. I have spent almost a month evaluating this product before joining Sanrad, as I need to convince myself before convincing others. Today, I can say with confidence and pride that both our permanent models Century 3000 0.3T and mstar 4500, world's first 0.45T are superior in specifications and image quality with any equivalent field strength permanent MRI available in the world.

MDT already developed world's highest strength permanent magnet model xstar 7000 which is 0.7T MRI, which is now undergoing testing in factory which will be launched in 2010.

We are very confident that Sanrad MDT MRI will be one of the most sought after permanent MRI in India this year and we focus on our customer first approach to take MDT to the number one slot in permanent MRI segment in India.

Contact:
Som Panicker
Email: sompanicker@yahoo.com
Tel: +919920246688