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Around 1 p.m. on Dec. 7, 2006, an MRI magnet exploded at Atlanta Diagnostic Center in Kennesaw, Ga. According to media reports, one of the workers moving the machine at the time suffered an injured arm, and the other worker had shrapnel in the back of his head. The blast also exacted a toll on the facility itself, leaving a 10-foot by 10-foot hole in a nearby wall.

About a month later, in January 2007, an MRI magnet at a facility in Birmingham, Ala., blew up in the middle of the night. While no one was injured, the explosion decimated the building's MRI suite and damaged the facility's exterior walls and roof.

Another MRI magnet explosion, which occurred in 2003 at the Peninsula Regional Medical Center in Salisbury, Md., was caught on tape by a local television station (video of the incident is available at www.youtube.com/watch?v=1R7KsfosV-o). A local news outlet reported that the magnet--in the process of being replaced at the time--was being vented when it burst.

At least five MRI magnet explosions have occurred in the U.S. within the last 10 years, and there may be others that have gone unreported, MRI safety experts say. Officially, no reasons have been given for such incidents, but there are links that would indicate a common cause. And like many other accidents, MRI magnet explosions can often be prevented by taking precautions.

Not quite a quench

An MRI magnet explosion is not quite the same as a magnet quench, and it's important to differentiate between the two, says Robert Junk, AIA, AHRA, founder and principal in charge of medical design with MRI-Planning in Kansas City, Mo.

Nearly all clinical MRI magnets have a cryogen vent, or quench pipe, which acts to conduct escaping cryogens to a safe discharge point, such as a rooftop.

A quench occurs when cryogens are suddenly released or vented from the unit's cryostat. This happens when the cryogens convert from a liquid to a gaseous state, he says.

A quench can be set off manually, by a technologist, when there is a need to rapidly reduce the magnetic field of the MRI unit, Junk says. This is only done in emergency situations, such as when a person is pinned to the magnet by a large metal object that cannot be removed by hand. A quench can also be caused by outside events that destabilize the magnet, including extended periods of power loss, extreme vibrations such as an earthquake, or improper maintenance or operation of the MRI, usually associated with servicing the cryogens. A handful of MRI units also spontaneously quench every year for no apparent reason, Junk notes.

A magnet explosion occurs when the release of gas is interrupted or blocked, causing pressure to build up and rupture the cryostat vessel or the quench pipe with explosive force.


MRI Magnet Explosions

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Mr. Wright's comments are right on mark! It is critical that trained, experienced and knowledgeable professionals be involved in all phases, from design to operation, to close out. Mistakes happen when these units are taken for granted, we see a lot of cases were inexperienced personal do not fully understand the implications of the vendors siting documents or assume that everything is the vendors responsibility. It is imperative that facilities keep up with on-going maintenance of elements such as quench pipe inspections along with the latest best practice developments in MRI safety.

Robert Junk,  President,  MRI-PlanningApril 01, 2009
Kansas City, MO



In two of the incidents mentioned in the article the magnet was being moved. No doubt, that the cryogen vent move kit was not properly installed ( installed at all) or an ice blockage was allowed to form during the quench pipe disconnection process. The middle occurance does not have enough information to form a conclusion, but if it was a functioning system the probable cause is an ice blockage in the quench pipe caused by moisture condensation. An incorrect installation of the quench pipe system. This shows that experienced, trained, and knowledgable service engineers need to be involved, (in charge) in the maintenance, installation, and removal of cryostats. Each incident you can site was caused ignorance and stupidity in the process if handling the cryostat. Helium expands some 500 times in volume when changing from a liquid to a gaseous state. A bomb waiting to go off if not cared for correctly. An anual inspection of the quench pipe system is required on all MRIs. Evidence of water condensation, ice buildup, and pipe blockages must be corrected. Cryostat pressure should be monitored at all times whether ramped up or not.
The RT is the first line of defense to notice something wrong on the installed MRI system. I trust and depend upon my RTs to assist me in preventing a disasterous service problem.

Tom Wright
Radiology Engineer
Heartland Health

Tom Wright,  Radiolgy Engineer,  Heartland HealthMarch 31, 2009
Saint Joseph, MO




     

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