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 Table of Contents  
Year : 2018  |  Volume : 13  |  Issue : 3  |  Page : 160-161

Magnetic resonance imaging mishaps: A brief review

1 Department of Prosthodontics, College of Dentistry, Gulf Medical University, Ajman, United Arab Emirates
2 Department of Oral Medicine and Radiology, College of Dentistry, Gulf Medical University, Ajman, United Arab Emirates
3 Department of Periodontics, College of Dentistry, Gulf Medical University, Ajman, United Arab Emirates
4 Department of Orthodontics, College of Dentistry, Gulf Medical University, Ajman, United Arab Emirates
5 Department of Pedodontics and Preventive Dentistry, College of Dentistry, Gulf Medical University, Ajman, United Arab Emirates
6 Department of Endodontics, Thumbay Dental Hospital, Ajman, United Arab Emirates

Date of Web Publication17-Jan-2019

Correspondence Address:
Dr. Shakeel Santerbennur Khazi
Department of Prosthodontics, College of Dentistry, Gulf Medical University, Ajman
United Arab Emirates
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdmimsu.jdmimsu_63_18

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Imaging and laboratory test are vital components for accurate diagnosis of any medical condition. In the current scenario, computerized tomography and magnetic resonance imaging (MRI) have dominated the field of imaging. Although much is spoken and written about the radiation hazards of computerized tomography, safety aspect of MRI hardly receives any importance. A recent accident involving a diagnostic MRI unit in Mumbai highlights the importance of safety aspects being neglected in MRI. The authors of this article have made an attempt to highlight the facts about MRI-related fatal accidents and briefly review the safety protocol and procedures.

Keywords: Accident, magnetic resonance imaging, mishap

How to cite this article:
Khazi SS, Shetty SR, Reddy SM, Vannala VR, Shetty RM, Shetty P. Magnetic resonance imaging mishaps: A brief review. J Datta Meghe Inst Med Sci Univ 2018;13:160-1

How to cite this URL:
Khazi SS, Shetty SR, Reddy SM, Vannala VR, Shetty RM, Shetty P. Magnetic resonance imaging mishaps: A brief review. J Datta Meghe Inst Med Sci Univ [serial online] 2018 [cited 2021 Nov 28];13:160-1. Available from: http://www.journaldmims.com/text.asp?2018/13/3/160/250107

  Introduction Top

Magnetic resonance imaging (MRI) is one of the most widely used diagnostic modalities in soft-tissue imaging. MRI is considered to be relatively safe. However, hazards associated with its powerful magnetic properties cannot be underestimated.[1] MRI-related accidents are usually underreported on most occasions.[1] There is an ever-increasing demand for MRI scans, and the MRI machines that are being manufactured are more powerful compared to their predecessors, and the probability of fatal and nonfatal accidents involving MRI units can be expected to rise if safety protocols are not followed consistently.

  Magnetic Resonance Imaging-Related Accidents Top

An unfortunate recent incident that hits the headlines of many Indian and International newspapers was of the death of a 32-year-old male after he walked into the MRI room to visit a sick elderly relative while carrying an oxygen cylinder.[2] Television reports stated that the victim's hand was stuck in the machine when the damaged cylinder burst, causing enormous oxygen leakage. Although he was hurried to the emergency room within 10 min, he was declared dead.[2]

In another recent incident in the neighboring island nation of Sri Lanka, a 5-year-old girl undergoing MRI scan was killed. The experts believed that the death had resulted due to escaping of a quench–cryogen gas into the MRI scanning room and displacing oxygen.[3]

The fatal accidents have also been reported from other parts of the world. In 2001, a 6-year-old boy was killed in an MRI-related accident in New York, USA. The cause of death was an oxygen canister which turned into a guided missile by the MRI magnet. The child received a fatal blow on the head, which resulted in his death.[4] This was the first ever fatal incident ever reported in MRI-related accidents.

Although fatalities involving MRI machines have been exceptionally few, nonfatal accidents have been reported frequently. In one such recent accident in a hospital in Delhi, India, two hospital workers were pinned down for 4 h between MRI machine and a large metal tank metal oxygen tank.[5]

There has been a considerable rise in the number of MRI-related accidents over the past few years. Recent database study revealed 185% upsurge in of MRI mishaps compared to previous years. This increase was attributed to the increased installation of MRI equipment and the lack of formal training programs for all the MRI imaging facility workers.[6]

One of the major concerns of MRI safety is attributed to the “missile effect.”[7] The “missile effect” occurs due to the peripheral field component of the static magnetic field of an MRI unit, which rapidly attracts a ferromagnetic object into the scanner by substantial force.[7] This kind of missile effect could have made MRI procedure a contraindication for patients with orthopedic implants, materials, and devices. Fortunately, most of these devices are made from nonferromagnetic materials, thereby not interfering in MRI procedures.[8]

Cardiac pacemakers and implantable cardioverter defibrillators cause problems to patients undergoing MRI procedures causing alteration in pulse generation.[9]

Over 600 of the 1800 equipment have been tested for the effect of MRI.[10] The list of equipment includes ferromagnetic objects which include metallic objects comprising iron such as scissors, laryngoscopes, nail clippers, pocket knives, and steel buckets. The list further includes equipment such as wheelchairs, gurneys, and intravenous poles.[11]

In some magnetic resonance systems, the stray field may decrease very quickly with distance.[12] It has been observed that an object that does not appear to demonstrate ferromagnetic properties at a longer distance suddenly be snatched from your grasp as you step closer.[12]

Besides the occurrence of missile effect injuries, there are reports of focal heating and patient burns sustained while undergoing radiographic investigations with magnetic resonance scanners.[13],[14],[15]

  Conclusion Top

This brief review tends to highlight the hazards of magnetic resonance scanning by providing brief accounts of rare but significant MRI scanner related.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Ng KH, Ahmad AC, Nizam MS, Abdulla BJ. Proceedings of the International Conference on Non-Ionizing Radiation. UNITEN, Selangor, Malaysia; 2003.  Back to cited text no. 1
Malloy M. Indian Man Dies after Freak MRI Machine Accident at Mumbai Hospital. The Telegraph. Available from: http://www.telegraph.co.uk/news/2018/01/29/indian-man-dies-freak-mri-machine-accident-mumbai-hospital. [Last accessed on 2018 Feb 19].  Back to cited text no. 2
Millburg S. 5-Year-Old Girl Dies during MRI in Sri Lanka. Diagnostic Imaging, Medical Ethics, Neuroradiology, Pediatric Radiology. Available from: http://www.radiologydaily.com/?p=10259. [Last accessed on 2018 Feb 19].  Back to cited text no. 3
Peck P. Fatal MRI Accident is First of its Kind. WebMD Archives. Available from: https://www.webmd.com/a-to-z-guides/news/20010801/fatal-mri-accident-is- first-of-its-kind#1. [Last accessed on 2018 Feb 19].  Back to cited text no. 4
Bloom D. Two Hospital Workers Spend FOUR HOURS Pinned to MRI Machine by Metal Oxygen Tank that was Catapulted across Room when Device's Giant Magnet was Turned on. Mail. Available from: http://www.dailymail.co.uk/news/article-2890088/Two-hospital-workers_spend-FOUR-HOURS-pinned-MRI-machine-metal-oxygen-tank-catapulted-room-device-s-giant-magnet-turned-on.html#ixzz56POlnEBf. [Last accessed on 2018 Feb 19].  Back to cited text no. 5
Souza AF, Moreira EF, Paiva F. Decreasing accidents and downtime of MRI equipment in a radiology service. Congr Bras Engenharia Bioméd 2010;22:1-4.  Back to cited text no. 6
Chaljub G, Kramer LA, Johnson RF 3rd, Johnson RF Jr., Singh H, Crow WN. Projectile cylinder accidents resulting from the presence of ferromagnetic nitrous oxide or oxygen tanks in the MR suite. AJR Am J Roentgenol 2001;177:27-30.  Back to cited text no. 7
McRobbie DW, Moore EA, Graves MJ, Prince MR. MRI: From Picture to Proton. Go with the flow: MR angiography. 2nd ed., Ch. 13. Cambridge: Cambridge University Press; 2007a. p. 258-64.  Back to cited text no. 8
Bonnet CA, Elson JJ, Fogoros RN. Accidental deactivation of the automatic implantable cardioverter defibrillator. Am Heart J 1990;120:696-7.  Back to cited text no. 9
Shellock FG, Spinazzi A. MRI safety update 2008: Part 2, screening patients for MRI. AJR Am J Roentgenol 2008;191:1140-9.  Back to cited text no. 10
Opoku S, Antwi W, Sarblah SR. Assessment of Safety Standards of Magnetic Resonance Imaging at the Korle Bu Teaching Hospital (KBTH) in Accra, Ghana., In: Kharfi F, editor. Imaging and Radioanalytical Techniques in Interdisciplinary. Research - Fundamentals and Cutting Edge Applications; 2013.  Back to cited text no. 11
McRobbie DW, Moore EA, Graves MJ, Prince MR. MRI from Picture to Proton. 2nd ed. Kindle Edition: Cambridge University Press; 2006. p. 11-29.  Back to cited text no. 12
ECRI Problem Reporting System. Hazard-thermal injuries and patient monitoring during MRI studies. Health Devices 1991;20:362-3.  Back to cited text no. 13
Shellock FG, Kanal E. Burns associated with the use of monitoring equipment during MR procedures. J Magn Reson Imaging 1996;6:271-2.  Back to cited text no. 14
Kanal E, Shellock FG. Burns associated with clinical MR examinations. Radiology 1990;175:585.  Back to cited text no. 15

This article has been cited by
1 Magnetic resonance imaging incidents are severely underreported: a finding in a multicentre interview survey
Johan Kihlberg,Boel Hansson,Annika Hall,Anders Tisell,Peter Lundberg
European Radiology. 2021;
[Pubmed] | [DOI]


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