Optimized fMRI Acquisition—Clinical Checklist

Designing a successful clinical fMRI program requires a balance between technical precision, patient-centered flexibility, and operational efficiency. Clinical fMRI can provide critical maps for surgical planning, but as 2025 ARRS Scholar Luca Pasquini, MD, clarified during ARRS 2026, its success depends on real-time quality assurance and the ability to adapt to patient limitations.

Real-Time Monitoring—Don’t wait for post-processing to check data quality.

• No Shoes! Ensure patients are barefoot if performing foot-wiggling motor tasks.
• Covert Language: For these tasks, monitor the pre-supplementary motor area, as it correlates highly with language planning and task compliance.
• Signal Validation: Use real-time depictions to determine if the patient is actually performing the task before the scan ends.

Performance Management—Patient distress, claustrophobia, or cognitive impairment (e.g., chemo brain) can compromise data.

• Fail Once: At Yale, Dr. Pasquini’s team allows for one failure; upon the second, they switch to low-compliance tasks or slower versions of the standard paradigm.
• Modify on the Fly: Slow down word generation tasks or switch to passive story listening if a patient cannot keep up.
• Sedation? Sure, bland anxiolytics can be used for task fMRI without significantly impacting the signal.

Pitfall ID—Be aware of neurovascular uncoupling, where the BOLD signal disappears—common in glioblastomas.

• Breath Fix: Use breath-holding tasks to test cerebrovascular reactivity. This creates a map that can confirm if a lack of activation is a false negative caused by non-reactive vasculature.
• Artifact, Check: Use susceptibility mapping to differentiate between real activation and drop-out artifacts from prior surgeries or hemorrhages.

Tech Woes—As Dr. Pasquini duly noted, your choice of software impacts both utility and billing alike.

• Compatibility: Ensure output is compatible with surgical navigation systems à la BrainLab.
• Flexibility: Opt for thin client software over hardwired licenses to avoid being tethered to a single workstation.
• Clear to Code: Software must be FDA cleared and capable of processing task fMRI to be billable.

RadFYI: If a patient is incapable of performing, you must know when to stop the acquisition to maintain your admin’s “vision of value,” as well as to avoid wasting scanner slots.