Conclusion: there is no indication of a malfunction of the mr system or coils used that could have contributed to the incident.The observed blistering is most likely caused by direct contact between the right shoulder and the bore wall.Even though it was mentioned that padding was used, considering the positioning required to position the opposite left shoulder within the field of view and the size of the patient, the affected area of the right shoulder must have been in contact with the bore.Contributing factors in this case: several scans with high sar values (>2 w/kg) were executed.High sar scans are a bigger challenge for the cool down mechanism than low sar scans.The patient was obese.The thermoregulation of obese patients is known to be impaired.The risk of rf energy-related injuries is higher in patients with impaired thermoregulation.The total administered specific energy dose of 7.2 kj/kg far exceeded the recommended limit of 2.0 kj/kg for patients with impaired thermoregulation.
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