What makes endolymphatic hydrops MRI work: a visual guide to better protocol choices

Endolymphatic hydrops MRI is used for the diagnostic evaluation of patients with primary or secondary endolymphatic hydrops. Delayed intravenous post-Gd 3-dimensional fluid-attenuated inversion recovery (3D-FLAIR) and 3-dimensional real inversion recovery (3D-real IR) sequences are the most widely applied techniques, because they exploit subtle Gd-related signal differences between perilymph and endolymph. Yet image quality and diagnostic confidence depend on protocol design, and variation persists between institutions, scanners, and vendors. This educational review provides a visually oriented, practical framework for optimising endolymphatic hydrops MRI, focusing on three core determinants: acquisition parameters, post-processing strategies, and contrast-agent selection. The physical principles underlying key sequence-parameter choices are explained, including the use of long echo trains to maximise acquisition efficiency, prolonged repetition times to enhance the perilymphatic signal, and inversion times tailored to the selected repetition time to achieve effective suppression of the endolymphatic signal. Representative graphs and imaging examples illustrate how protocol modifications influence contrast and diagnostic performance. The review further discusses post-processing approaches and emerging artificial intelligence-based techniques, including deep learning reconstruction, as tools to improve image quality, shorten scan time, or support higher spatial resolution. Finally, the role of gadolinium-based contrast agents, scan delay, and clinical protocol design is also addressed. Four-hour delayed intravenous imaging remains the current standard, although sequence-specific timing, single- or two-step protocols, and half-dose high-relaxivity agents may offer opportunities for tailored imaging, reduced Gd exposure, and improved sustainability. By linking sequence principles to practical protocol choices, this review aims to support reproducible, high-quality hydrops MRI across clinical settings. KEY POINTS: Question Optimisation and standardisation of 3D-FLAIR and 3D-real IR protocols are essential for accurate, reproducible assessment of endolymphatic hydrops across institutions, scanner platforms, and vendors. Findings Use TE 500-700 ms and a long echo train for efficiency/background suppression, TR ~ 16,000 ms to enhance perilymph, and TI 2400-3000 ms to suppress endolymph. Critical relevance statement Emerging deep-learning reconstruction techniques may shorten acquisition times or improve spatial resolution, while half-dose, high-relaxivity GBCAs may provide hydrops visualisation comparable to higher-dose conventional contrast protocols.