Medical Imaging Sciences

Fall Term (2022-2023)

Principle of Imaging II - MIMG207

I. Introduction

Contrast Media (CM) are substances used to highglight areas of the body in radiographic contrast
to the surrounding tissues.

Contrast media enhance the radiopacity and optical density of the area under investigation so that
the structure absorption differentials are sufficient to produce adequate contrast with adjacent
structures.
When used for imaging purposes CM can be administered by injection, insertion or ingestion.

Example: in case of chest X-ray, the bones the airiferous lungs, the heart and other tissues
provide adequate natural contrast.
In the abdomen, the composition of the organs is similar that the differences in absorption are too
small; they are radiographically anonymous and must be made visible by additional measures.

II. Requirements of the Ideal Contrast Media

No CM on the market that is considered to be ideal. CM should fulfil cerain requirements for
safe and effective application.

• Easy to administer
• Non-toxic
• A stable compound
• Concentrated in the required area when injected
• Rapidly eliminated when necessary

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 • Non-carcinogenic
• Of appropriate viscosity for administration
• Tolerated by the patient
• Cost effective

III. Contrast Media classification

Contrast Media are classified into 2 types

a) Negative Contrast Media:

They are radiolucent and of low atomic number.

They absorb less x-radiation and produce greatest density on the radiographic image i.e. they
appear darker on the X-ray image
Used in combination with radiopaque media to outline the lumens of, or spaces within,
body structures

Example : Air, Oxygen, Carbon dioxide

b) Positive Contrast Media :

Radiopaque contrast media frequently are used to aid in visualizing body tissues.
The chemical structure of most types of contrast media (e.g., iodinated contrast) is derived from
triiodinated benzoic acid.
Other types of contrast media may contain barium or heavy metals such as gadolinium.

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They are radiopaque and of high atomic number.
They cause an increase in the absorption of X-rays _ this contrast agent-filled area appears
denser than body tissue.
Barium and iodine-based solutions are used in medical imaging to produce positive contrast.

N.B.: Both positive and negative contrast can be employed together in double contrast
examinations to produce a radiographic image.
The positive contrast medium is used to coat the walls of the cavity and the negative contrast is
used to distend the area being imaged.

§ Barium Sulphate solutions (BaSO4) used in Gastrointestinal Imaging

Barium solutions are the universal contrast media used for radiographic examinations of the GI
tract.
The following characteristics of barium solutions make them suitable for imaging of the
gastrointestinal tract:

• High atomic number (56) producing good radiographic contrast

• Insoluble
• Stable
• Relatively inexpensive
• Excellent coating properties of the GI mucosa

Barium suspensions are composed from pure barium sulphate mixed with additives and
dispersing agents.

Dispersing agent to prevent sedimentation is added, ensuring an even distribution of particles

within the suspension.

A defoaming agent employed to prevent bubbles that may mimic pathology in the GI tract.

Flavorings are usually added to oral solutions making them more palatable for patients.

Patients rarely have allergic reactions to barium sulphate solutions but may react to the additives
or preservatives in the solutions.

v Density Of Barium Mixtures

The density of Barium in the solution is normally stated as a percentage weight to volume ratio
(w/v) or weight/weight.

The concentration of Barium in the solution is normally stated as a percentage weight to volume
ratio (w/v)

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v Toxicity and Complications

Barium sulfate is usually safe as long as the GI tract is patent and intact.
Patients may react to preservatives and additives in the solutions.
A severe inflammatory reaction may develop if it is extravasated outside the GI tract i.e. when
there is perforation.
If barium sulphate escapes into the peritoneal cavity inflammation and peritonitis may occur.
Escaped barium causes pain and hypovolaemic shock. Despite treatment there is still 50%
mortality rate.
Aspiration of barium solutions during UGI is considered harmless.
Oral barium sulfate should not be administered in cases of obstruction.

N.B: Post procedure,Instruct patient to drink plenty of fluids after the procedure to avoid barium
impaction.

Sedated patients cannot undergo examinations of the UGI tract.

N.B.: when preparing barium solutions for administration it is important to check expiry dates
and ensure the packing is intact.

Solutions administered rectally should be administered at body temperature.

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v Contraindications

• Suspected perforation
• Suspected fistula or to check anastomosis site
• Suspected partial or complete stenosis
• Paralytic ileus
• Hemorrhage in the GI tract
• Toxic megacolon
• Prior to surgery or endoscopy

N.B.: When barium sulphate is contraindicated for GI imaging , a watersoluble, iodine based CM
should be employed i.e. If the patient has had a recent GI wide bore biopsy (usually within 3-5
days).

§ Iodine-Based CM used in medical imaging

The largest group of contrast media used in imaging departments are the water soluble organic
preparations in which molecules of iodine are the opaque agent.
These compounds contain iodine atoms (Z=53) bound to a carrier molecule.
This holds the iodine in a stable compound and carries it to the organ under examination
The carrier molecules are organic and are of low toxicity and high stability.

v Essential criteria for the ideal intravenous contrast agent:

• Water soluble
• Heat/chemical/ storage stability
• Available at the right viscosity and density
• Low viscosity
• Persistent enough in the area of interest to allow its visualization

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 • Lower or the same osmolarity compared to plasma
• Nontoxic
• Low cost
• Rapidly eliminated

v Physiochemical properties of water-soluble CM

Percentage solution

The percentage solution indicates the amount of solute (Both the carrier molecules and their
iodine) in the solvent (in which the carrier molecules are dissolved)

Iodine concentration of solution = Amount of iodine in the contrast medium: mg I/ml

Example: Percentage solution Iodine Concentration of solution

Urografin 370 76% 370 mg I/ml

Viscosity

The viscosity is the resistance to flow of CM. It relates to the concentration, molecular size and
the temperature of CM.

It strongly increases with increasing concentration and falling temperature.

Osmolality

Measures of the total number of particles in solution per kilogram of water (mOsm/kg of water).

Osmolarity

Osmolarity = number of particles per liter of a solution

Many papers use the 2 terms osmolarity and osmolality interchangeably.

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v Chemical properties of contrast media solutions

Ionic monomers – High Osmolar contrast media

The basic molecule of all water soluble iodine containing contrast media is the benzene ring
C6H6 ( monomeric).

C CH≡CH≡CH

H —C C— H

C— H
H—C

C
│
H
Modifications: Carboxyl acid COOH is added.
3 hydrogens are replaced by iodine rendering it opaque.

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 Tri-iodinated benzoic acid
The remaining 2 hydrogens are replaced by hydrocarbons called R1 & R2 to make it less toxic.

Sodium (Na) or Meglumine salts replaces the hydrogen atom in the carboxyl group to provide
solubility.

Ionic compounds dissolve into charged particles when entering solutions i.e a positive
ion(cation) and a negative ion (anion).
Their effect ratio is 3:2. These solutions are highly hypertonic with an osmolality aproximately 5
times higher than human plasma (1500-2000 mOsm/Kg H2O compared with 300 mOsm/Kg H2O
for plasma.

Ionic dimers - Low Osmolar CM

Attempt was made to produce a CM with lower osmolarity.

2 conventional ionic contrast agent molecules are linked together, a molecule of the type shown
below will result.
Reduced osmolality (600 mOsm/Kg H2O) made the contrast more tolerable for patients.
Each molecule carries 6 iodines 6:2 ( 3:1 in the non-ionic), so to achieve the same iodine
concentration, only half the number of molecules are needed.

Non-ionic monomers

If a side chain R3, which does not ionize in solution and contains some hydroxyl ions to promote
solubility, replaces the carboxyl group (COONa) !the result is a non-ionic compound.

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In solution this remains as one particle still containing 3 iodine
Atom-to-particle ratio of 3:1(3:2 for ionic agents)
2 major advantages arise:
Carboxyl group is eliminated, i.e., eliminating neurotoxicity
The elimination of the positive ion reduces osmolality to 600-700 mOsm/Kg H2O.

Non-ionic dimers (isotonic)

These are dimeric non-dissociating molecules.

For every one molecule there are six iodine atoms.
The ratio is therefore 6:1
They are isotonic i.e., the contrast solution has similar osmolality to blood plasma (300
mOsm/Kg H2O).

§ Possible Side-Effects of iodinated CM

Any ionic CM introduced into the vascular system can cause potential physiological adverse
effects.
Ionic and non-ionic iodine media have physiological effect on the body.
The perfect contrast agent would cause no adverse effects at all.
Acute adverse reactions do occur and are defined as reactions that occur within 1 hour after
administration of CM.

70% occur within 5 minutes of injection

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16% within 5 minutes after injection
14% within 15 minutes of the injection

v Adverse events:

Whenever possible, LOCM should be administered to all patients but especially:

Infants
The elderly
Those with cardiac or renal impairment
Diabetics
Patients with a history of asthma or severe allergy
Patients with a history of a previous reaction to CM
Reactions from the administration of a CM are not predictable and all patients should be
monitored closely during the procedure.

Cardiovascular toxicity

Pain can occur at the injection site during IV administration

Hot flushing
Systemic hypertension and pulmonary edema

Nephrological toxicity

ionic CM may affect renal output

causing a temporary impairment
the following conditions may increase the incidence of nephrotoxicity
pre-existing kidney disease
diabetes
dehydration
age of the patient
large volume of contrast injected
multiple myeloma

Neurotoxicity

The incidence of serious Neurotoxic effects is low following the administration of intravascular
CM.
The blood brain barrier gives protection for the brain by acting as a a selective barrier
Seizures are more likely to occur in patients with brain tumors that disrupt the blood-brain
barrier

N.B.: it is advisable that a suitably qualified staff remains with the patient for at least 15 minutes
post injection.
pNon-ionic contrast is used primarily in examinations where the contrast is administered directly
into the vascular system.
v Reactions to IV administration of CM can be classified into 3 categories:

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 I. Mild reaction
II. Moderate reaction
III. Severe reaction

I. Mild reaction
Nausea
A warm feeling that may be associated with hot flushing
Sneezing
Headache
Pallor itching and sweating

II. Moderate reaction

Erythema
Urticaria
Chest pain
Abdominal pain
Facial swelling caused by oedema
Vasovagal syncope

III. Severe Reaction

Paralysis
Seizures
Pulmonary oedema
Bronchospasm
Laryngeal oedema
Anaphylactic shock
Respiratory arrest
Cardiac arrest

N.B. : Acute lethal dose (LD50) : LD50 is the dose of a contrast medium required to cause a
mortality rate of 50% following an intravenous injection of 1 minute duration.
The LD50 for CM is usually expressed as the gm iodine/kg body weight .The injection duration
is an important variable. At equal doses, mortality increases as duration decreases.

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 c) Specialty Contrast Agents

Contrast agents of varying types are also being used in other modalities, such as magnetic
resonance imaging (MRI) and diagnostic medical sonography
Gadolinium-DTPA
o Metallic and magnetic agent
o Affect the signal intensity used to image the anatomic area of interest

Gas-filled microbubbles
o Ultrasound contrast agents
o Affect the sound wave to enhance ultrasound contrast

d) Oily Contrast Agents (not used anymore)

Oily contrast medium is made up of Iodinized poppy seeds.

It has been used for myelography (myodil), for lymphatic system, sialography and fisulography.

Oily contrast media cannot be excreted from the body through the kidneys.

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 Activity

What are the systems or organs that can be studied with BaSO4?

What are the systems or organs studied with water soluble contrast agents?

Activity 1:

Explain the physical properties of the barium sulfate?

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Activity 2:

Instructions: Brochures will be provided to each student

You have to identify the below

Name of the Product:

Physio-chemical property:

1. Iodine concentration:

2. Osmolality:

3. Viscosity:

4. % Solution:

5. Ionic/non-ionic:

6. Indications:

7. Contra-Indications:

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Activity 3:

Instructions:
Identify if they are ionic/ nonionic- Dimeric/Monomeric and ratio of Iodine

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 Activity 4:
Instructions: Every student will complete the below questions in one of their chosen
modalities that uses Radiopaque Contrast Media (Barium/Iodine/Gadolinium)
You have to select one procedure performed in the modality and discuss the below points:

I. Procedure:

II. Types of Contrast Media used i.e., Chemical composition

III. Routes of administration-injection techniques…

IV. Choice of CM for the procedure

V. Maximum amount that can be administered and how to calculate it.

VI. Preliminary steps taken before the administration of CM

VII. Indications for the use of CM.

VIII. Importance of the use of CM in imaging

Activity 5:

List the precautions/steps taken to the patient before injecting iodinated contrast media
(ionic/non-Ionic into a vessel) for a procedure with IV injection of CM?

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