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Basics of contrast media   

Mohammad Naufal

Oct. 27, 2017 • 225 likes • 29,502 views

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VERY BASICS OF CONTRAST MEDIA IN RADIOLOGY.

CLASSIFICATION OF CONTRAST MEDIA.
APPLICATION OF CONTRAST MEDIA.
XRAY, CT, ULTRASOUND AND MRI CONTRAST
AGENTS.

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 Basics of contrast media

1. BASICS OF CONTRAST MEDIA Dr. MOHAMMAD NAUFAL B.Y.
(M.D. RADIODIAGNOSIS) AL AMEEN MEDICAL COLLEGE
VIJAYAPURA, KARNATAKA.
2. OVERVIEW OF CONTENT 1) History 2) Introduction 3)
Physiology 4) Mode Of Administration 5) Classification 6)
Contrast media for XRAY and CT 7) Ultrasound contrast media 8)
MR contrast agents
3. BRIEF HISTORY • 1896 -WALTER BRADFORD discovered
contrast media. • 1897 - First reported GI contrast study
performed using Bismuth - TOXIC! • 1910 - Barium Sulphate used
(safer) • 1920’s - Sodium Iodide used to treat syphilis. Iodine was
found to be radio opaque to x-rays. Basis of all modern contrast
agents. • 1927 - First reported IVU with iodised organic salts
(Uroselectan)
4. INTRODUCTION 1)CONTRAST: It is the di!erence in optical
density between di!erent parts of image on radiograph. It
depends on absoprption coe!icients of di!erent tissues.
5. 2)CONTRAST MEDIUM: It is a chemical substance of very high
or very low atomic number or weight, therefor it increase or
decrease the density of the organ under examination. A
substance which when introduced into the body will increase
the radiographic contrast in an area where it was absent or low
before. OR
6. 3)USE: Arteriography Angiography (DSA) – Cardiology
Venography (replaced by ultrasound Doppler) IVU
Fluoroscopy – Alimentary tract, hyserosalpingography,
sialography, CT MRI Ultrasound – Liver, kidney
Myelography (replaced by MRI) Arthrography – Knee joints.
7. 4)M/C Side e!ect: metal taste feeling of warmth 5)Products
like air, carbon dioxide, tap water, and juices containing
manganese,(e.g. blueberryjuice, pineapple juice)can be used as
contrast media.
8. PHYSIOLOGY Concentration and excretion 1) >90%: passive
glomerular filtration. 2) 1%: liver and intestine. Half life: 30-60
minutes. Do not enter the interior of cells. Rapidly excreted,
over 90% being eliminated by glomerular filteration by kidneys
within 12 hrs. Leaves the body within 24 hours(if normal
kidney) and weeks( if diseased kidney). IV CONTRAST
EXTRAVASCULAR SPACE EXCRETED EQULIBIRIUM BETWEEN
INTRA AND EXTRAVASCULAR SPACE IN 10 MINUTES
9. MODE OF ADMINISTRATION 1) Orally. 2) Rectally. 3)
Intravenously – (injection/ infusion). 4) Mechanically – Filling of a
body cavity or potential space. 5) Intra-muscularly
10. CLASSIFICATION OF CONTRAST MEDIA X-RAY & CT
ULTRASOUND MRI Oily/non water soluble IODINATED CM Water
soluble IODINATED CM Hepatic excretion Renal excretion
Iopanoic acid High osmolar low osmolar Ionic monomers Ionic
dimers Non-ionic monomers Non ionic dimers IOTHALAMATE
DIATRIZOATE IOXAGLIC ACID IOCAMIC ACID METRIZAMIDE
IOHEXOL IOTROL IOTROLAN Non water soluble BaSO4
IODINATED CM Positive CM Negective CM water,air,CO2
11. POSITIVE CONTRAST Contrast material is radiopaque.
high atomic number material white on film Example: 1)
Barium sulfate USE: GI Studies. 2) Iodine compounds. USE:
angiography, intravenous and retrograde urography
hysterosalphingography sialography myelography
cholangiography NEGATIVE CONTRAST Contrast material that
is not radiopaque Low atomic number material Black on film
Example: 1) Water, Air and carbon dioxide CONTRAST MEDIA FOR
X-RAY AND CT
12. BARIUM SULPHATE 1) Atomic number:56 2) Highly
radiopaque. 3) Non absorbable. 4) Non toxic. 5) Insoluble in
water/lipid. 6) Inert to tissues. 7) Can be used for double contrast
studies. 8) Route: Orally Or Rectally (aqueous suspension with
0.3 to 1 g dry weight per milliliter) 9) Uses: barium swallow
barium meal barium meal follow through Enteroclysis
barium enema
13. BARIUM SWALLOW BARIUM MEAL BARIUM MEAL FOLLOW
THROUGH
14. ENTEROCLYSIS BARIUM ENEMA
15. 10) CONTRAINDICATION: Integrity of gut wall compromised
or GI Perforation. Previous allergic reactions to barium.
Suspected fistula between oesophagus and lung. 11) Side
e!ects: Aspiration. Granuloma(Leakage:Mediastinum, tissue
around Rectum or Intraperitoneal cavity). Leakage into the
vasculature(life threatening). Constipation. worsening
ulcerative colitis inflammation. peritonitis through perforation.
Fatal Reaction(rare).
16. IODINATED CONTRAST MEDIA Oily/non water soluble
IODINATED CM Water soluble IODINATED CM Hepatic excretion
Renal excretion Iopanoic acid High osmolar low osmolar Ionic
monomers Ionic dimers Non-ionic monomers Non ionic dimers
IOTHALAMATE DIATRIZOATE IOXAGLIC ACID IOCAMIC ACID
METRIZAMIDE IOHEXOL IOTROL IOTROLAN
17. IODINE: 1) Atomic number 53 2) Atomic weight 127 1)
Radioopacity depends on: iodine concentration of the
solution, so dependent on number of iodine atoms in each
molecule of the contrast medium. 4) Iodine particle ratio: the
ratio of number of iodine atoms per molecule to the number of
osmotically active particles per molecule of solute in solution 5)
Iodine is preferred because: High contrast density due to high
atomic number Allows firm binding to highly variable benzene
ring Low toxicity
18. OILY/NON WATER SOLUBLE IODINATED CM Fatty Acids
Insoluble in water White on the radiograph Examples: 1)
Iophendylate (Myodil, Pantopaque)- myelographic agent 2)
Lipiodrol Ultrafluide (Ethiodol)- lymphangiographic agent.
COMPLICATION: 1) Fat Embolism LYMPHANGIOGRAPHY
19. USE: 1) Sialography 2) Hysterosalpingography 3)
Myelography 4) Lymphangiography 5) Dacryocystography 1)
Galactography 2) Broncography
20. SIALOGRAPHY HYSTROSALPHINGOGRAPHY MYELOGRAPHY
21. DACROCYSTOGRAPHY GALACTOGRAPHY BRANCHOGRAPHY
22. Hepatic excretion Renal excretion Iopanoic acid High
osmolar low osmolar Ionic monomers Ionic dimers Non-ionic
monomers Non ionic dimers IOTHALAMATE DIATRIZOATE
IOXAGLIC ACID IOCAMIC ACID METRIZAMIDE IOHEXOL IOTROL
IOTROLAN WATER SOLUBLE IODINATED CM
23. IOPANOIC ACID is an iodine-containing radiocontrast
medium. potent inhibitors of thyroid hormone release from
thyroid gland, as well as of peripheral conversion of thyroxine
(T4) to triiodothyronine (T3) Hepatic excretion • Use: 1)
Cholecystography 2) Hyperthyroidism:adjunctive therapy with
thioamides (propylthiouracil, carbimazole).
24. HIGH OSMOLAR IODINE CONTRAST MEDIA IONIC MONOMER
25. HIGH-OSMOLAR IODINE CONTRAST MEDIA a.k.a
Conventional contrast media. All are Ionic monomers Salts
with sodium or meglumine(N-methylglucamine) as the non-
radiopaque cation and a radiopaque tri-iodinated fully
substituted benzoic acid ring as the anion. triiodinated at (C2,
C4 & C6) of benzene ring. C3 & C5 are connected to amines
which reduce the toxicity & increase the solubility. Iodine
particle ratio= 3:2 Molecular weight= 600-800 Iodine content
at 0.3 osmol/kg H2O= 70mg I/ml Osmolality at 280mgI2/ml=
1500 osmol/kg H2O LD50(lethal dose) = 7(g of I/kg wt of
mouse) Rarely used.
26. DIFFERENCES B/W MEGLUMINE & SODIUM SALTS
MEGLUMINE SALTS SODIUM SALTS • Solubility Better Same, less
in some acids • Viscosity High Low • Tolerance Better Less,nausea
& vomiting • Blood Brain Barrier No e!ect Crosses BBB • Vascular
e!ects Less Marked • Diuretic e!ect Strong Less • Opacification
Poor Better • Bronchospasm causes(C/I:Asthma) No
27. Example: 1) Diatrizoate(urogra!in, angiogra!in , urovideo,
urovision, trazogra!) 2) Iothalamate(conray, Triovideo) 3)
Ioxithalamate 4) Metrizoate Disadvantage: High osmolality (8 X
plasma) because of the non radiopaque cations (Na &
meglumine) is responsible for the adverse e!ects.
28. LOW OSMOLAR IODINE CONTRAST MEDIA 1) IONIC DIMERS. 2)
NON IONIC MONOMERS. 3) NON IONIC DIMERS.
29. IONIC DIMERS Ioxaglate (Hexabrix) Only compound,
mixture of sodium and meglumine salts Two benzene rings
(each with 3 iodine atoms) are linked by a bridge to form a large
compound, carries only one carboxyl group, so known as
monoacid dimers Iodine particle ratio is= 6:2 or 3:1 Molecular
weight is= 1269 Iodine content at 0.3 osmol/kg H2O= 150mg
I/ml Osmolality at 280mgI2/ml= 560 osmol/kg H2O LD50 =
12(g of I/kg wt of mouse)
30. NON IONIC MONOMERS • Carboxyl group (-COOH) at C-1 is
replaced by non ionising radical & CONH2 • Iodine particle ratio=
3:1 • Molecular weight= 600-800 • Iodine content at 0.3 osmol/kg
H2O= 150mg I/ml • Osmolality at 280mgI2/ml= 600 osmol/kg
H2O • LD50 = 22(g of I/kg wt of mouse)
31. • First generation- *Metrizamide(ampipaque-expensive &
unstable) • Second generation- *Iopromide (Ultravist) *Iohexol
(Omnipaque)- USED IN OUR DEPARTMENT. *Iopamidol
(Iopamiro) *Ioversol (Optiray) *Ioxilan *Iomeron *Xenetix
32. NONIONIC DIMERS Example: *Iotrolan(Isovist) *Iodixanol
(Visipaque) A.k.a Isoosmolar C.M. Each molecule contains 2
non ionosing tri- iodinated benzene rings linked together.
Iodine particle ratio= 6:1 Molecular weight= 1550-1626
Iodine content at 0.3 osmol/kg H2O= 300mg I/ml Osmolality
at 280mgI2/ml= 300 osmol/kg H2O LD50 = >>26(g of I/kg wt of
mouse)
33. IONIC MONOMER IONIC DIMER NONIONIC MONOMER
NONIONIC DIMER Iodine particle ratio 3:2 6:2 OR 3:1 3:1 6:1
Molecular weight 600-800 1269 600-800 1500-1626 Iodine
content at 0.3 osmol/kg H2O (300mg I/ml) 70 150 150 300
Osmolality at 280mgI2/ml (osmol/kg H2O) 1500 560 600 300
LD50 (g of I/kg wt of mouse) 7 12 22 >>26
34. ADDITIVES USED IN CONTRAST MEDIA 1) Stabilizer: Ca or Na
EDTA 2) Bu!ers: Stabilizes pH during storage, Na acid
phosphates 3) Preservatives: Generally not disclosed by the
manufacturers.
35. IDEAL CONTRAST MEDIA 1) High water solubility. 2) Heat &
chemical stability(shelf life) ideally- 3 to 5yrs. 3) Biological
inertness( non antigenic). 4) Low viscosity. 5) Low or isoosmolar
to plasma. 6) Selective excretion, like excretion by kidney is
favorable. 7) Safety: LD50 (lethal dose) should be high. 8)
Reasonable cost.
36. POINTS TO REMEMBER Contrast media used for
myelography- non-ionic CM. CM used for cerebral angiography-
only meglumine salt. Least osmolar- Ioxaglate (Hexabrix).
Most hyperosmolar- Iohexol. Max nausea & vomiting-
Ioxaglate (Hexabrix). Bronchospasm- Meglumine salts.
Viscosity: • Increase with concentration • Higher for dimers(big
size) • High viscosity interferes with mixing of contrast media
with plasma & body fluids. • Least viscosity- Omnipaque240
Meticulous heparinization is required during angiography as
incidence of thromboembolic phenomenon is high when CM is
mixed with blood.
37. ULTRASOUND CONTRAST AGENTS • A.k.a Echo Enhancing
Agents. • These agents Increase The Echogenicity Of Blood,
which heightens the tissue contrast & allows better delineation
of body cavities. • Consist of Microscopic Gas Filled Bubbles. •
Their Extremely High Reflectivity(backscatter) arises from the
fact that microbubbles easily change their size, contracting in
compression part of the ultrasonic cycle & expanding in the
rarefaction part. • Thus They Resonate in the ultrasound beam
when there is a mismatch b/w their diameter and ultrasonic
wavelength, which occurs for microbubbles in 2 to 7um at usg
freq of 2-10 MHz
38. GENERATIONS OF ECHO ENHANCERS FIRST GENERATION
SECOND GENERATION THIRD GENERATION 1) unstabilised
bubbles in indocyanine green. 2) cant survive pulmonary
passage, therefore used only for cardiac & large vein study.
Longer lasting bubbles coated with shells of protein, lipids or
synthetic polymers. Encapsulated emulsions or bubbles, o!er
high reflectivity.
39. NON ENCAPSULATED MICROBUBBLES ENCAPSULATED
MICROBUBBLES Encapsulated Air Microbubbles Encapsulated
Perflurocarbon MB 1)Albunex 2)Echovist galactose 3)Levovist
galactose & palmitic acid 4)Cavisomes – gas filled cyanoacrylate
microspheres for Liver, spleen & LN Optison: Albumin coated
microspheres that contain Octafluropropane gas Uses:Cardiac
app 1)Formed by hand agitation 2)Unstable & breech quickly
3)Large size, small fraction pass through pulmonary circulation
4)Adequate for right heart visualization TYPES OF ULTRASOUND
AGENTS
40. IDEAL ULTRASOUND CONTRAST AGENT 1) Be injectable by a
peripheral vein 2) Be non toxic 3) Small enough to pass through
pulmonary, cardiac & capillary systems 4) Stable enough to
undergo the shear forces, hydrostatic pressure changes &
diameter changes 5) Half life should be su!icient to allow
complete examination 6) Should require little preparation
41. MECHANISM OF ACTION Primary mechanism of signal
enhancement is Microbubble Backscatter, which relates to
di!erences in microbubble versus blood compressibility.
Increased echogenicity may be seen as an increased signal in
color or spectral doppler signal strength or gray scale image
intensity. The halflife or rsistence of microbubble depends on:
1) size(<7um passes through pulmonary circulation) 2) surface
tension & gas di!usion across the bubble shell. 3) transducer
frequency & power Mechanical index (MI): Peak pressure of
USG beam calculated from frequency & power of USG beam.
Higher the MI, more likely the bubble will break
42. DOPPLER RESCUE Application of ultrasound contrast agents
results in enhancement of colour, power & spectral doppler
waveform & this improves doppler imaging & is termed as
“doppler rescue “
43. APPLICATIONS 1) Evaluating normal, increased or decreased
vascularity. 2) Detecting vascular stenosis & occlusions. 3)
Improving neoplasm detection. 4) Analysing & characterizing
tumour neovascularity. 5) Di!erentiating normal variants such
as renal column of bertin from neoplasm. 6) Echocardiography –
cardiac cavities, valves, coronary artery & myocardial viability
44. APPLICATIONS HEPATIC 1)Neoplasm evaluation. 2)Vessel
evaluation: -portal hypertension. -TIPSS. -Buddchiari syndrome.
-Liver transplant evaluation. RENAL 1)Solid masses.
2)Pseudomases. 3)Cysts. 4)Renal artery stenosis. 5)Renal
transplants. VASCULAR 1)Lower extremity Doppler: native &
bypass gra"s 2)Abdominal arterial examination: -stenosis. -
Coeliac. -SMA. -Renal. 3)Carotid & transcranial Doppler.
45. HEPATIC RENAL
46. VASCULAR
47. ARTIFACTS 1)COLOUR BLOOMING: Grey scale pixels are
displayed as colour pixel in areas that lack flow, occurs when
high concentration of ultrasound contrast agents is delivered by
bolus inj. 2)Bubble Noise: Audible sound accompanied on visible
spectral doppler tracing blips. 3)An increase (17 to 45 %) in
maximum Doppler Shi" Frequency. COLOUR BLOOMING
48. CONTRAST MEDIA USED IN MRI 1) Gadolinium chelates 2)
Blood pool agents 3) Liver contrast agents 4) Endoluminal
contrast agents 5) Targeted contrast agents
49. GADOLINIUM Is the standard exogenous contrast agent
used in clinical MR imaging. It is T1 relaxing agent
Paramagnetic. It belongs to lanthanide metal group with
atomic no. 64. It has a high spin contrast number which
produces desirable relaxivity contrast agents. Three agents
have been approved by FDA, they are- 1) Gd-HP-DO3A:
Gadoteridol/ProHance (non ionic) 2) Gd-DTPA : Gadopentetate
diglumine/Magnevist (ionic) 3) Gd-DTPA-BMA:
Gadodiamide/Omniscan (nonionic)
50. These function as extracellular contrast agents. They are
rapidly excreted by glomerular filteration half lives: 1 – 2hrs.
As these compounds are excreted by renal excretion, caution
shoud be taken in renal impaired patients. S/E: Nausea(3 –5%)
Dose: 0.1 to 0.3mmol/kg body weight Disadvantages: 1)
Enhancement is non specific neither organ specific or pathology
specific. 2) Short window for imaging of blood vessels as it is
diluted in blood stream and excreted rapidly.
51. WITHOUT CONTRAST WITH CONTRAST
52. BLOOD POOL AGENTS These agents reversibly bind to
plasma albumin achieving a substantial improvement in
magnitude and duration of blood pool enhancement.
EXAMPLE: 1)SPIO-super paramagnetic iron oxide crystals
2)USPIO 3)Magnetite These cause predominant T2 shortening.
USES: • 1)To image small vessels (eg:coronary artery). 2)Vessels
with slow flow (eg pulmonary embolism, DVT), 3)Arteriovenous
malformation 4)Perfusion studies DISADVANTAGE: • Overlap
b/w arterial and venous structures and separation is di!icult
53. BLOOD POOL AGENTS
54. LIVER CONTRAST AGENTS Gadobenate dimeglumine: -
MultiHance,Bracco. Small iron particles: -Endorem & Resovist.
Manganese containing contrast agents: -Teslascan: Absorbed
by liver, pancreas and cortex of kidneys, T1 relaxation.
MANGANESE CONTAINING CONTRAST
55. ENDOLUMINAL CONTRAST AGENTS 1)Negative contrast
agents: • Based on iron particles(Abdoscan, Nycomed-
Amersham) for • Use: 1)MR Enteroclysis. 2)MR imaging of rectal
cancer. 2)Combination of Methyl Cellulose Solution for bowel
distention & I.V Gadopentate Dimeglumine for bowel wall
enhancement. 3)Natural contrast: • Blueberry juice acts as a
negative contrast in upper abdominal MR imaging. • eg MRCP
56. MR ENTEROCLYSIS MRCP
57. TARGETED CONTRAST AGENTS 1) Blood pool agents 2) Liver
specific agents 3) Necrosis specific agents (bis-gadolinium-
mesoporphyrin) 4) Lymphographic contrast agents 5) Agents
targeted at inflammation detection.
58. REFERENCES 1) Grainger & Allison –Diagnostic radiology. 2)
Radiological procedures- Dr.Bhushan N Lakhkar.

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