CONTRAST MEDIA

(HISTORY & CLASSIFICATION)

ADIL AHMAD WANI

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 WHAT IS CONTRAST MEDIA (C.M.)?

Contrast media (CM) enhance the quality of images, revolutionizing the radiologist’s ability to
differentiate soft-tissue densities. Ideally, CM should achieve very high concentration in the tissues
without producing any adverse effects. Unfortunately this has not been possible so far and all CM
have adverse effects.
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 INTRODUCTION
 Contrast media, also known as contrast agents or contrast substances, are chemical
substances or dyes used in medical imaging to enhance the visibility of structures and
organs within the body during diagnostic procedures. These substances work by altering
the way X-rays, computed tomography (CT) scans, magnetic resonance imaging (MRI),
or other imaging techniques interact with the body's tissues, making certain areas more
distinguishable and providing valuable information to healthcare professionals.
 Contrast give better tissue differentiation
 Often, contrast materials allow the radiologist to distinguish normal from abnormal
conditions.
 It is a chemical substance of very high or very low atomic number or weight, there for it
increase or decrease the density of the organ under examination.
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 Theseare the chemical substances that are administer In

the body by different routes
 Contrast materials are not dyes that permanently discolor
internal organs.
 They are substances that temporarily change the way x-
rays or other imaging tools interact with the body.
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WHY IS CM REQUIRED?
 TO VISUALISE  ENHANCE THE
PARTICULAR QUALITY OF IMAGE,
SOFT TISSUE REVOLUTIONIZING
CLEARLY WHICH THE RADIOLOGIST’S
ABILITY TO
IS DIFFICULT TO
DIFFERENTIATE SOFT
VISUALISED IN A TISSUE DENSITY.
PLAIN IMAGE
• CAN ALSO BE USED TO
SEE THE FUNCTIONING
OF A PARTICULAR
SYSTEM SUCH AS
URINARY, GIT, ARTERIAL,
VENOUS ETC.
 Improved Visualization:
 CM enhances the visibility of certain body structures and tissues that may be difficult to
discern on imaging without contrast.
 Itmakes specific areas stand out more clearly, aiding in the accurate diagnosis of medical
conditions.
 Highlighting Abnormalities:
 CM helps identify abnormalities, such as tumors, lesions, blood vessel blockages, or organ
malfunctions, that may otherwise go unnoticed.
 Vascular Imaging:
 CM is crucial for vascular imaging (angiography), allowing healthcare providers to examine
blood vessels, detect blockages, and plan interventions like angioplasty or stent placement.
 Delineating Organs and Structures:
 In many diagnostic procedures, CM is used to differentiate organs and structures with
similar densities or appearances, improving the precision of diagnosis.
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 Cardiac Imaging:
 In cardiac catheterization and coronary angiography, CM is
indispensable for assessing the coronary arteries and diagnosing
heart conditions like coronary artery disease.
 Monitoring Response to Treatment:
 CM can be used to assess how tumors respond to therapies,
enabling adjustments in treatment plans if necessary.
 Characteristics of ideal CM
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SELECTIVE
HIGH WATER Biological EXCRETION Reasonable
SOLUBILITY inertness (FAVORABLY
cost
KIDNEY)

Heat & LOW

Low or iso-
chemical VISCOSITY
osmolar to
stability plasma
Biocompatibility: ideal contrast media should be biologically compatible, meaning they
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do not cause harmful or adverse reactions within the body. They should be well-tolerated
by the patient's system, with minimal risk of allergic or toxic responses.

Low Toxicity: They should have low toxicity, both in terms of acute toxicity (short-term
effects) and cumulative toxicity (long-term effects). This ensures patient safety during and
after the procedure.

High Radiopacity: Contrast media should have a high radiopacity, which means they
strongly absorb X-rays or other imaging radiation. This property enhances the visibility of
the contrast agent and the structures it is meant to highlight.

Stability: Ideal contrast media should be stable under normal storage conditions and
maintain their radiopaque properties throughout the duration of the imaging procedure.
Solubility: They should be readily soluble in a suitable carrier solution (e.g., water
or saline) to facilitate easy injection and distribution within the body.

Low Viscosity: A low viscosity is desirable to ensure that the contrast medium can
flow easily through the vascular system and reach the target area without causing
excessive resistance.

Minimal Osmolality: Contrast agents should have an osmolality similar to that of

human blood to prevent osmotic imbalances and minimize the risk of renal
complications.

Ionic or Non-ionic: Contrast media can be either ionic or non-ionic. Non-ionic

contrast agents are generally preferred because they are associated with fewer side
effects and allergic reactions.
Rapid Elimination: After the imaging procedure, an ideal contrast medium 18
should be efficiently excreted or metabolized by the body, minimizing the risk of
long-term retention and potential toxicity.
Compatibility with Imaging Modalities: The contrast agent should be
compatible with the specific imaging modality being used, whether it's X-ray, CT,
MRI, ultrasound, or another technique.
Low Cost: Cost-effectiveness is important to ensure that the contrast medium is
accessible to a wide range of patients and healthcare settings.
Long Shelf Life: Ideal contrast media have a long shelf life, allowing them to be
stored for extended periods without deterioration in quality.
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Ease of Use: They should be easy to prepare and administer, allowing for efficient
use in clinical settings.
Versatility: Ideal contrast media can be used for a variety of diagnostic purposes,
covering a broad spectrum of medical conditions and anatomical regions.
Minimized Allergic Reactions: While it may be impossible to completely
eliminate the risk of allergic reactions, ideal contrast media should have
formulations and properties that minimize the likelihood and severity of such
reactions.
 WHO FORMULATE CONTRAST MEDIA?
In 1896, WALTER BRADFORD discovered contrast media
In 1897, Haschek & Lindenthal experimented on an amputated hand to develop the first angiogram in Vienna using
Bismuth
1897 first reported gi contrast study performed using bismuth-toxic.
1910-barium sulfate used for studies[safe].
1920-sodium iodide was used to treat syphilis
Iodine was found to be radio-opaque to x-rays that became the basis for all modern contrast agents.

 Discovery of IODINATED CONTRAST was accidental observed by Osborn

 the First pyelogram was performed in @mayo clinic in 1923
 Berberich & Hirsch successfully employed STRONTITIUM BROMIDE to perform FEMORAL
ANGIOGRAM.
 IN 1924, Brooks used sodium iodide to perform an angiogram.
 In 1927, Moniz perform successful CAROTID ANGIOGRAM using Sodium Iodine.
 In 1931 Schering introduced this agent Uroselectan and Uroselectan B
 In the early 1950s, Schering and Winthrop launched a new generation of iodinated agents, which were derivatives of triiodinated benzoic acid,
e.g. diatrizoate (Urografin etc.)
 CLASSIFICATION
Negative CM Air, CO2

X-RAY/CT
Water Soluble CM BaSO4

Positive CM
Non water
Powder
soluble

CONTRAST MEDIA Oil CM

Paramagnetic CM
e.g., Lipiodol
MRI
Super paramagnetic
GADOLINIUM
CM

USG MICROBUBBLE
 CLASSIFIICATION

UROGRAFFIN,
Hepatic Excretion IONIC
High Osmolar ANGIOGRAFFIN
CM MONOMER
CONRAY
Water Soluble CM
Ioxaglic acid
Renal Excreation IONIC Dimers
(Hexabrics)

OMNIPAQUE,
Non-Ionic
Low Osmolar OPTITRAY,
Monomers
ULTRAVIST

Iotrol, Iotrolan
Non-Ionic Dimers
(Isovist)
X-ray/ CT CM
FOR CT/X-RAY, CONTRAST MEDIA APPEAR
ACCORDING TO THEIR ATTENUATION.
AND ON THE BASIS OF ATTENUATION, IT IS
DIVIDED INTO 2 TYPES
• POSITIVE CM
• NEGATIVE CM
 Negative CM

• Negative contrast media, also known as radiolucent or radiographic contrast media, are
substances used in medical imaging to help visualize certain anatomical structures or
abnormalities within the body. Unlike positive contrast media, which appear white on x-rays
and make structures stand out by increasing their opacity, negative contrast media appear black
or dark and decrease opacity, allowing the visualization of normally radiopaque structures
• Attenuate x-rays less than soft tissue.
• No commercial cm product is available
• Air:-introduced to the patient during the examination by the radiographer i.e. During double
contrast barium enema
• Oxygen:- introduced during cavity of the body i.e. In the knee during arthrography to
demonstrate knee joint
• Co2 :- introduced during barium study to visualize mucosal pattern.
• Cystography: to examine the bladder for abnormalities or injuries.
• Myelography: to visualize the spinal cord and nerves within the spinal canal.
 POSITIVE CM
• POSITIVE CONTRAST MEDIA, ALSO KNOWN AS RADIOPAQUE
CONTRAST MEDIA, ARE SUBSTANCES USED IN MEDICAL
IMAGING TO ENHANCE THE VISIBILITY OF CERTAIN
ANATOMICAL STRUCTURES OR ABNORMALITIES WITHIN THE
BODY. UNLIKE NEGATIVE CONTRAST MEDIA, WHICH DECREASE
OPACITY AND APPEAR DARK ON X-RAYS, POSITIVE CONTRAST
MEDIA APPEAR WHITE AND INCREASE OPACITY, MAKING
STRUCTURES STAND OUT MORE PROMINENTLY ON
RADIOGRAPHIC IMAGES
• ATTENUATE MORE X-RAYS THAN SOFT TISSUE
• APPEARS BRIGHT WHITE
• COMMERCIALLY AVAILABLE.
• TWO TYPE
• WATER SOLUBLE IODINATED CM
• NON-WATER SOLUBLE
 types of positive contrast media, each suited for different imaging techniques and
applications: 26
 Iodine-based contrast agents: These are commonly used in X-ray and CT (computed
tomography) scans. They contain iodine, which absorbs X-rays more readily than soft tissues,
making blood vessels, organs, and other structures containing the contrast agent appear brighter
in the images.
 Barium sulfate: Barium contrast is used primarily in gastrointestinal studies. Patients swallow
a barium-containing liquid, which coats the lining of the digestive tract and makes it visible on
X-ray or fluoroscopy.
 Gadolinium-based contrast agents: These are used in magnetic resonance imaging (MRI) to
improve the visibility of specific tissues and blood vessels. Gadolinium is a rare earth metal
that alters the magnetic properties of tissues, making them appear brighter in MRI images.
 Contrast microbubbles: These are tiny gas-filled bubbles used in ultrasound imaging. They
enhance the visibility of blood vessels and can help visualize blood flow.
 Non-water-soluble based positive cm
THESE CONTRAST AGENTS DON’T MIXED WITH WATER 27
COMPLETELY.
TYPES ARE
 POWDER BASED:- AVAILABLE IN FORM OF TABLET. E.G..
BILOPTIN, CISTOBIL ETC.
 OIL BASED:- IN 1921, INTRODUCED BY SICAR AS FIRST
GENERATION CM FOR MYELOGRAPHY. ALSO USED FOR
BRONCHOGRAPHY, HSG, LYMPHOGRAPHY ETC.
 BARIUM-BASED:- HIGH ATOMIC NO. (56) & VERY HIGH
DENSITY. CAN BE EASILY PREPARED IN COMPOUND FORM
E.G. BARIUM CARBONATE, BARIUM CHLORIDE ETC. BUT
EXCEPT FOR BARIUM SULFATE REST ALL COMPOUNDS ARE
HIGHLY TOXIC. WATER MIX SUSPENSION IS FORMED BUT
QUICKLY SEDIMENTED
AVAILABLE IN POWER AND PASTE FORM.
USED FOR GIT INVESTIGATION MAINLY.
DON’T ABSORBED IN BLOOD AND STAYS IN BODY FOR LONG
PERIOD OF TIME.
 Water soluble cm
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 Water-soluble contrast media are substances that can be mixed with water and readily dissolved,
creating a homogeneous solution. They contain iodine, a radiopaque material, which means they
can absorb X-rays and appear white on radiographic images. This property allows radiologists to
visualize and assess specific anatomical structures, organs, or vessels with greater clarity and
contrast.
 Types of Water-Soluble Contrast Media
 There are several types of water-soluble contrast media used in radiology, each formulated for
specific applications:
 Gastrointestinal Contrast Media (Barium Sulfate): Barium sulfate contrast agents are primarily
used for imaging the upper and lower gastrointestinal tracts. These contrast agents come in various
forms, such as liquids, powders, or pastes. When ingested or administered rectally, they coat the
lining of the GI tract, making it easier to detect abnormalities like ulcers, polyps, and tumors.

 Intravenous Contrast Media (Iodinated Contrast): These contrast agents, containing
iodine compounds, are administered intravenously for vascular imaging, including CT
angiography and conventional angiography. They help visualize blood vessels,
highlighting areas of stenosis, aneurysms, or other vascular abnormalities.
 Cystography Contrast Media: Water-soluble contrast media are used for cystography,
a diagnostic procedure to visualize the urinary bladder. These agents can be injected
directly into the bladder to detect issues like urinary tract infections, bladder stones, or
structural abnormalities.
 Hysterosalpingography Contrast Media: In gynecological radiology, water-soluble
contrast agents can be used to visualize the uterine cavity and fallopian tubes. This aids
in diagnosing conditions like infertility or uterine abnormalities.
Water soluble cm
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 Water soluble iodinated cm administrated

directly into the body cavity.
 Based on benzene ring to which 3 iodine
atoms are attached.
1. monomer contains 1 tri iodinated benzene ring
2. DIMER CONTAINS 2 TRI IODINATED BENZENE RINGS.

DIVIDED INTO 2 GROUPS BASED

ON THEIR WATER SOLUBILITY

1. IONIC
2. NON IONIC
 Iodinated CM 31
 Iodine is a chemical element with the symbol I and atomic number
53.
 It exists as a lustrous, purple-black non-metallic solid at standard
conditions that melts to form a deep violet liquid at 114 degrees
Celsius, and boils to a violet gas at 184 degrees Celsius.
 Iodinated contrast media are among the most commonly used
injectables in radiology today.
 Modern iodinated contrast agents can be used almost anywhere in the
body.
 Most often they are used intravenously but can be administered intra
arterially, and intra abdominally.
 They are usually safe, and adverse effects are generally mild and self-
limiting.
 All the currently used contrast media are chemical modifications of a
2,4,6-triiodinated benzene ring.
 The parent molecule from which the contrast agents are derived is benzene. 32
 This is a toxic water-insoluble liquid.
 The carbon atoms on a benzene ring are numbered clockwise from 1 to 6.
 Benzoic acid is produced by introducing an acid group at position 1 on the benzene ring.
 2,4,6-triiodobenzoic acid is obtained by introducing iodine atoms at positions 2, 4, and 6 on the
ring.
 Iodine is the element used in contrast media as it possesses 3 important properties
essential for the production of contrast media:
I. high-contrast density,
II. firm binding to the benzene molecule, and
III. low toxicity.
What is Ionic Contrast Media?
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 Ionic contrast media are iodinated contrast agents that can dissociate
into cations and anions when they enter a solution. In other words, ionic
contrast media can dissolve into charged particles when entering a solution.
In this type of media, every two cations are associated with three anionic
components. Therefore, these agents are commonly known as 3:2
compounds.
 Typically, ionic contrast media are high osmolarity contrast agents. Injecting
this type of agent can cause a big increase in the number of particles that
occurs in the vascular system. The ions that come from dissociation of ionic
contrast media have the potential to destroy the electrical charges that are
associated with the brain and heart. This disruption condition is named
neurotoxicity.
What is Nonionic Contrast Media? 34
 Nonionic contrast media are iodinated contrast agents that do not dissociate
into cations and anions when entering a solution. In other words, nonionic
contrast media cannot dissolve into charged particles when it enters a
solution. This type of media contains one neutral component per every three
iodine molecules. Therefore, these are named as 3:1 compounds.
 Moreover, most of the nonionic contrast media are low osmolarity contrast
media. When a nonionic contrast media is introduced into a vascular system,
it can result in the movement of water from body tissues to the vascular
system during attempting to equalize the concentrations. This increased fluid
volume also can cause dilation of the vascular vessels.
What is the Difference Between Ionic and
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Nonionic Contrast Media?
 Iodinated contrast media is available in two types as ionic
and nonionic contrast media. The key difference between
ionic and nonionic contrast media is that ionic contrast
media can dissolve into charged particles when it is
entering a solution, whereas nonionic contrast media
cannot dissolve into charged particles when it enters a
solution. Moreover, ionic contrast media show high
osmolarity media whereas nonionic contrast media show
low osmolarity media. In addition, nonionic contrast media
is comparatively less toxic than ionic contrast media;
therefore, there is a high demand for the nonionic type.
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 High-osmolar contrast media (HOCM)
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 High-osmolar contrast media (HOCM), also known as high-osmolality contrast
media, are a type of contrast agent used in medical imaging studies, particularly
in radiology procedures such as x-ray and computed tomography (CT) scans.
These contrast agents are used to enhance the visibility of specific structures and
organs within the body.

Composition:
 High-osmolar contrast media typically consist of iodine compounds as the active
ingredient. These compounds have a high osmolality, which means they have a
greater number of particles in solution per unit of volume compared to blood
plasma.
 Purpose: 38
 The primary purpose of HOCM is to increase the contrast or difference in density between the targeted
structures or organs and the surrounding tissues in medical images. This enhanced contrast allows for
better visualization and assessment of specific anatomical areas.
Imaging modalities:
 High-osmolar contrast media are primarily used in x-ray and CT imaging procedures. They are
particularly effective for highlighting blood vessels (angiography) and urinary tract structures
(urography).
Administration:
 HOCM can be administered through various routes, including:
 Oral: swallowed, often for gastrointestinal studies.
 Intrathecal: injected into the spinal canal, used for certain spinal and myelographic studies.
IONIC MONOMERS
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Ionic Monomers in High-Osmolality Contrast Media

High-osmolality contrast media (HOCM) contain ionic monomers with higher osmotic
properties, meaning they have a greater number of particles per unit volume. This results
in a more significant osmotic effect when injected into the bloodstream. The most
common ionic monomers in high-osmolality contrast media include:

Diatrizoate (Sodium and Meglumine)**: Diatrizoate, often combined with sodium and
meglumine salts, is a classic example of an ionic monomer used in high-osmolality
contrast media. It is primarily utilized in conventional angiography and certain CT
imaging procedures.
bIodoxamate: is another ionic monomer found in high-osmolality contrast media. It has
been used in urography, angiography, and other imaging applications.
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 Low-osmolar contrast media (lOCM)
 Low-osmolar contrast media (LOCM) is a type of contrast agent used in41medical
imaging procedures, such as X-ray and computed tomography (CT) scans, to
enhance the visibility of specific structures or organs within the body. It is
considered a safer alternative to high-osmolar contrast media due to its lower risk
of adverse reactions.

Composition:
 Low-osmolar contrast media typically contain iodine as the active ingredient. The
iodine is bound to a water-soluble molecule, which reduces its osmolality, making
it less likely to cause adverse reactions.
 Osmolality:
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Osmolality refers to the number of dissolved particles in a solution. Low-
osmolar contrast media have lower osmolality compared to high-osmolar
contrast media. This lower osmolality reduces the risk of osmotic effects and
adverse reactions.

Administration:
 Low-osmolar contrast media are typically administered intravenously for CT
scans and intravascular procedures. The specific route of administration may
vary depending on the imaging modality and the target area.
 Types of low-osmolar contrast media
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 Ionic Dimers: Two benzene rings(each with three
iodine atoms) are linked by a bridge to form a large
compound e.g., hexabrix
 This group carries only one carboxyl group.so
known as monoacid dimers
 Iodine particle ratio is 6:2.
 Ionic dimers are a type of contrast media that
contain charged molecules and exist as dimers,
meaning they consist of two monomeric units. These
types of contrast media were developed to reduce
the osmolarity and potential side effects associated
with traditional high-osmolar ionic contrast media.
Examples of ionic dimers include ioxaglate and
iotrolan.
 Non-Ionic Monomers: Non-ionic monomers are contrast media that do not contain
charged molecules and exist as single molecules (monomers). They have a lower osmolarity
compared to ionic contrast media and are associated with fewer adverse reactions.44
 non-ionic monomers include and Carboxyl group (-COOH) at C-1, of monomeric salts is
replaced by a nonionizing radical & CONH producing an iodine.
 Metrizamide (Amipaque) was the earliest non-ionic monomer & proved as an excellent
contrast media but was very expensive, impossible to autoclave and unstable in solution so
second grnrration of NIM were included later such as:
 iohexol (omnipaque )
 Iopromide (ultravist)
 Iodine ratio is 3:1
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 Non-Ionic Dimers: Non-ionic dimers
are a type of contrast media that like 46
ionic dimers, consist of two
monomeric units but do not contain
charged molecules. These contrast
media are designed to further reduce
the osmolarity and potential side
effects compared to non-ionic
monomers. An example of a non-ionic
dimer is iodixanol.
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TOXICITY
When discussing toxicity in the context of contrast media, it generally refers to
the potential harm or adverse effects that these substances can have on the
human body. Contrast media are used to improve the visibility of internal
structures during medical imaging procedures, but like any medical intervention,
they can have associated risks and side effect.
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TOXICITY
 Reactions unrelated to contrast media.
 Hyperosmolality.
 Chemotoxic.
 Immunological.
 Reactions Unrelated to Contrast Media
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1.Pyrogenic (Unsterile injection).
 Management
 Stop injection.
 Reassure the patient.
 Cover the patient with Blanket.
 Once chills occur-change the syringe, contrast and scalp vein set.
 No need for medication.
2.Vasovagal especially in anxious or psychosomatic patient.
3.Hypertensive attacks in patient with pheochromocytoma.
4. Excessive dehydration, hypoglycaemia.
 Hyper Osmolarity
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 This is due to the high osmolarity of contrast media than plasma. More with conventional
contrast media. These reactions include
 Erythrocyte damage.
 Capillary endothelial damage.
 Vasodilatation.(Vasodilation refers to the widening of the arteries and large blood vessels. It is a natural process that occurs
in response to low oxygen levels or increases in body temperature. It increases blood flow and oxygen delivery to areas of the
body that require it most.)

 Hypervolemia.(Hypervolemia is a condition where your body has too much fluid. Another name for
hypervolemia is “fluid overload” or “volume overload.” )
 Cardiovascular effects.
 Vascular pain.
 Disturbance of BBB (Blood Brain Barrier).
 Thrombosis and thrombophlebitis. (Thrombophlebitis is an inflammatory process that causes a blood clot to
form and block one or more veins, usually in the legs.)
 Chemotoxic Action
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 Chemotoxic effects are usually due to the cations. Especially Na+. The effects are
seen in
 Neurons.
 Myocardial cells.
 Capillary endothelium.
 RBC.
 Kidney.
 Nephrotoxicity of contrast media is due to 52
 Decreased renal perfusion. (low B.P., peripheral vasodilatation).
 Glomerular injury - manifest as proteinuria (high levels of protein in your
urine)

 Tubularinjury (Acute tubular necrosis (ATN) is a kidney disorder involving

damage to the tubule cells of the kidneys)- due to osmolarity,
chemotoxicity, ischaemia.
 Contrast media precipitation of Tamm Horsfall proteins that block
tubules.
 Swelling of renal tubular cells causing obstruction
 Immunological (Allergic) Toxicity
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 Immunological toxicity due to contrast media, also known as

contrast-induced hypersensitivity reactions or contrast-induced
allergic reactions, occurs when the body's immune system responds
inappropriately to the administration of contrast agents during
medical imaging procedures.
 Anaphylactic Reactions:
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 Anaphylactic reactions are true allergic reactions mediated by immunoglobulin E (IgE)
antibodies. This means that the patient has developed an allergy to the contrast media.
 These reactions are triggered when the body's immune system recognizes the contrast media as
foreign and mounts an immune response, which can lead to the release of histamines and other
inflammatory mediators.
 Anaphylactic reactions typically occur upon re-exposure to the same contrast agent, as the
immune system has previously been sensitized to it.
 Symptoms of anaphylactic reactions can range from mild to severe and may include hives,
itching, swelling, difficulty breathing, drop in blood pressure, and in extreme cases,
anaphylactic shock.
 Anaphylactoid Reactions:
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 Anaphylactoid reactions, on the other hand, do not involve an IgE-mediated immune response.
Instead, they are direct non-immune responses to the contrast media.
 These reactions are often indistinguishable from anaphylactic reactions in terms of symptoms
and severity.
 Anaphylactoid reactions can occur even in individuals who have never been exposed to the
contrast media before, as they do not require prior sensitization.
 The mechanism behind anaphylactoid reactions is believed to involve the direct release of
histamines and other inflammatory substances by mast cells and basophils, independent of the
immune system's involvement.
 The most important single medication in treatment of Anaphylactoid reactions is
EPINEPHRINE
 Allergic reactions 56

 Allergic reactions to contrast media, also known as

contrast-induced hypersensitivity reactions, can
occur in response to the administration of contrast
agents during medical imaging procedures such as
X-rays, CT scans, and MRIs. These reactions can
vary in severity and may manifest as immediate or
delayed hypersensitivity reactions
Immediate Hypersensitivity Reactions:
 57 the
Timing: Immediate hypersensitivity reactions typically occur within minutes to one hour after
administration of contrast media.
 Symptoms: These reactions can range from mild to severe and may include:
 Skin Reactions: Hives (urticaria), itching (pruritus), rash, flushing.
 Respiratory Symptoms: Sneezing, nasal congestion, coughing, wheezing, shortness of breath.
 Gastrointestinal Symptoms: Nausea, vomiting, diarrhea, abdominal pain.
 Cardiovascular Symptoms: Palpitations, chest pain, a drop in blood pressure (hypotension).
 Anaphylaxis: In severe cases, anaphylactic reactions can occur, leading to a sudden and potentially
life-threatening systemic response. Symptoms can include difficulty breathing, swelling of the face
and throat, rapid heart rate, and shock.
 Risk Factors: Patients with a history of allergies, especially prior reactions to contrast media, asthma,
or other allergic conditions, are at a higher risk of immediate hypersensitivity reactions.
 Delayed Hypersensitivity Reactions:
 Timing: Delayed hypersensitivity reactions occur more gradually and 58
may not become evident until several hours to days after contrast media
exposure.
 Symptoms: Symptoms of delayed reactions can include:
 Skin Reactions: Skin rash, redness, or swelling.
 Systemic Symptoms: Fever, joint pain, fatigue, malaise.
 Gastrointestinal Symptoms: Nausea, vomiting, diarrhea.
 Mechanism: Delayed hypersensitivity reactions are T-cell-mediated and
involve a different immune pathway than immediate reactions. These
reactions may be less severe but can still be uncomfortable and require
medical attention.
 Management and Prevention:
 59
Immediate Treatment: If a patient develops severe allergic symptoms, including anaphylaxis,
during or after contrast media administration, immediate medical attention is crucial. This may
involve administering epinephrine and other emergency measures.
 Discontinuation: The administration of contrast media should be stopped if an allergic reaction
occurs.
 Antihistamines and Corticosteroids: For mild allergic reactions, antihistamines (e.g.,
diphenhydramine) and corticosteroids (e.g., prednisone) may be administered to alleviate
symptoms.
 Alternative Contrast Agents: In patients with known contrast allergies, alternative contrast
agents with a lower risk of allergic reactions may be considered.
 Pre-Medication: In some cases, patients at higher risk of reactions may be pre-medicated with
antihistamines and corticosteroids before contrast administration to reduce the risk of allergic
reactions.
 High Risk Group Persons 60
 Prior reactions to contrast media - 11 times more prone.
 History of allergy - 4 times more prone.
 Cardiac disease - 4 times more prone.
 Asthma - 5 times more prone.
 Diabetes - 4 times more prone.
 Old age - 4 times more prone
 Neonates - 4 times more prone.
 Myelomatosis, polycythemia.
 Sickle cell anaemia, pheochromocytoma, homocystinuria
 61
Premedication for High Risk Group

 Tab. Wysolone (10 mg) q.i.d. for 2-3 days

(Prednisolone).
 Tab Rantac (150 mg) b.d. for 2 days.
 On the day of procedure, if necessary. Injection 1
ampoule of Hydrocortisone.
  Severity of reactions
62

 MILD : 1 in 20 cases - 5%.

 Mild Reactions
 Reassure the patient and tell him the reaction will go away. Loosen tight
clothing if any. Tell the patient to take a few deep breaths in and out to relax.
Stay with the patient and watch until symptoms subside.
 Nausea, vomiting, mild rash, light headache and mild dyspnoea. Needs no
treatment.
 MODERATE 1 in 100 - 1%.
 63
Extensive urticaria, facial edema, bronchospasm, laryngeal oedema, dyspnoea,
mild chest pain or hypotension. Requires treatment but generally there is no need
for hospitalization.

 Severe reactions (l in 2000 - 0.05%).

 Circulatory collapse, pulmonary oedema, severe angina, myocardial infarction,
convulsions, coma, cardiac or respiratory arrest. Requires hospitalization and
intensive care.
 Mortality - (1 in 40,000 - 0.0025%)
 Treatment
64
 Whenever contrast medium is being injected, the radiologist must make sure that appropriate
equipment for initial treatment of contrast reactions, is kept ready.
 Two basic rules to be remembered are
 Make sure that the drugs for allergic reactions are available before injecting the contrast.
 Never leave the patient unattended after contrast has been injected until examination is
complete. No patient will have a serious reaction after 60 min. of contrast administration.
 General principles in the use of:
 Oxygen.
 Epinephrine.
 Corticosteroids.
 Oxygen
 Oxygen and equipment for assisting ventilation should be readily available. 65
 Current recommendation for use of high dose oxygen is at the rate of 10-12 L/min via
face mask.
 02 can be provided at up to 100% concentration.

 Epinephrine
 The most important single medication in treatment of anaphylactoid reaction is
epinephrine.

 Corticosteroids
 They do not play a significant role in acute reactions, they may be effective in
reducing late reactions, which can be observed as long as 48 hours. after contrast
injection
 Extravasation of Contrast Material
 66
Contrast media extravasation (CMEX) is a complication where there is leakage of intravenously
administered contrast agents (either iodine or gadolinium-based), into the surrounding soft-
tissues . This can vary in severity from minor discomfort to compartment syndrome, skin
ulceration and necrosis.
 Extravasation of contrast material refers to the accidental leakage or escape of a contrast agent
from the blood vessel or organ where it was intended to be injected during a medical imaging
procedure, such as a contrast-enhanced CT scan, MRI, or angiography
 The reported incidence of intravenous (IV) contrast media extravasation related to power
injection for CT has ranged from 0.1% to 0.9% (1/1000 patients to 1/106 patients).
 Extravasation can occur during hand or power injection.
 The frequency of extravasation is not related to the injection flow rate.
67
 Management
68

 Elevation of affected extremity above the heart level.

 Ice packs (20 min t.i.d. for 2-3 days)
 Plastic surgery consultation if
 Large volume extravasation (>30 ml ionic or > 100 ml non-ionic)
 Skin ulceration or blistering
 Worsening symptoms after 2-4 hours.
 Close follow-up until resolution
 REFERENCE
1. Quader, M. A., Sawmiller, C. J., & Sumpio, B. E. (2000). Radio contrast agents: History and evolution.
In Textbook of Angiology (pp. 775–783). Springer New York.
2. Weinmann, H. J., Platzek, J., Schirmer, H., Pietsch, H., Carretero, J., Harto, J., Medina, J., Riefke, B., & Martín,
J. (2005). Contrast media: future aspects. European Radiology, 15 Suppl 4, D70-3.
https://doi.org/10.1007/s10406-005-0119-4
3. Thomsen, H. S., Bellin, M.-F., Jakobsen, J. Å., & Webb, J. A. W. (2014). Contrast media classification and
terminology. In Medical Radiology (pp. 3–11). Springer Berlin Heidelberg
4. Kumar, J. (n.d.). Oil contrast media in radiology. Slideshare.net. Retrieved August 6, 2022, from
https://www.slideshare.net/JaiKumar331/oil-contrast-media-in-radiology
5. Weinmann, H. J., Platzek, J., Schirmer, H., Pietsch, H., Carretero, J., Harto, J., Medina, J., Riefke, B., &
Martín, J. (2005). Contrast media: future aspects. European Radiology, 15 Suppl 4, D70-3.
https://doi.org/10.1007/s10406-005-0119-4
6. Nyman, U., Ekberg, O., & Aspelin, P. (2016). Torsten Almén (1931–2016): the father of non-ionic iodine
contrast media. Acta Radiologica (Stockholm, Sweden: 1987), 57(9), 1072–1078.
https://doi.org/10.1177/0284185116648504
7. Themes, U. F. O. (2016, March 3). Contrast media. Radiology Key. https://radiologykey.com/contrast-media-2/
8. Radiologocal Procedures (A Guideline) Dr Bhushan N. Lakhkar
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