Contrast Agents and

Vascular Imaging Methods

 5 basic radiographic densities from black to bright white

• Air
• Fat
• Soft tissue/fluid
• Bone/mineral
• Metal

Basis = differential absorption of X-rays by tissues = for

ex. bone absorbs X-ray more than soft tissue

Terms – Radiolucent, lucent

Radio-opaque, opaque (shadow)
 Contrast Media in Radiology
• Negative Contrast – Air

• Positive Contrast

• Barium – X-ray
• Iodinated – X-ray, CT
• vascular
• Biliary, Urinary
• CSF

• Gadolinium - MRI

• Microbubbles - Ultrasound
Positive X-Ray Contrasts
• High Atomic Number
• High absorptivity of X-rays
Barium Sulphate (BaSO4)
• Barium (Ba), a metallic chemical element with atomic number 56
• Used in fluoroscopic examinations of the gastrointestinal tract.
• Barium sulfate is insoluble in water
• First perform “Scout”
Iodinated Contrast Medium
High atomic number – I-53
Use of Iodinated Contrast Medium

• Angiography
• Myelography
• Arthrography
• Ductography
• Fistulogrphy
• Sialography…
Contrast enhanced tumor
CT Perfusion
Contrast
• What are the risks of iodinated contrast?
• Contrast reaction
• 1 in 10,000 have true anaphylactic reaction
• 1 in 100,000 to 1 in 1,000,000 will die
• Medical Issues
• Acute renal failure
• Lactic acidosis in diabetics
• If on Glucophage, patient must stop Glucophage for 48
hours after exam to prevent serious lactic acidosis
• Cardiac
• Extravasation
Contrast
• Who is at risk for an anaphylactic reaction?
• Patients with a prior history of contrast reaction
• Patients with a history asthma react at a rate of 1 in 2,000
• Patients with multiple environmental allergies, ie foods, hay fever,
medications

Amin MM, et al. Ionic and nonionic contrast media: Current status and
controversies.

Appl Radiol 1993; 22: 41-54.

Contrast
• Pretreatment for anaphylaxis
• 50 mg Oral Prednisone 13, 7 and 1 hour prior to exam
• 50 mg oral Benedryl 1 hour prior to exam
• In emergency, 200 mg iv hydrocortisone 2-4 hours prior to exam
 Contrast
• What are the risk factors for contrast induced
acute renal failure?
• Pre-existing renal insufficiency
• Contrast volume
• Dehydration
• Advanced age
• Drugs
• Multiple myeloma
• Cardiac failure
 Gadolinium

1794 J. Gadolin studied rare earth

rock from Ytterby, Sweden, giving start of
the research of lanthadines

1880 Gadolinium oxide (Gadolinite) was discovered

by J. C. Galissard de Marignac

Pure Gadolinium was Isolated in 1886

by P. E. Lecoq de Boisbaudran

1760-1852
Gadolinium Based Contrast Agents
registered in Georgia

Non-ionic linear
• Gadodiamide – Omniscan
Ionic linear
• Gadopentetate (Gadopentate dimeglumine) – Gd-
DTPA2 - Magnevist, Magnetolux, Magnatol
Non-ionic Macrocyclic
• Gadobutrol – Gadovist
Ionic Macrocyclic
• Gadoteric Acid – Scanlux (Dotarem)
Gadolinium as MRI contrast agent
 Contrast Agents
Extracellular
• Intravascular – Interstitial (Gd-DTPA etc.) – through diffusion,
hydrostatic and osmotic pressure.
• Does not pass BBB
• Intravascular (Gadofesveset trinatrium – Vasovist) – blood pool
agents.

Intracellular
• Hepatobiliar (Gadoxetic Acid – Primovist)

• Manganum Compounds – experimental

Microcirculation - filtration
 Tumor Contrast Enhancement
• Pathologic vascularization –
neoangiogenesis – disorganized, dilated,
tortuous, immature new vessels
• Hyperperfusion of malignant tumors
• Higher permeability of tumor capillary
walls
• Ease of diffusion in interstitial space
• Disruption of BBB
• Accumulation of GdBCA in interstitial
space
Ga3+ based contrast agent
Facilitating the relaxation
Cerebral metastases
Leptomeningeal metastases
Cerebral Metastases - response to irradiation
MR-angiography

Off-label use of GdBCA?

Bolus injection with saline flush
Dynamic Enhancement of Pituitary Microadenoma
Recurrent Glioma –
Perfusion MR
Postradiation
Necrosis – Perfusion
MR
Dynamic contrast enhanced breast MR
Elevated rCBV in glioblastoma
 Acute adverse reaction to CM
• Anaphylactoid – without development of IgE-allergen
complexes, not dose dependent, no sensitization is
needed.
• Chemotoxic – depends on osmolarity, ion compound,
dose and concentration.
• Extravasation

• Gadolinium-based contrast media :

• All reactions: 0.03-0.2%
• Severe reactions only: 0.002-0.01%
 Anaphylactoid Reaction

Prevention in case of known allergy to CA

• Prednisolone (30mg orally) 12 and 6 hours prior to investigation.

• Diphenhydramin – 50mg orally 1 hour prior to investigation.
• Steroids later than 2 hours prior to investigation are ineffective.
• Prick and Intradermal tests.
Nephrogenic systemic
sclerosis
Nephrogenic systemic sclerosis
Risk factors
GFR <30ml/min/1,73m2
Hemodyalisis
Proinflammatory state:
Recent surgery
Tissue trauma
Infection
Malignancy
Thrombosis
Institutional guidelines to avoid the use of linear
GdBCA

• GFR lower that 30ml/min/1.73m2 – Informed Consent questionary –

Allergy, Diabetes, Chronic kidney disease, Creatinine test in last two
weeks
• Age younger than 1 month
• Recent liver transplant
• Pregnancy (excluding cases of high urgency)
Gd Deposition in the brain
 Gd-deposition - Who are at risk, what are
consequences
• Multiple injections (5 and more) of linear GdBCA
• Chronic kidney disease
• Chronic disease (Cancer, multiple sclerosis etc.) – multiple injections
in drug trials

• Deposition in dentate nucleus, n. pallidus, skin and bone - evident in

linear agents, not in macrocyclic

• Suggestive role of apoptosis, oxidative stress, and competition of

Gd3+ with Ca2+ for cellular processes. Transmetallation with Zn, Cu,
Fe

• No known clinical signs yet

MR-Angiography
MRA of peripheral vessels
BOLD – fMRI - imaging

• “Oversupply” of oxyhemoglobin after activation

• Total deoxyhemoglobin decreases
• Magnetic field randomness decreases
• NMR signal goes up [near veins and capillaries]

• Increased capillary perfusion

• Inflowing spins exchange to parenchyma at capillaries
• Can be detected with perfusion-weighted imaging methods
• This is also the basis for 15O water-based PET
Memory fMRI
BOLD (Blood oxygen level dependent)
- fMRI – Motor function
Language fMRI
fMRI in Epilepsy Surgery
fMRI plays crucial role in establishing the
functional integrity of so-called eloquent
cortex.

To investigate the functional reserve of

medial temporal lobe.

To predict the risks of postoperative

functional decline.

Sidhu M., Stretton J., Winston G. et al. Neurology. 2015 Apr

14;84(15):1512-9
Jokeit H., Okujava M., Woermann F. Neurology. 2001 Nov
27;57(10):1786-93
Arterial Spin Labeling (ASL) Perfusion
Cellular density and Diffusion in
tumors

Glioblastoma Fibrillary
multiforme Astrocytoma
1H-MR Spectroscopy – Recurrent
Tumor