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with MS receive a timely and accurate diagnosis.
9
Nevertheless, because many people with unconventional
clinical features might still have MS, incorporating the
characteristic MRI features described into the diagnostic
process should help improve diagnostic accuracy.
Table 4.9
Typical Location of White Matter Lesions in Multiple Sclerosis
Periventricular region
Corpus callosum
Subcortical region
Brainstem
U-fibers
Optic nerves
Gadolinium Use in MRI
Gadolinium-based contrast agents (GBCAs) have become
indispensable in routine MRI imaging. 71 When used at
clinically approved doses (0.1-0.2 mmol/kg for most agents),
they have a long-standing excellent cumulative safety profile
and are extremely well tolerated by the vast majority of
patients. 72 MS lesions remain active for an average of
3 weeks. Gadolinium can be used to help increase the
diagnostic accuracy and to provide information regarding
disease activity and treatment response. In this regard, the
presence of contrast-enhancing lesions on follow-up MRI can
be used as a surrogate marker of disease activity and treatment
response. 66 In addition, the simultaneous presence of
asymptomatic enhancing and nonenhancing lesions on a T1weighted scan can serve as evidence of DIT when making a
diagnosis of MS.
12
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Adverse events (AEs) are extremely rare (reported in about
0.06%-0.3% of cases). 71 According to pathophysiologic
mechanism, AEs can be divided into immediate
hypersensitivity reactions (typically occur within seconds or
minutes after the injection and imply an immune response to
the whole or part of the GBCA) and physiologic reactions
(coldness, warmth, or pain at the injection site; nausea with or
without vomiting; headache; paresthesias; and dizziness),
which can manifest in minutes to hours after gadolinium
administration.
73
According to severity, adverse events can be classified into
mild (typically self-limited with no evidence of progression),
moderate (bronchospasm, laryngeal edema, generalized
erythema), or severe (severe laryngeal edema, convulsions,
profound hypotension, unresponsiveness, arrhythmia, and/or
cardiopulmonary arrest).
73
Severe life-threatening
anaphylactic and fatal reactions have been reported but are
exceedingly rare (0.001%-0.01%).
74
Most GBCAs are nonspecific extracellular contrast agents that
are cleared almost exclusively by the kidneys. 72 Renal
function has been considered a critical determinant of subacute
gadolinium toxicity because of impaired contrast agent
71,73
In these
individuals, gadolinium can remain inside the body for
extended periods with the potential to cause toxicity.
71
Nephrogenic systemic fibrosis (NSF) has been linked with
gadolinium exposure in patients with renal insufficiency. 2 It is
a debilitating and potentially life-threatening disease
characterized by widespread progressive tissue fibrosis. 72 The
exact underlying mechanism is not fully understood. In recent
years, NSF has been almost completely eliminated as a result
of preadministration renal disease screening and by using
lower GBCA doses (typically half doses) or by avoiding
GBCAs altogether on patients with renal disease or low
estimated glomerular filtration rates. 73 Nevertheless, the
nephrotoxic effects in patients with renal impairment remains
controversial and needs further investigation.
A few anecdotal case reports regarding neurologic and
nonneurologic gadolinium-induced toxicities without clear
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evidence of causality from other entities, including GBCAinduced encephalopathy, cognitive impairment, recurrent
pancreatitis, and acute tubular necrosis, have been reported.
71,73
The storage state of gadolinium in the body has received
considerable interest in recent years. Originally, higher
concentrations of gadolinium were observed in bone and more
recently in the brain in patients with renal impairment
compared with healthy controls. 71 This entity has recently
been termed “gadolinium storage condition” (GSC). 73 The
principal symptoms of GSC include peripheral and central
bone pain and skin and subcutaneous tissue burning pain
typically in a glove and stocking distribution but can also be
central, and in late-stage disease (after 3 mo) progressive
thickening and discoloration of the skin and subcutaneous
tissue of the distal extremities has been reported.
71,73
Preliminary findings from recent publications highlight the
need to systematically study gadolinium-induced symptoms in
larger controlled studies. Treatment for symptomatic patients
will likely involve rechelation therapy, possibly supplemented
by immune modulation therapy.
37,73
At present, there are no
specific recommendations from the various professional
societies regarding gadolinium retention. However, current
recommendations are to utilize GBCAs only when clinically
necessary.
71,75
Gadolinium Use During Pregnancy
MRI during pregnancy is generally thought to be safe for the
fetus. 72 However, administration of gadolinium during
pregnancy is discouraged owing to possible teratogenicity in
the first trimester during organogenesis. 76 Gadolinium may
cross the placenta in the second and third trimesters where it
can be excreted into the amniotic fluid in small amounts
(0.01% of the injected dose in animal models) and recirculated
by the fetus. 77 This raises concern for gadolinium retention
and associated NSF in the child. Although no cases of NSF in
newborns have been reported to date, a large retrospective
study evaluating the long-term safety of gadolinium exposure
during pregnancy reported an increased fetal risk of
rheumatologic, inflammatory, or infiltrative skin conditions in
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123 children of women who were exposed to gadolinium
during pregnancy versus 384,180 births (adjusted hazard ratio,
1.36; 95% confidence interval [CI], 1.09-1.69). 76 In addition,
stillbirths and neonatal deaths also occurred more frequently
among seven gadolinium MRI-exposed versus 9844 MRIunexposed pregnancies (adjusted relative risk [RR], 3.70; 95%
CI, 1.55-8.85), although there was no increased risk of harm to
the fetus or in early childhood in children of women who were
exposed to MRI without gadolinium. 76 A limitation of these
conclusions is the use of a control group who did not undergo
MRI (rather than patients who underwent MRI without
gadolinium). Additional larger studies are needed to establish
the risks of gadolinium administration to the developing fetus.
Although MRI is not contraindicated in pregnancy, until
further studies are performed, current general consensus
among the American College of Obstetricians and
Gynecologists is that every effort should be made to avoid the
administration of gadolinium to the pregnant woman and
alternative imaging strategies such as ultrasound should be
used whenever possible.
76
Gadolinium Use During Lactation
The water solubility and minimal protein binding of
gadolinium-based agents limit their excretion into breast milk.
74
Within 24 hours of gadolinium administration, less than
0.04% of the administered dose is excreted into breast milk
and, of this amount, less than 1% will be absorbed by the
infant’s gastrointestinal tract. 72 Although theoretically any
gadolinium excreted into breast milk could reach the infant,
there are no reports of breastfeeding-related toxicity to date.
However, the lack of knowledge about its long-term safety and
the possible risks associated with immature renal function in
the neonate are all causes for concern. Overall, the decision
about whether to cease breastfeeding for a short period of time
after gadolinium administration may be best made on a caseby-case basis, depending on the specific GBCA administered
to the lactating mother. However, the current general
consensus among the American College of Obstetricians and
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Gynecologists is that breastfeeding should not be interrupted
after gadolinium administration.
76
MRI Safety in Patients With Implanted
Devices
Potential safety concerns exist regarding the safety of MRI
evaluation in patients with implanted devices primarily
because of factors that include electromagnetic field
interactions, MRI-related heating, and the creation of image
artifacts. 78 In the Unites States, the Food and Drug
Administration (FDA) is responsible for reviewing the
labeling provided by manufacturers regarding the safety of
their devices and their compatibility for use in an MRI
environment. 79 Clinicians should always include all medical
devices (cardiac pacemakers, implantable infusion pumps, or
other metal implants) in their assessment of a patient’s
suitability for MRI scanning. Strict adherence to basic
screening and scanning protocols is also required. 79 Devices
are classified as MR Safe, MR Conditional, or MR unsafe
according to the FDA. 79 MR Safe devices have no known
MRI contraindications, whereas MR Conditional devices
should be used only within the MRI environment if all of the
conditions for safe use provided by the manufacturer are
followed. 80 Devices without information regarding MRI
compatibility should be assumed to be unsafe. A complete list
of FDA-approved implanted devices for use in MRI can be
found at www.fda.gov. Additional recommendations regarding
the various implantable devices are discussed in the following.
Cardiac Pacemakers
Although new implants are now required to be fully MRI
compatible, not all implanted cardiac devices are considered
safe for MRI. 81 The most commonly observed effect of MRI
on a cardiac device is a change in the device parameters.
81,82
With the use of specific protocols of patients with pacemakers,
reprogramming of the device before and after the MRI, or
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complete deactivation in some settings, MRI evaluations can
be safely performed in most patients.
82
Implantable Infusion Pumps
MRI scanning may affect the programming or function of
implantable infusion pumps. 83 To prevent drug withdrawal or
unintended medication overdose, some pump models may
need to be reprogrammed before and/or after the examination.
80
Therefore, it is important to be aware of the specific
instructions and safety issues delivered by the manufacturer
based on the specific model of the device. Depending on the
medication being administered and the device model, some
pumps may need to be emptied before an MRI in some
situations.
80
Vagus Nerve Stimulators
As with cardiac implantable devices or implantable infusion
pumps, all vagus nerve stimulator devices should be
interrogated and reprogrammed before and after an MRI by an
appropriate health care professional.
MRI-Compatible Metals
The strong magnetic field of an MRI scanner attracts ferrous,
or iron-containing, metals and can cause serious injury to
patients with certain implanted metallic devices.
3,78
Specific
metals that have been cleared for use during MRI scans by
safety experts include titanium, cobalt-chromium, copper, and
stainless steel. 78 Nevertheless, careful patient screening
before, during, and after an MRI scan is imperative in all
patients with implantable devices.
Conclusion
MS and related CNS demyelinating disorders present unique
diagnostic and management challenges in clinical practice. In
the absence of definite diagnostic testing, MRI serves as an
important diagnostic tool and a reliable and sensitive surrogate
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biomarker of disease activity and progression that is also
commonly employed as a key outcome measure in
pharmaceutical clinical trials. Rapidly advancing
neuroimaging techniques will continue to improve our
understanding of the underlying pathophysiology of this
disease.
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