Does Gadoterate Meglumine Cause Gadolinium Retention in the Brain of Children? A Case-Control Study

A non-inferiority study of MRI versus CT for staging and image-defined risk factor assessment in the preoperative work-up of abdominopelvic neuroblastoma

BACKGROUND

Neuroblastoma accounts for 15 % of cancer deaths in children. Complete surgical resection is associated with a higher overall survival rate but also a higher morbidity rate. An international group of experts has defined a nomenclature of image-defined risk factors (IDRFs) for the determination of operability and the anticipation of reasonably foreseeable complications of surgery. However, there is no consensus on the optimal imaging modality (CT or MRI) for the assessment of IDRFs. The objective of the present study was to determine the non-inferiority of MRI vs. CT in the preoperative assessment of abdominopelvic neuroblastoma. The secondary objective was to assess the contribution of gadolinium contrast enhancement.

METHODS

All children diagnosed with abdominopelvic neuroblastoma and whose preoperative work-up included a contrast-enhanced CT or MRI scan of the abdomen and pelvis between January 2014 and January 2023 were included. To evaluate the IDRFs, all the images were reviewed in three steps: (i) non-contrast MRI scans, (ii) both non-contrast and contrast-enhanced MRI scans, and (iii) contrast-enhanced CT scans.

RESULTS

Twenty-five patients were found to be eligible, and fifteen were included. The mean time interval between MRI and preoperative CT was 23 days. In all patients, the identified IDRFs were similar for all three imaging modalities. Fourteen patients underwent full resection of the tumour. The surgical reports were fully consistent with the IDRFs described on CT and/or MRI.

CONCLUSION

A high-resolution three-dimensional T2 MRI sequence agreed fully with contrast-enhanced CT for the detection of IDRFs. Contrast-enhanced MRI did not add value. However, surgeons will need time to adapt to this MRI-based approach and learn how to interpret the results with confidence.

Importance of Cardiovascular Magnetic Resonance Applied to Congenital Heart Diseases in Pediatric Age: A Narrative Review

Congenital heart diseases (CHDs) represent a heterogeneous group of congenital defects, with high prevalence worldwide. Non-invasive imaging is essential to guide medical and surgical planning, to follow the patient over time in the evolution of the disease, and to reveal potential complications of the chosen treatment. The application of cardiac magnetic resonance imaging (CMRI) in this population allows for obtaining detailed information on the defects without the necessity of ionizing radiations. This review emphasizes the central role of CMR in the overall assessment of CHDs, considering also the limitations and challenges of this imaging technique. CMR, with the application of two-dimensional (2D) and tri-dimensional (3D) steady-state free precession (SSFP), permits the obtaining of very detailed and accurate images about the cardiac anatomy, global function, and volumes' chambers, giving essential information in the intervention planning and optimal awareness of the postoperative anatomy. Nevertheless, CMR supplies tissue characterization, identifying the presence of fat, fibrosis, or oedema in the myocardial tissue. Using a contrast agent for angiography sequences or 2D/four-dimensional (4D) flows offers information about the vascular, valvular blood flow, and, in general, the cardiovascular system hemodynamics. Furthermore, 3D SSFP CMR acquisitions allow the identification of coronary artery abnormalities as an alternative to invasive angiography and cardiovascular computed tomography (CCT). However, CMR requires expertise in CHDs, and it can be contraindicated in patients with non-conditional devices. Furthermore, its relatively longer acquisition time and the necessity of breath-holding may limit its use, particularly in children under eight years old, sometimes requiring anesthesia. The purpose of this review is to elucidate the application of CMR during the pediatric age.

Gadolinium Contrast Agent Deposition in Children

Over the past few years, a large number of studies have evidenced increased signal intensity in the deep brain nuclei on unenhanced T1-MRI images achieved by the application of gadolinium-based contrast agents (GBCAs). The deposition of gadolinium in the brain, bone, and other tissues following administration of GBCAs has also been confirmed in histological studies in rodents and in necropsy studies in adults and children. Given the distinct physiological characteristics of children, this review focuses on examining the current research on gadolinium deposition in children, particularly studies utilizing novel methods and technologies. Furthermore, the article compares safety research findings of linear GBCAs and macrocyclic GBCAs in children, with the aim of offering clinicians practical guidance based on the most recent research outcomes. LEVEL OF EVIDENCE: 5 TECHNICAL EFFICACY: Stage 2.

MRI detection of brain gadolinium retention in multiple sclerosis: Magnetization transfer vs. T1-weighted imaging

BACKGROUND AND PURPOSE

Evidence of brain gadolinium retention has affected gadolinium-based contrast agent usage. It is, however, unclear to what extent macrocyclic agents are retained and whether their in vivo detection may necessitate nonconventional MRI. Magnetization transfer (MT) could prove suitable to detect gadolinium-related signal changes since dechelated gadolinium ions bind to macromolecules. Therefore, this study aimed to investigate associations of prior gadolinium administrations with MT and T1 signal abnormalities.

METHODS

A cohort of 23 persons with multiple sclerosis (MS) (18 females, 5 males, 57 ± 8.0 years) with multiple past gadolinium administrations (median 6, range 3-12) and 23 age- and sex-matched healthy controls underwent 1.5 Tesla MRI with MT, T1-weighted 2-dimensional spin echo, and T1-weighted 3-dimensional gradient echo. The signal intensity index was assessed by MRI in gadolinium retention predilection sites.

RESULTS

There were dose-dependent associations of the globus pallidus signal on gradient echo (r = .55, p < .001) and spin echo (r = .38, p = .013) T1-weighted imaging, but not on MT. Relative to controls, MS patients had higher signal intensity index in the dentate nucleus on T1-weighted gradient echo (1.037 ± 0.040 vs. 1.016 ± 0.023, p = .04) with a similar trend in the globus pallidus on T1-weighted spin echo (1.091 ± 0.034 vs. 1.076 ± 0.014, p = .06). MT detected no group differences.

CONCLUSIONS

Conventional T1-weighted imaging provided dose-dependent associations with gadolinium administrations in MS, while these could not be detected with 2-dimensional MT. Future studies could explore newer MT techniques like 3D and inhomogenous MT. Notably, these associations were identified with conventional MRI even though most patients had not received gadolinium administrations in the preceding 9 years, suggestive of long-term retention.

SCMR expert consensus statement for cardiovascular magnetic resonance of acquired and non-structural pediatric heart disease

Cardiovascular magnetic resonance (CMR) is widely used for diagnostic imaging in the pediatric population. In addition to structural congenital heart disease (CHD), for which published guidelines are available, CMR is also performed for non-structural pediatric heart disease, for which guidelines are not available. This article provides guidelines for the performance and reporting of CMR in the pediatric population for non-structural ("non-congenital") heart disease, including cardiomyopathies, myocarditis, Kawasaki disease and systemic vasculitides, cardiac tumors, pericardial disease, pulmonary hypertension, heart transplant, and aortopathies. Given important differences in disease pathophysiology and clinical manifestations as well as unique technical challenges related to body size, heart rate, and sedation needs, these guidelines focus on optimization of the CMR examination in infants and children compared to adults. Disease states are discussed, including the goals of CMR examination, disease-specific protocols, and limitations and pitfalls, as well as newer techniques that remain under development.

Gadolinium deposition in the brain is related to various contrast agents: a matched case-control study

AIM

To assess the relationship between gadolinium deposition in the brain and various gadolinium-based contrast agents (GBCAs) and to explore confounding variables.

METHODS

The study group included 87 patients with multiple enhanced brain magnetic resonance imaging (MRI) examinations of which 48 patients were in the linear GBCA group (33 patients in gadopentetate dimeglumine group and 15 patients in gadobenate dimeglumine group) and 39 patients in the macrocyclic GBCA group (22 patients in gadobutrol group and 17 patients in gadoterate meglumine group). The control group included 87 normal participants who were matched regarding age, sex, MRI machine and imaging sequences to the study cohort. T1 signal intensity (SI) ratios of the dentate nucleus to the pons (DN/pons) and of the globus pallidus to the frontal white matter (GP/FWM) in both groups were calculated and compared. The relationships between SI ratios and confounding variables were analysed.

RESULTS

Significant differences were detected between two linear GBCA groups and control groups in T1 SI ratios of the DN/pons and GP/FWM (all p<0.001). There were no differences for two the macrocyclic GBCA groups compared with matching control groups (all p>0.05). T1 SI ratios of the linear GBCA group were significantly higher than those of the macrocyclic GBCA group (p<0.001). In the linear GBCA group, the T1 SI ratios of the DN/pons correlated moderately positively with the number of GBCA administrations (r=0.643, p<0.001), and MRI machine and sequence used.

CONCLUSIONS

Increased T1 SI could be observed after repeated administrations of linear GBCA. T1 SI of the DN correlated with the number of linear GBCA administrations, and detection might be affected by MRI machine and sequence.

Evaluation of the effect of multiple administrations of gadopentetate dimeglumine or gadoterate meglumine on brain T1-weighted hyperintensity in pediatric patients

BACKGROUND

Repeated administrations of linear gadolinium-based contrast media (GBCM) are associated with T1-weighted (T1-W) signal intensity change in brain structures.

OBJECTIVE

The purpose of this study was to compare different brain structures in children after unconfounded, repeated administrations of either a macrocyclic or linear GBCM.

MATERIALS AND METHODS

We performed a retrospective cohort study, identifying subjects with ≥5 unconfounded administrations of gadoterate meglumine. We matched subjects with repeated administrations of gadopentetate dimeglumine to the gadoterate meglumine arm based on the number of unconfounded GBCM administrations. Two reviewers drew regions of interest on 27 structures in and around the brain. We recorded demographic, modality and study parameters and evaluated them to determine whether they were associated with T1-W signal intensity (SI) changes. Linear mixed effects models evaluated the relationships between the number of GBCM doses and T1-W SI ratio. Finally, we identified differences in the rate of T1-W SI ratio change among individuals using a linear mixed effects model with random slope.

RESULTS

We included a total of 52 patients (age range at first MRI: 6.0 months to 17.1 years), 26 in each arm. We detected a significant change in the T1-W SI ratio with repeated administrations of GBCM in one location in the gadoterate meglumine arm and in four locations in the gadopentetate dimeglumine arm. Patient gender and age were not associated with T1-W SI change. Modality vendor, imaging sequence and field strength were variably associated with a systematic difference in the ability to detect a T1-W SI change. Finally, linear mixed effects model with random slope showed that there were individual differences in the slope of SI change at various structures among individuals for both arms. This effect was present in more brain structures in the gadopentetate dimeglumine arm (14 vs. 8).

CONCLUSION

There is a significant change in the T1-W SI ratio over time in multiple brain structures after repeated gadopentetate dimeglumine administrations. This effect was only seen in one ratio after repeated administrations of gadoterate meglumine. There are individual differences in the rate of change of SI ratios over time after repeated administration of gadopentetate dimeglumine and gadoterate meglumine, suggesting that individual differences are present.

The switch from Gd-DTPA to Gd-DOTA is not associated with decrease of the T1 signal intensity of the pallidus and dentate in a pediatric population

BACKGROUND

The switch from the linear gadolinium-based contrast agent (GBCA) gadopentate dimeglumine (Gd_DTPA) to the macrocyclic GBCA gadobutrol is associated with a decrease of the T1 signal intensity (SI) in brain gray matter nuclei. The effects of the switch to other macrocyclic GBCAs are not yet established.

PURPOSE

To explore the effects of switching from Gd-DTPA to the macrocyclic GBCA gadoterate meglumine (Gd-DOTA) in pediatric patients.

MATERIAL AND METHODS

We measured the pallidus/middle cerebellar peduncle (MCP) SI ratio and the dentate/MCP SI ratio in pre-contrast sagittal T1-weighted spin-echo images in nine patients who had received ≥6 administrations of Gd-DTPA and then of Gd-DOTA, in 18 patients who had received ≥6 administrations of Gd-DOTA alone, and in nine age-matched controls without prior GBCA administrations. Serial assessment was performed in patients who switched from Gd-DTPA to Gd-DOTA. Finally, the rate of change of pallidal/MCP and dentate/MCP SI ratios between the first and last Gd-DOTA administrations was compared.

RESULTS

The pallidal/MCP and dentate/MCP SI ratios were (P < 0.05) higher in patients with prior Gd-DTPA and Gd-DOTA administrations compared to the controls. After the switch, the pallidal/MCP SI ratio increased in nine patients and the dentate/MCP ratio in seven patients. The rate of change of pallidal/MCP SI ratio after Gd-DOTA was higher (P < 0.01) in patients who had previously received Gd-DTPA (mean 2.89 ± 2.6%) than in patients who had received Gd-DOTA alone (mean 0.53 ± 0.89%).

CONCLUSION

T1 SI in gray matter nuclei does not decrease after switching from Gd-DTPA to Gd-DOTA. The switch effects from Gd-DTPA to each macrocyclic GBCA should be individually evaluated.

Impact of Kidney Function on CNS Gadolinium Deposition in Patients Receiving Repeated Doses of Gadobutrol

BACKGROUND AND PURPOSE

Studies associate repeat gadolinium-based contrast agent administration with T1 shortening in the dentate nucleus and globus pallidus, indicating CNS gadolinium deposition, most strongly with linear agents but also reportedly with macrocyclics. Renal impairment effects on long-term CNS gadolinium deposition remain underexplored. We investigated the relationship between signal intensity changes and renal function in patients who received ≥10 administrations of the macrocyclic agent gadobutrol.

MATERIALS AND METHODS

Patients who underwent ≥10 brain MR imaging examinations with administration of intravenous gadobutrol between February 1, 2014, and January 1, 2018, were included in this retrospective study. Dentate nucleus-to-pons and globus pallidus-to-thalamus signal intensity ratios were calculated, and correlations were calculated between the estimated glomerular filtration rate (minimum and mean) and the percentage change in signal intensity ratios from the first to last scan. Partial correlations were calculated to control for potential confounders.

RESULTS

One hundred thirty-one patients (73 women; mean age at last scan, 55.9 years) showed a mean percentage change of the dentate nucleus-to-pons of 0.31%, a mean percentage change of the globus pallidus-to-thalamus of 0.15%, a mean minimum estimated glomerular filtration rate of 69.65 (range, 10.16-132.26), and a mean average estimated glomerular filtration rate at 89.48 (range, 38.24-145.93). No significant association was found between the estimated glomerular filtration rate and percentage change of the dentate nucleus-to-pons (minimum estimated glomerular filtration rate, r = -0.09, P = .28; average estimated glomerular filtration rate, r = -0.09, P = .30,) or percentage change of the globus pallidus-to-thalamus (r = 0.07, P = .43; r = 0.07, P = .40). When we controlled for age, sex, number of scans, and total dose, there were no significant associations between the estimated glomerular filtration rate and the percentage change of the dentate nucleus-to-pons (r = 0.16, P = .07; r = 0.15, P = .08) or percentage change of the globus pallidus-to-thalamus (r = -0.14, P = .12; r = -0.15, P = .09).

CONCLUSIONS

In patients receiving an average of 12 intravenous gadobutrol administrations, no correlation was found between renal function and signal intensity ratio changes, even in those with mild or moderate renal impairment.

Safety and diagnostic efficacy of gadoteridol for magnetic resonance imaging of the brain and spine in children 2 years of age and younger

BACKGROUND

Neonates and young children require efficacious magnetic resonance imaging (MRI) examinations but are potentially more susceptible to the short- and long-term adverse effects of gadolinium-based contrast agents due to the immaturity of their body functions.

OBJECTIVE

To evaluate the acute safety and diagnostic efficacy of gadoteridol (ProHance) for contrast-enhanced MRI of the central nervous system (CNS) in children ≤2 years of age.

MATERIALS AND METHODS

One hundred twenty-five children ≤2 years old (including 57 children <6 months old) who underwent contrast-enhanced MRI of the CNS with gadoteridol at 0.1 mmol/kg body weight were retrospectively enrolled at five imaging centers. Safety data were assessed for acute/subacute adverse events in the 48 h following gadoteridol administration and, when available, vital signs, electrocardiogram (ECG) and clinical laboratory values obtained from blood samples taken from 48 h before until 48 h following the MRI exam. The efficacy of gadoteridol-enhanced MRI compared to unenhanced MRI for disease diagnosis was evaluated prospectively by three blinded, unaffiliated readers.

RESULTS

Thirteen changes of laboratory values (11 mild, 1 moderate, 1 unspecified) were reported as adverse events in 7 (5.6%) patients. A relationship to gadoteridol was deemed possible though doubtful for two of these adverse events in two patients (1.6%). There were no clinical adverse events, no serious adverse events and no clinically meaningful changes in vital signs or ECG recordings. Accurate differentiation of tumor from non-neoplastic disease, and exact matching of specific MRI-determined diagnoses with on-site final diagnoses, was achieved in significantly more patients by each reader following the evaluation of combined pre- and post-contrast images compared to pre-contrast images alone (84.6-88.0% vs. 70.9-76.9%; P≤0.006 and 67.5-79.5% vs. 47.0-66.7%; P≤0.011, respectively).

CONCLUSION

Gadoteridol at 0.1 mmol/kg body weight is safe, well tolerated and effective for contrast-enhanced MRI of the CNS in children ≤2 years of age.

Increased flow rate of hyperpolarized aqueous solution for dynamic nuclear polarization-enhanced magnetic resonance imaging achieved by an open Fabry-Pérot type microwave resonator

A continuous flow dynamic nuclear polarization (DNP) employing the Overhauser effect at ambient temperatures can be used among other methods to increase sensitivity of magnetic resonance imaging (MRI). The hyperpolarized state of water protons can be achieved by flowing aqueous liquid through a microwave resonator placed directly in the bore of a 1.5 T MRI magnet. Here we describe a new open Fabry-Pérot resonator as DNP polarizer, which exhibits a larger microwave exposure volume for the flowing liquid in comparison with a cylindrical TE013 microwave cavity. The Fabry-Pérot resonator geometry was designed using quasi-optical theory and simulated by CST software. Performance of the new polarizer was tested by MRI DNP experiments on a TEMPOL aqueous solution using a blood-vessel phantom. The Fabry-Pérot resonator revealed a 2-fold larger DNP enhancement with a 4-fold increased flow rate compared to the cylindrical microwave resonator. This increased yield of hyperpolarized liquid allows MRI applications on larger target objects.

T1 signal intensity in the dentate nucleus after the administration of the macrocyclic gadolinium-based contrast agent gadoterate meglumine: an observational study

INTRODUCTION AND AIMS

Contradictory results have been reported about hyperintensity of the globus pallidus and/or dentate nucleus on unenhanced T1-weighted magnetic resonance (MR) images after exposure to various gadolinium-based contrast agents. This change in signal intensity varies with different gadolinium-based contrast agents. We aimed to determine whether signal intensity in the dentate nucleus is increased in unenhanced T1-weighted images in patients who have undergone multiple studies with the macrocyclic gadolinium-based contrast agent gadoterate meglumine. We thoroughly reviewed the literature to corroborate our results.

MATERIALS AND METHODS

We included patients who had undergone more than 10 MR studies with gadoterate meglumine. We quantitatively analyzed the signal intensity in unenhanced T1-weighted MR images measured in regions of interest placed in the dentate nucleus and the pons, and we calculated the dentate nucleus-to-pons signal intensity ratios and the differences between the ratio in the first MR study and the last MR study. We used t-tests to evaluate whether the differences between the signal intensity ratios were different from 0. We also analyzed the subgroups of patients who had been administered<15 and ≥15 doses of gadoterate meglumine. We used Pearson correlation to determine the relationships between the differences in the signal intensity ratios and the number of doses of gadoterate meglumine administered.

RESULTS

The 54 patients (26 men) had received a mean of 13.8±3.47 doses (range, 10-23 doses). The difference in the dentate nucleus-pons signal intensity ratio between the first and last MR study was -0.0275±0.1917 (not significantly different from 0; p=0.2968) in the entire group, -0.0357±0.2204 (not significantly different from 0; p=0.351 in the patients who had received <15 doses (n=34), and -0.0135±0.1332 (not significantly different from 0; p=0.655) in those who had received ≥15 doses (n=20). Differences in signal intensity ratios did not correlate significantly with the accumulated dose of gadoterate meglumine (P=0.9064; ρ=-0.0164 [95%]).

CONCLUSIONS

Receiving more than 10 doses of gadoterate meglumine was not associated with increased signal intensity in the dentate nucleus.

Magnetic resonance imaging diagnosis of subependymal giant cell astrocytomas in follow-up of children with tuberous sclerosis complex: should we always use contrast enhancement?

BACKGROUND

Subependymal giant cell astrocytomas (SEGAs) arise in 10-26% of tuberous sclerosis complex (TSC) patients. SEGAs cause obstructive hydrocephalus and increase morbi-mortality. It is recommended that TSC patients be followed with contrast enhanced magnetic resonance imaging (CE-MRI), but repetitive use of gadolinium-based contrast-agents (GBCAs) may cause organ deposits.

OBJECTIVE

To compare the diagnostic performances of non-CE- and CE-MRI to differentiate SEGAs from subependymal nodules in TSC patients during follow-up.

MATERIALS AND METHODS

Thirty-five TSC patients (median age: 2.4 years) were enrolled in this retrospective single-center study from September 2007 to January 2019. Inclusion criteria were a certain diagnosis of TSC and at least three follow-up brain MRIs with GBCA injection. Two consecutive MRI scans per patient were selected and anonymized. Three radiologists performed a blinded review of non-enhanced and enhanced MRI sequences during different sessions. The diagnostic performances were compared (sensitivity, specificity, positive/negative predictive values, accuracy, inter/intra-observer agreements).

RESULTS

The accuracies for detecting SEGAs were good and similar between the non-enhanced and enhanced MRI sequences. The sensitivity and specificity of non-CE-MRI to diagnose SEGA ranged from 75% to 100% and from 94% to 100%, respectively. The differences in numbers of false-positive and false-negative patients between non-CE- and CE-MRI never exceeded one case. Nodules size >10 mm, location near the Monro foramen, hydrocephalus and modifications between two consecutive MRI scans were significantly associated with the diagnosis of SEGA for the three readers (all P-values <0.05). Inter- and intra-observer agreements were also excellent for non-enhanced and enhanced MRI sequences (kappa=0.85-1 and 0.81-0.93, respectively).

CONCLUSION

The performances of non-enhanced and enhanced MRI sequences are comparable for detecting SEGAs, questioning the need for systematic GBCA injections for TSC patients.

Two Non-gadolinium-based, Innovative Approaches to Preoperative Lymphangiography

Most magnetic resonance lymphangiography techniques employ intravenous gadolinium-based contrast agents, which carry a US Food and Drug Administration warning about gadolinium retention in the body when used intravenously. Because of this, there may be reluctance to perform intradermal injections of gadolinium-based contrast agents in patients with obstructed lymphatic drainage due to concerns about gadolinium retention in the skin and soft tissues and potential-related toxicity. The aim of this study was to show proof of concept of 2 preoperative lymphangiographic techniques that do not use gadolinium-based contrast agents. One technique used contrast-enhanced ultrasound with intradermal injections of microbubbles (Lumason) in a patient with stage 3, nonpitting left upper extremity edema. Another technique used magnetic resonance imaging with intradermal injections of 0.03 mg/mL or 0.003% ferumoxytol (Feraheme) in a patient with stage 3, nonpitting right lower extremity edema. Both contrast-enhanced ultrasound with microbubbles and magnetic resonance lymphangiogram with ferumoxytol were able to identify candidates for lymphovenous bypass surgery. These candidates were not identified by conventional indocyanine green injections. The authors conclude that (1) low-dose ferumoxytol is a potentially effective non-gadolinium–based contrast alternative to gadolinium-based contrast agent in magnetic resonance lymphangiography and (2) contrast-enhanced ultrasound can identify candidate lymphatic vessels for anastomosis.