“The gadolinium chelates (the GBCAs) are critical to disease diagnosis by MR, indeed to clinical medicine worldwide, and have proven to be overall a very safe class of contrast media.” This review focuses on the current knowledge regarding accumulation of gadolinium in the brain (dentate nucleus and other structures) and body, with clinical recommendations based on that and other safety data, including the recent European Agency recommendation.
The established class of intravenous contrast media for magnetic resonance imaging is the gadolinium chelates, often referred to as the gadolinium-based contrast agents (GBCAs). These can be differentiated on the basis of stability in vivo, with safety and tolerability of the GBCAs dependent fundamentally on chemical and biologic inertness. This review discusses first the background in terms of development of these agents and early safety discussions (including hypersensitivity/allergic reactions), and second their relative stability based both on in vitro studies and clinical observations before and including the advent of nephrogenic systemic fibrosis (NSF). This sets the stage for the subsequent focus of the review, the current knowledge regarding accumulation of gadolinium in the brain and body, and specifically the dentate nucleus after intravenous administration of the GBCAs and differentiation amongst agents on this basis.
“The gadolinium chelates (the GBCAs) are critical to disease diagnosis by MR, indeed to clinical medicine worldwide, and have proven to be overall a very safe class of contrast media.”(1) However, the information available to date, from the initial conception of these agents in 1981 to the latest reports concerning safety, demonstrates a significant difference between the macrocyclic and linear chelates. Specifically, Omniscan, Optimark, Magnevist, MultiHance and Primovist/Eovist (all being linear gadolinium chelates) are now known to be associated with dentate nucleus hyperintensity, specifically high signal intensity within the dentate nucleus on T1-weighted scans seen pre-contrast after multiple prior contrast injections. Dotarem, Gadovist and ProHance, the macrocyclic chelates, are not so associated.(2) Dentate nucleus hyperintensity is likely to reflect more general gadolinium deposition throughout the body (and specifically in the skin and bones), in these patients with normal renal function. In patients receiving a very high number of injections of the linear agents, hyperintensity is also observed in many other nuclei and structures within the brain. Initial reports suggest possible clinical symptomatology, but are not definitive.
The following recommendation has been made by the National Institutes of Health - “When GBCAs are required, consider the use of a macrocyclic GBCA (eg, gadobutrol, gadoteridol, gadoterate meglumine) rather than a linear agent”.(3) And, most importantly, on March 10, 2017, the Pharmacovigilance and Risk Assessment Committee (PRAC) of the European Medicines Agency (the equivalent of the FDA in Europe) recommended suspension of the marketing authorization for four linear gadolinium contrast agents – specifically Omniscan, Optimark, Magnevist and MultiHance – for intravenous injection.(4) Cited in the report was convincing evidence of gadolinium deposition in the brain months after injection of these linear agents. Primovist/Eovist will remain available, being used at a lower dose for liver imaging, as it meets an important diagnostic need. In addition, a formulation of Magnevist for intraarticular injection will remain available, due to its very low gadolinium concentration. These recommendations were based on an extensive review of the safety of the gadolinium agents that began in March 2016.
1. Runge VM. Commentary on T1-Weighted Hypersignal in the Deep Cerebellar Nuclei After Repeated Administrations of Gadolinium-Based Contrast Agents in Healthy Rats: Difference Between Linear and Macrocyclic Agents. Invest Radiol. 2015;50(8):481-2.
2. Runge VM. Safety of the Gadolinium-Based Contrast Agents for Magnetic Resonance Imaging, Focusing in Part on Their Accumulation in the Brain and Especially the Dentate Nucleus. Invest Radiol. 2016;51(5):273-9.
3. Malayeri AA, Brooks KM, Bryant LH, et al. National Institutes of Health Perspective on Reports of Gadolinium Deposition in the Brain. J Am Coll Radiol. 2016;13(3):237-41.
4. Runge VM. Critical Questions Regarding Gadolinium Deposition in the Brain and Body - Reflecting Possible Safety Issues - Following Injections of the Gadolinium-based Contrast Agents, with Clinical Recommendations and Reflection upon the EMA’s Pharmacovigilance and Risk Assessment Committee (PRAC) Recommendation for Suspension of the Marketing Authorizations for Four Linear Agents. Invest Radiol. 2017;52:(on line).