Mark BM Hofman1, Cristina Lavini2, Albert van der Zwan3, Carola van Pul4, Sara H Muller5, Mette K Stam6, Marinette van der Graaf7, Carla Kloeze8, Bastiaan J van Nierop9, Wouter Teeuwisse10, Peter Kappert11, Evie EM Kolsteren12, Kristie Venhorst12, and Joost PA Kuijer13
1Radiology and Nuclear Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam, Netherlands, 2Radiology and Nuclear Medicine, Amsterdam UMC location AMC, Amsterdam, Netherlands, 3, Neurology and Neurosurgery, UMC Utrecht Brain Center, Utrecht, Netherlands, 4Maxima Medical Centre, Eindhoven, Netherlands, 5Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands, 6Radiology, LUMC, Leiden, Netherlands, 7Imaging, Radboud UMC, Nijmegen, Netherlands, 8Catharina Hospital, Eindhoven, Netherlands, 9Radiology and Nuclear Medicine, University Medical Centre Utrecht, Utrecht, Netherlands, 10CJ Gorter Center for High Field MRI, LUMC, Leiden, Netherlands, 11Radiology, UMCG, Groningen, Netherlands, 12Knowledge Institute Medical Specialists, Utrecht, Netherlands, 13Radiology and Nuclear Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
Synopsis
The Dutch Association of
Medical Specialists wrote a guideline for
MR safety experts for an MRI examination in a patient with a cerebral aneurysm
clip for known and unknown clip types. Risk stratification
for unknown clip types was based on a survey in the Netherlands that identified
time frames and locations of ferromagnetic clip use.
Introduction
Although in the Netherlands nowadays only
MR-conditional or MR-safe clips are utilized, ferromagnetic type clips have
been used until late in the last century. As this treatment is given to
patients in different age groups including young adults, patients with an
aneurysm clip, implanted in a period when ferromagnetic types were still in use
can present themselves for MRI for decades to come.
If
the type of cerebral aneurysm clip is known, it is possible to determine
whether the patient can safely undergo an MRI examination. However, in the
past, patients have received clips that are an absolute contraindication for
MRI, so caution is advised when the type of clip is unknown or it is not
possible to determine with certainty what clip was implanted. In daily practice
in the Netherlands, it is often unknown which the type of clip was implanted, as
it is also in other countries 1,2. Therefore, the Dutch
Association of Medical Specialists (called FMS) has written a guideline for MR safety experts to develop a local policy for safely performing an
MRI examinations in patients with a cerebral aneurysm clip, including strategies for known and unknown clip types, for 1.5T or 3T
whole body MRI systems with a horizontal closed bore superconducting magnet. Methods
The guideline has been
developed conforming to the standard within the FMS as described in Guidelines
for Medical Specialists 2.0 3, based on the AGREE II instrument 4.
The guideline, initiated by Society for Medical
Physics of the Netherlands (NVKF), was written by a working group together with participants from the Dutch Society for Medical Imaging and
Radiotherapy (NVMBR), Radiological Society of the Netherlands (NVvR),
Netherlands Society for Neurosurgery (NVvN) and advisors from the Knowledge
Institute of the FMS. A series of searches for evidence were performed in
existing guidelines, literature, MRI safety.com and MagResource 5, and implant incident databases of FDA, the Health Inspection Service in the
Netherlands, and the 'Implant' and 'Event' database of the International
Consortium of Investigative Journalists.
In addition to the scientific
evidence, other aspects are important and were taken into account, such as the
expertise of the working group members, availability of facilities and organization
of healthcare.
The concept guideline was
subjected to commentaries by the involved Dutch (scientific) associations,
agencies and (patient) organizations. The final version was authorized in 2019 by the FMS.Literature Review
Literature was searched to
answer the question “what is the chance of a negative outcome for an MRI in a
patient with a ferromagnetic clip?”. There is a chance that a patient with a
ferromagnetic aneurysm clip can undergo the MRI examination without
complications, but there is also a realistic chance that the examination turns
out to be fatal: estimating the individual risk to the patient is complicated
and depends on the condition of the vessel wall on which the aneurysm clip is
placed 6-9. Non-ferromagnetic clips appear to be safe in the MRI
environment 10-13.
On the question regarding the
period of implantation of contraindicated clips in the Netherlands, based upon studies
mainly from the United States, we inferred the chance that a cerebral clip is
ferromagnetic is high for implantation before the mid-80s and low after the
mid-90s. It should be noted that the implantation of ferromagnetic clips
continued for some time after the production of these clips ended 8,14,15.Considerations
A
list of MR unsafe clips was made (Table 1). In none of the incident databases
we found reports to be relevant for this guideline. However, one incident was
identified in the literature
16, and recently one was reported
17. Because no information was found on the
timeframe when implantation of contraindicated clips took place in the Netherlands, a survey was conducted, see Table 2 and 3.
Risks
assessment for the clips was performed based on the standard risks for metallic
implants in the MRI:
- Risk of displacement and
rotation of the implant due to the presence of the static magnetic field and
the spatial gradient of this field.
This is the main risk for ferromagnetic clips.
For non-ferromagnetic models the risk is negligible. For an unknown type of clip
the working group estimated the risk (Table 4).
- Risk of implant heating
due to interaction with RF field.
Less than 1 degree is expected.
- Risk of vibration or
induction of currents by the oscillating magnetic field gradients applied for
the spatial encoding of the MRI signal.
Due to the size of the implant this is negligible.
- Artifact in the MRI
image.
For ferromagnetic clips up to 4 cm, otherwise
typically <1 cm.
- Risk of forces due to the Lenz effect during rapid
movement of conductive implants in the static magnetic field of the MRI
scanner.
Due to the size of the implant this is negligible.
- Risk of Implant Disruption.
We concluded that the only significant risk of disruption is in the displacement
and rotation, considered under 1.
Recommendation
The recommendation is
presented in a flowchart in Figure 1.
The whole guideline can be
found in the guideline database of the FMS 18.
An English
translation will appear early 2021. The guideline will be reviewed in five
years, or earlier when necessary.Acknowledgements
The guideline development was financed by the
Quality Funds for Medical Specialists (Stichting Kwaliteitsgelden Medisch
Specialisten: SKMS). We thank Diana P Gutierrez for secretary support of the
guideline project, and Marco JW Götte and Evert J Vonken for participating in the working group.References
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