FactFinders for Patient Safety: Are Gadolinium-Based Contrast Media Safe Alternatives to Iodinated Contrast Agents for the Safe Performance of Spinal Injection Procedures?

Popescu, Adrian; Patel, Jaymin; McCormick, Zachary L; Maus, Timothy P.; Rodes, Meghan Elizabeth; Walega, David R.; Smith, Clark

doi:10.1093/pm/pny090

Cited by 8 publications

(13 citation statements)

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“…Second, the safe dose limits (2.5-µmol/g brain) suggested by animal studies for intrathecal GBCAs do not appear to directly correlate with humans 14 46. Toxicity in humans has occurred at doses of approximately 1-µmol/g brain and in the fatal case reported here, the patient only received approximately 2.3 µmol/g brain 12. Li et al 18 suggested that humans may be less tolerant to intrathecal gadolinium than animals; we are in agreement with this suggestion.…”

Section: Discussion and Review Of The Literaturesupporting

confidence: 90%

Fatal gadolinium-induced encephalopathy following accidental intrathecal administration: a case report and a comprehensive evidence-based review

Provenzano

Pellis²,

DeRiggi

2019

Reg Anesth Pain Med

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Gadolinium-based contrast agents (GBCAs) have been suggested as off-label alternatives to iodine-based contrast agents for fluoroscopic imaging during interventional pain procedures. We report a case of accidental intrathecal administration of a GBCA during a neuraxial interventional pain procedure leading to acute gadolinium neurotoxicity, which resulted in encephalopathy and ultimately death. To our knowledge, it is the first published case of fatal intrathecal gadolinium-induced encephalopathy and the first published case of intrathecal gadoteridol causing serious neurologic complications. In addition, the case presented here is placed in context with an associated comprehensive, evidence-based review of the use of gadolinium in interventional pain procedures, addressing gadolinium chemistry and pharmacologic properties, neurotoxicity and radiology. Physicians must be aware that gadolinium poses a significant risk of acute neurotoxicity even in small doses. Until further safety research is performed, GBCAs should not be considered a safe alternative for use in neuraxial interventional spine procedures when there is a risk of inadvertent intrathecal administration.

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Section: Discussion and Review Of The Literaturesupporting

confidence: 90%

Fatal gadolinium-induced encephalopathy following accidental intrathecal administration: a case report and a comprehensive evidence-based review

Provenzano

Pellis²,

DeRiggi

2019

Reg Anesth Pain Med

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“…1 2 GBCAs are also used as an alternative to iodinated contrast agents for neuraxial procedures routinely performed by interventional pain physicians. 3 A patient with chronic pain with shellfish allergy inadvertently received 2 mL of gadobutrol (a type of GBCA) intrathecally during lumbar epidural steroid injection, which was confirmed fluoroscopically (figure 1A,B).…”

Section: Descriptionmentioning

confidence: 93%

Gadolinium-based contrast agent-induced neurotoxicity: seeing is believing!

Chauhan¹,

Upadhyay

2021

BMJ Case Rep

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“…GBCAs have the intrinsic feature to attenuate X-rays. Therefore, the epidural/intrathecal injection of GBCAs is applied as off label alternative to iodine-based contrast media in interventional pain procedures in patients with history of hypersensitivity reactions to iodine, although this procedure is not Food and Drug Administration (FDA) approved [9,60].…”

Section: Epidural and Intrathecal Administration Of Gbcasmentioning

confidence: 99%

Exposure to gadolinium and neurotoxicity: current status of preclinical and clinical studies

2020

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Purpose Gadolinium is a rare-earth lanthanide metal that is known to have a direct neurotoxic effect. The scope of the present review is to summarize the current preclinical and clinical evidence on the association between exposure to gadolinium of the central nervous system and neurotoxicity. Methods A literature review was performed by searching for original research papers investigating on gadolinium exposure and neurotoxicity. Results Gadolinium is neurotoxic through multiple mechanisms, mainly involving Ca ++ homeostasis and mitochondrial functions, as shown by preclinical in vitro studies. The available evidence related to the four different classes of gadolinium-based contrast agents commonly applied in clinical practice (i.e., linear and macrocyclic based on ligand structure, and ionic and non-ionic based on their net molecular charge) suggests that serial intravenous injections of gadolinium-based contrast agents and gadolinium brain depositions are not associated to histological changes, as confirmed by preclinical animal and human (MR imaging and autopsy) studies. Conclusion To date, no cause-effect relationship has been demonstrated in patients between brain gadolinium exposure and clinical consequences specific to neurological toxicity. Keywords Gadolinium-based contrast agents . Gadolinium . Neurotoxicity . MRI . Safety Abbreviations IL-1 interleukin-1 TNFα tumor necrosis factor alpha INFγ interferon gamma ROS reactive oxygen species Pb lead Cd cadmium Hg mercury Ni nickel Al aluminum GBCAs gadolinium-based contrast agents NSF nephrogenic systemic fibrosis DN dentate nucleus GP globus pallidus CSF cerebrospinal fluid BBB blood-brain barrier ATP adenosine triphosphate LDH lactate dehydrogenase MS multiple sclerosis EDSS expanded disability status scale ADC apparent diffusion coefficient FDA Food and Drug Administration This paper is endorsed by the ESMRMB-GREC working group.

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FactFinders for Patient Safety: Are Gadolinium-Based Contrast Media Safe Alternatives to Iodinated Contrast Agents for the Safe Performance of Spinal Injection Procedures?

Cited by 8 publications

References 0 publications

Fatal gadolinium-induced encephalopathy following accidental intrathecal administration: a case report and a comprehensive evidence-based review

Fatal gadolinium-induced encephalopathy following accidental intrathecal administration: a case report and a comprehensive evidence-based review

Gadolinium-based contrast agent-induced neurotoxicity: seeing is believing!

Exposure to gadolinium and neurotoxicity: current status of preclinical and clinical studies

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