Indications for Adult and Pediatric Magnetic Resonance Imaging Gadolinium-Enhanced Cisternography and Myelography: Experience and Review of the Literature

Abstract

Context: Intravenous administration of contrast materials in imaging studies is critical in detection of lesions which may be otherwise missed. Both computed tomography (CT) and magnetic resonance imaging (MRI) benefit from addition of contrast agents. MRI is superior to CT in evaluation of most diseases involving the brain and spine. Contrast resolution and anatomic display are two of the main factors that contribute to the superiority of MRI. Disorders affecting the cerebrospinal fluid (CSF) containing spaces may be under-diagnosed or poorly understood on conventional CT or MRI. Although intrathecal CT-cysternography/myelography with water-soluble iodinated contrast media and radionuclide cisternography (RC) are routinely used, few studies have dealt with intrathecal use of Gadolinium (gadopentetate dimeglumine) (Gd) although it appears superior to both techniques and seems to be potentially less risky. Currently, Gdenhanced MRI cisternography/myelography is not approved by the US Food and Drug Administration and is used offlabel.Objective: i-To summarize the existing literature regarding the use, safety, and indications of intrathecal and intraventricular use of paramagnetic contrast MRI agents, specifically intrathecal Gd-enhanced cisternography or myelography; ii-To outline the technical procedures, safety, and indications, and iii-To provide a critical comparison with other approved studies such as CT-cysternography/myelography and RC.Methods: We reviewed the literature by MEDLINE searches using the terms gadopentate dimeglumine, gadodiamide, diethylenetriaminepentaacetic acid (Gd-DTPA), MRI-cysternography/ventriculography, intrathecal Gd-enhancement, CSF leaks, intracranial hypotension syndrome, spontaneous rhinorrhea and otorrhea, radioisotope cisternography. Reference lists of these articles and ongoing investigations in this area were used as well.Evidence Synthesis: There are no grade III studies of scientific evidence in comparative studies. The major drawback of available comparative studies, which evaluate the accuracy of each imaging technique, including enhanced-MR or CTcisternography/myelography or RC, is the lack of a recognized "gold standard" imaging study, so that sensitivity or specificity of each imaging study cannot be fully assessed. Currently available studies demonstrate a superiority of intrathecal Gd MRI over CT cisternography/myelography and RC in some applications such as spontaneous or postoperative cranial fistulae, hypotension intracranial syndrome, and specific neurological/neurosurgical diseases of children. Superiority and safety of Gd-enhanced MR cisternography/ventriculography rests on absence of ionizing radiation, absence of bone artifacts, and superior spatial anatomic detail coupled with relatively high contrast resolution. Side effects and toxicity are low.Conclusions: It is unlikely that further studies will compare the efficacy of Gd-enhanced MR cisternography/ventriculography with their CT or RC counterparts since it is unethical to perform two intrathecal enhanced i...

Imaging Diagnosis: Traumatic Dural Tear Diagnosed Using Intrathecal Gadopentate Dimeglumine

“…Intrathecal Gd‐DTPA has been used to detect CSF spinal leakage, which is the most common cause of spontaneous intracranial hypotension in humans 11 . Other indications for intrathecal Gd‐DTPA use in humans are evaluation of cystic masses, congenital obstructions and communications of the subarachnoid space, cystic arachnoiditis, and differentiation between an empty sella and an intrasellar cyst 12,13 …”

“…11 Other indications for intrathecal Gd-DTPA use in humans are evaluation of cystic masses, congenital obstructions and communications of the subarachnoid space, cystic arachnoiditis, and differentiation between an empty sella and an intrasellar cyst. 12,13 Reports of CSF leakage in animals are scant. [14][15][16][17][18][19] Dural rupture in animals is typically associated with trauma or vigorous exercise.…”

“…The development of the new neurologic signs, 424 h after intrathecal Gd-DTPA injection, supports the intracranial hypotension hypothesis. 20 We have used similar a concentration of Gd-DTPA intrathecally, both in humans 12 and dogs (unpublished data), with no neurological or systemic side effects.…”

Development of novel bifunctional agents with and without tumor imaging ability

“…39 This in vivo stability markedly reduces the potential for toxicity from Gd(III). 40 As the contrast agent clears from the circulation, tumor enhancement may appear to increase, due to the rising tumor-to-background ratio, however the tumor signal rapidly declines, as non-bound contrast medium leaches from the lesion. Slower clearance from the tumor would enable MR scanning of larger body volumes.…”

Intracystic Gadolinium‐Enhanced MRI in the Evaluation of Residual Giant‐Cystic Craniopharyngiomas in Children: Report of Four Cases

“…Gadolinium dimeglumine (Gd‐DTPA) enhanced MR imaging whether intrathecal, intraventricular, or intracystic are current neuroradiological tests that are progressively being used and substituting previous CT iodinated‐enhanced counterparts, both in adults and children an even in veterinary medicine, because its superior effectiveness and potentially less risks, when dealing with cerebrospinal fluid (CSF)‐flow alterations diseases, communicating or noncommunicating cyst masses bordering CSF pathways, or craniospinal CSF leaks . In this study, we review and analyze our experience of intracystic injection of Gd in children with residual giant craniopharyngioma cysts.…”