What Is an MRI With Contrast?

What to expect when undergoing this test

MRI scan
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In This Article

Magnetic resonance imaging (MRI) scans are used by doctors to evaluate a variety of health conditions. MRIs are able to produce highly detailed images of internal organs using powerful magnetic fields and radio waves. MRIs are especially useful at imaging soft tissues such as muscles, tendons, cartilage, and ligaments.

There are situations where an MRI may be ordered with something called contrast enhancement. MRI contrast agents are types of dye that contain a rare earth metal called gadolinium that helps sharpen and improve the overall quality of MRI images. While valuable in diagnosing and monitoring certain diseases, they do pose potential health risks.

What Is an MRI With Contrast?

Gadolinium-based contrast agents (GBCAs) are typically infused into the body intravenously (through a vein), although there are some that are taken orally (by mouth) or injected into a joint space. The magnetic properties of gadolinium help provide greater contrast, and therefore clarity, to MRI images.

There are several different types of GBCAs, which are differentiated by their route of administration, chemical composition, magnetic properties, and the ways in which they disperse through the body.

Some are organ-specific, while others have a heavier molecular weight so that they remain within the circulatory system and not diffuse into adjacent tissues. Others still are sensitive to the acid/alkaline balance or can target specific cells like tumors.

The following MRI contrast agents are approved for use by the U.S. Food and Drug Administration (FDA):

  • Dotarem (gadoterate)
  • Evoist (gadoxetate disodium)
  • Gadavist (gadobutrol)
  • Magnevist (gadopentetate)
  • Multihance (gadobenate)
  • Omniscan (gadodiamide)
  • OptiMARK (gadoversetamide)
  • Prohance (gadoteridol)

When It Is Needed

GBCAs are valuable tools by which to produce the most accurate MRI Images possible but are not suitable for every condition. In fact, only one in three MRIs will involve the use of a GBCA.

Their appropriateness is based on clinical judgment but are also largely directed by the American College of Radiology (ACR) Appropriateness Criteria.

There are times when a GBCA may not be useful. For example, GBCAs are not able to readily cross the blood-brain barrier. While GBCAs may be useful with diseases like multiple sclerosis in which the blood-brain barrier is compromised, they may be of little use in imaging the brain if the blood-brain barrier is intact.

The decision to use an MRI contrast agent is based on whether the aim of the procedure is diagnostic (to diagnose disease) or interventional (to aid with the treatment of a known condition).

Due to safety concerns, the number of MRIs with contrast may be limited. MRIs may also be interspersed with other imaging techniques, such as X-ray or computed tomography (CT) scans, to reduce exposure.

List of Appropriate MRI Uses

The list of conditions in which GBCAs may or may not be used is extensive and are broadly outline by the ACR as follows:

Body Part  MRI with contrast MRI without contrast MRI with or without contrast
Brain Gamma knife surgery Alzheimer disease
Memory loss
Metastatic cancer
Multiple sclerosis
Pituitary gland
Eyes     Infections
Cervical spine
Disc degeneration
Disc herniation
Neck pain

Disc infection
Thoracic spine   Back pain
Disc compression
Disc herniation
Disc infection
Lumbar spine   Back pain
Disc compression
Disc herniation
Disc infection
Post-lumbar surgery

Muscle tear
Tendon tear
Joints Direct arthrography of a joint (delivered via a joint injection)
Cartilage tear
Joint pain
Meniscus tear
Muscle tear
Tendon tear

Pelvis   Pelvic pain
Muscle tear
Tendon tear
Sacroiliac joint
Uterus abnormality
Menses problems
Ovarian cysts
Known fibroids
Fibroid embolism 
Abdomen   Adrenal glands Kidney

As the guidelines illustrate, the decision to use or not use a GBCA is largely subjective and relies on clinical experience and expertise to make the appropriate choice.

Possible Side Effects

GBCAs are generally considered safe with relatively mild side effects. If side effects do occur, they tend to be transient and will resolve on their own without treatment.

Intravenous Side Effects

GBCAs are most commonly delivered by an intravenous (IV) infusion. If a GBCA is required, an IV catheter would be inserted into your arm by a nurse or technologist. The contrast agent would then be injected into a port in the catheter with either a hand injector or auto-injector.

The most common side effects of GBCA infusions are:

  • A cold sensation when first injected
  • Headache
  • Nausea
  • Dizziness

Although rare, some people may experience a mild allergic reaction to gadolinium. The main symptom is itchy skin, and the allergy itself is rarely severe.

Oral Side Effects

Oral GBCAs are sometimes used for MRI scans of the gastrointestinal tract. These are consumed in liquid form prior to the scan. The contrast agent typically involves a form of gadolinium called gadolinium-DPTA mixed with mannitol, a type of sugar alcohol that is poorly absorbed by the intestines.

Mannitol is known to cause nausea, vomiting, and diarrhea in some. Gadolinium can be used on its own with few, if any, gastrointestinal side effects but needs mannitol to remain stable in the harsh acidic environment of the stomach and intestine.

Intra-Articular Side Effects

Arthrography is an MRI technique that uses a gadolinium contrast agent to image inside a joint space. Arthrography may be ordered if a standard X-ray does not provide enough detail of a joint structure.

Arthrography requires an injection of GBCA into the joint space. Prior to the injection, the skin would be numbed with a topical anesthetic. In some cases, excess joint fluid may need to be removed via arthrocentesis.

The injection itself may cause pressure and localized pain within the joint. Some mild swelling and fullness may be felt after the procedure, which can usually be treated with ice application. There may be also pain, redness, and bruising at the injection site.

Call your doctor immediately if you experience worsening pain, redness, swelling, fever, and a pus-like discharge after undergoing arthrography. These are likely signs of a serious infection.

Rare Side Effects

On rare occasions, certain GBCAs have been known to cause a serious condition called nephrogenic systemic fibrosis (NSF) in people with severe kidney disease.

NSF can cause the tightening and hardening of the skin (similar to scleroderma) as well as the contraction of tendons and muscle (impairing movement and joint mobility). The function of certain organs, such as the heart, lung, diaphragm, stomach, intestines, or liver, may also be impaired.

There is no cure for NSF, and no treatment has been known to deliver consistent results. As such, GBCAs should be used with extreme caution in people with reduced kidney function and avoided in anyone with severe chronic kidney disease or acute kidney injury, as well as those receiving dialysis.

Safety Concerns

There remains ongoing concern about the long-term safety of GBCAs, particularly when used extensively or on an ongoing basis (such as can occur when monitoring multiple sclerosis).

In 2015, the FDA released a safety announcement citing studies in which the prolonged use of gadolinium in people with MS resulted in deposits of the metal in brain tissues.

Recent research suggests that the risk of accumulation is dose-dependent, meaning that the longer gadolinium is used, the greater the risk. For people exposed to GBCAs only once or several times, the risk appears to be negligible.

What the FDA advisement failed to say is whether the deposits pose any actual health risk. While there have been concerns that such accumulations may cause neurotoxicity ("poisoning" of the brain), there has to date been scant evidence of this.

A 2017 review of studies in Lancet Neurology concluded that no harm or behavioral changes have been seen in studies in which animals were exposed to high doses of gadolinium over a long period of time. The few studies involving humans also demonstrated no ill effects.

Despite the conclusions, the researchers would not go so far as to say that the buildup of gadolinium in the brain would never cause problems. Rather, they suggested further research is needed before gadolinium can be confidently regarded as safe.

A Word From Verywell

If a doctor recommends a contrast-enhanced MRI, it is not unreasonable to ask if the contrast agent is really necessary. There may be reasons why contrast is needed, but it's fair to ask if there are other options. This is especially true if you have known kidney dysfunction or have undergone multiple MRIs with contrast in the past.

If in doubt, do not hesitate to seek a second opinion.

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Article Sources

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