What Is an MRI With Contrast?

What to expect when undergoing this test

MRI scan
Monty Rakusen / Getty Images


Magnetic resonance imaging (MRI)
is an imaging technique used to evaluate a variety of health conditions. In certain situations, a doctor may order an MRI with contrast to help improve the diagnostic quality of the images. MRI with contrast can generate highly detailed visuals of internal organs and soft tissues.

Though valuable in diagnosing or monitoring disease, MRI contrast agents are used for specific purposes and pose potential health risks.

Purpose of the Test

The magnetic properties of gadolinium help provide greater contrast and, therefore, clarity, to MRI images. MRI contrast agents contain a rare earth metal called gadolinium that interacts with the magnetic field emitted by the MRI machines. Gadolinium-based contrast agents (GBCAs) are able to produce the most accurate MRI images possible but are not needed for every condition.

The decision to use a GBCA is based on whether the aim of the procedure is diagnostic (to identify disease) or interventional (to aid with the management of a known condition). Their use is directed in part by the American College of Radiology (ACR) Appropriateness Criteria.

There are times when a GBCA may not be useful. Gadolinium, for example, is not able to readily cross the blood-brain barrier that protects the brain from harmful substances. While helpful in diagnosing diseases like multiple sclerosis in which the blood-brain barrier is compromised, GBCAs may be of little use if the blood-brain barrier is intact.

The list of conditions in which GBCAs may or may not be useful is extensive. They are broadly outlined by the ACR as follows:

Body Part  MRI With contrast MRI Without Contrast MRI With or Without Contrast
Brain Gamma knife surgery Alzheimer disease
Headache/migraine
Memory loss
Seizures
Stroke 
Trauma
Infections
Metastatic cancer
Multiple sclerosis
Neurofibromatosis
Pituitary gland
Eyes     Infections
Tumors
Cervical spine
 
Disc degeneration
Disc herniation
Neck pain
Radiculopathy
Trauma

 
Disc infection
Mass/lesions
Osteomyelitis
Thoracic spine   Back pain
Disc compression
Disc herniation
Radiculopathy
Trauma
Disc infection
Mass/lesions
Osteomyelitis
Lumbar spine   Back pain
Disc compression
Disc herniation
Radiculopathy
Stenosis
Trauma
Disc infection
Mass/lesions
Osteomyelitis
Post-lumbar surgery
Extremities
(non-joint)

 
  Fractures
Muscle tear
Tendon tear
Abscesses
Cellulitis
Osteomyelitis
Tumors/mass
Ulcers
Joints Direct arthrography of a joint (delivered via a joint injection)
 
Arthritis
Cartilage tear
Fracture
Joint pain
Meniscus tear
Muscle tear
Tendon tear
 
Abscesses
Cellulitis
Osteomyelitis
Tumor/mass
Ulcers


 
Pelvis   Pelvic pain
Muscle tear
Tendon tear
Sacrum/coccyx
Sacroiliac joint
Uterus abnormality
Endometriosis
Menses problems
Abscesses
Ulcers
Osteomyelitis
Ovarian cysts
Known fibroids
Fibroid embolism 
Abdomen   Adrenal glands Kidney
Liver
Tumor/mass

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

Types of Contrast Agents

There are several different types of gadolinium-based contrast agents, each of which is differentiated by its chemical composition, magnetic properties, the ways in which it is dispersed through the body, and the route of administration.

Some GBCAs are organ-specific, while others have a heavier molecular weight so that they remain within the circulatory system and do not diffuse into adjacent tissues. Others still 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 meglumine)
  • Evoist (gadoxetate disodium)
  • Gadavist (gadobutrol)
  • Magnevist (gadopentetate dimeglumine)
  • Multihance (gadobenate dimeglumine)
  • Omniscan (gadodiamide)
  • OptiMARK (gadoversetamide)
  • Prohance (gadoteridol)

Risks and Contraindications

GBCAs are generally considered safe with relatively few side effects. If side effects do occur, they tend to be transient and resolve on their own without treatment. In rare instances, certain groups of people, including those with kidney dysfunction, may experience severe side effects or complications.

The long-term, cumulative effects of GBCAs are as of yet unknown. Due to this, your doctor may limit the number of MRIs with contrast you receive or interspersed MRIs with other imaging techniques, such as X-rays or computed tomography (CT) scans.

Intravenous Side Effects

GBCAs are most commonly delivered by an intravenous (IV) infusion into a vein. The most common side effects of GBCA infusions are:

  • A cold sensation during the injection
  • Headache
  • Nausea
  • Dizziness
  • Cough
  • Vomiting
  • Rapid heartbeat
  • Shortness of breath

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.

A study published in the British Journal of Radiology reported that between 0.18% and 0.76% of people who undergo MRI with contrast experience side effects, mostly nausea and vomiting.

Oral Side Effects

Oral GBCAs are sometimes used for MRI scans of the gastrointestinal tract. These are taken by mouth 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 people. While gadolinium can be used on its own with few, if any, gastrointestinal side effects, it needs mannitol to remain stable in the acidic environment of the stomach and intestine.

Intra-articular Side Effects

Arthrography is an MRI technique used to image joints if a standard MRI does not provide enough detail. Arthrography requires an intra-articular injection of GBCA into the joint space.

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

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 tightening and hardening of the skin similar to scleroderma, as well as the contraction of tendons and muscles, 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. For this reason, GBCAs should be used with extreme caution in people with reduced kidney function and avoided in anyone with severe chronic kidney disease, acute kidney injury, or on dialysis.

Long-Term Safety

There remains ongoing discussion about the long-term safety of GBCAs, particularly when used extensively or on an ongoing basis (such as when monitoring multiple sclerosis). In 2015, the FDA issued a safety announcement citing studies in which the prolonged use of gadolinium in people with MS resulted in deposits of the material in brain tissues.

More 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 health risks. Though some scientists have suggested that the accumulations may cause neurotoxicity (poisoning of the brain), there has been little evidence of this.

A 2017 review of studies in Lancet Neurology concluded that no harm or behavioral changes were seen in animals 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 would never cause problems. Rather, they suggested that further research is needed before gadolinium can be empirically regarded as safe.

Before the Test

An MRI study is performed by a radiology technician (also known as a radiographer or radiology technologist) and interpreted by a radiologist.

Timing

An MRI scan with contrast can take anywhere from 30 minutes to 90 minutes, depending on the area of the body being scanned, the agent used, and the route of administration of the GBCA. MRIs using oral GBCAs may take up to two and a half hours, requiring you to drink multiple doses and wait until the agent passes into the intestine.

Be sure to arrive 15 to 30 minutes before your appointment to fill out the necessary paperwork and settle in.

Location

MRIs are performed in outpatient MRI clinics and in hospitals. The MRI machine will be situated in its own room within the facility. After placing you inside the machine, the radiology technician will operate the unit from behind a glass partition. You are able to communicate via a two-way speaker system installed inside the unit.

The MRI machine itself is a tube-like device into which a flatbed is inserted and removed via remote control. There are also smaller units that allow you to insert only an arm or leg. Many newer models are open on the sides, reducing the claustrophobia that some people feel when being scanned.

What to Wear

Because MRI utilizes strong magnetic fields, you will not be allowed to wear anything that contains metal during the procedure, including zippers, buckles, metal buttons, and underwire bras. It is best to leave jewelry at home and to remove metal accessories from the body, such as piercings and hairpieces.

You will be given a gown to change into if your clothing interferes with the MRI readings. Some people come with their own clothes, such as drawstring pants, sweatpants, plain T-shirts, or workout wear. To avoid walking on bare feet, bring along socks or a pair of slippers.

Dentures and hearing aids should be removed prior to the procedure. Medical staff will provide you with a secure place to store your belongings.

Food and Drink

For GBCAs delivered by injection or IV, you can usually eat, drink, and take medications as you normally would. The same does not apply to oral GBCAs, which may require you to stop eating and drinking four or more hours in advance.

The radiology staff will advise you if any dietary or medication restrictions apply to your procedure.

Cost and Health Insurance

MRIs with contrast can cost anywhere from $300 to $3,000, depending on the body part being scanned as well as your location. Many insurance companies will cover at least a portion of the cost but require prior authorization to ensure that it is medically indicated.

The extent of coverage can vary by the insurance plan, so check on copay or coinsurance costs in advance of the procedure and confirm that the radiology unit and radiologist are both in-network providers.

What to Bring

Be sure to bring your photo ID and insurance card with you as well as an approved form of payment for any copay/coinsurance costs. If you plan to wear any small jewelry there, you may want to bring a pouch for safekeeping.

Other Considerations 

Let the radiology staff know in advance if you have any of the following: a metal implant, pacemaker, drug infusion pump, artificial limbs or joints, or tattoos containing metal ink. While many of these are MRI-safe, they can potentially interfere with the reading.

The staff should also be advised if you are pregnant.

If you suffer from claustrophobia, let the staff know in advance. In some cases, a light sedative may be prescribed. If one is used, you will need to arrange for someone to drive you home after the procedure.

During the Test

For an MRI with contrast, you will be working with a technician certified in the administration of intravenous, oral, and intra-articular GBCAs. Qualified technicians are also allowed to administer sedation, although a nurse may be on hand to do so.

Pre-Test

After filling out the necessary paperwork and signing a consent form, you will be led to a changing room to change into a hospital gown (if needed). Prior to the MRI, the technician or nurse will check your weight, height, heart rate, temperature, and blood pressure.

The technician will then prepare you for the scan in one of several ways:

  • Intravenous: If the GBCA is intravenous, an IV catheter will be placed in a vein (usually in your arm). There may be a sharp poke and a momentary cold sensation as the GBCA is delivered, but you will otherwise feel little pain. If there is, let the technician know. A sedative can also be administered through a portal in the catheter if needed.
  • Oral: If the GBCA is oral, you will be given one or several doses of the agent to drink. Some are berry-flavored, while others have a sweet, syrupy taste. Some people may develop a metallic taste in their mouth or feel the need to go to the bathroom after drinking the solution. This is normal. However, if you feel nauseated or have stomach pain, let the technician know immediately.
  • Intra-articular: If the GBCA is delivered intra-articularly, the radiologist may use a topical numbing agent prior to delivering the injection. In some cases, excess joint fluid may need to be removed via arthrocentesis. During the injection, there may be a feeling of pressure or pain along the injection route along with a momentary cold sensation. The injection usually takes around 30 seconds to a minute.

Throughout the Test

After the GBCA is delivered, you will be led to the flatbed of the MRI machine and strapped in to prevent movement. For MRIs of the head, a cage-like head brace may be used. Depending on the level of sedation used, breathing, heart rate, blood oxygen, and blood pressure may be tracked during the procedure, especially in children.

A pair of noise-reducing headphones may also be given through which you can communicate with the technician.

The MRI itself can take anywhere from 15 minutes to an hour to complete once preparations have been made. To ensure the best quality images, you will need to follow the technician's instructions and keep absolutely still until you are told to relax. You may also need to hold your breath during some parts of the scan.

It is not uncommon to feel a little warmth during the scan. You will also need to be prepared to experience a loud noise, which some describe as locomotive-like, as each image is taken. Newer machines are far quieter, however.

If you are unable to hold a position, are cramping, or suddenly feel nauseated, let the technician know. It is not a problem to stop and rest until you are ready to proceed.

Once the technician has completed the requested scans, the images will be reviewed to ensure that all are clear and correctly positioned. In some cases, a part of the scan may need to be repeated.

Post-Test

If a sedative was not used, you can usually dress and leave immediately. The technician or nurse may want to check that you have no ill effects before you are allowed to go.

If a sedative was used, you will be taken to a recovery room and monitored until you are able to sit up steadily. Once you are able to stand, someone will need to drive you home. Ideally, that person will stay with you for 24 hours in the event of an unexpected side effect.

After the Test

In most cases, there will be no immediate or lasting effects from an MRI with contrast. Still, it is important to call your doctor immediately if you have any unusual or severe symptoms, including:

  • Abnormal heartbeat
  • Shortness of breath
  • Severe pain, redness, swelling, or discharge at an injection site

If you are breastfeeding, some doctors will tell you to wait 24 to 48 hours before nursing your baby. However, the American College of Obstetricians and Gynecologists (ACOG) says that this is unnecessary and that breastfeeding can continue uninterrupted after an MRI with contrast.

Interpreting Results

MRI with contrast scans are interpreted by a radiologist who will review the findings in context with previous scans and your available medical history. A radiology report will then be issued within one or several days, which your doctor will review with you.

A typical radiology report includes a copy of each individual scan along with notations of any abnormalities seen. Typically, each image will be broadly classified as either normal, abnormal, or inconclusive. Specific details will be listed in the impressions section of the report, which your doctor can explain to you.

Based on an evaluation of the scans and a review of your medical history, the radiologist may offer a specific diagnosis or a list of possible causes in a differential diagnosis.

Follow-Up

If an abnormal or potential abnormal finding is found, additional imaging tests or procedures may be ordered to either confirm the diagnosis or determine the severity of the condition. For example, a growth suspected of being cancerous may require a positron emission tomography (PET) scan, which can identify malignancies based on changes in metabolism, or a biopsy, in which a tissue sample is obtained for examination by a pathologist.

If a finding is inconclusive, the MRI may be repeated or an alternative method of imaging may be used. For example, CT scans are often better at imaging bone disorders than MRIs, which are better able to image soft tissues.

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 disease or have undergone multiple MRIs with contrast. If in doubt, do not hesitate to seek a second opinion.

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