Skip to main content
Advertisement

Main menu

  • Home
  • Content
    • Current Issue
    • Accepted Manuscripts
    • Article Preview
    • Past Issue Archive
    • Video Articles
    • AJNR Case Collection
    • Case of the Week Archive
    • Case of the Month Archive
    • Classic Case Archive
  • Special Collections
    • AJNR Awards
    • ASNR Foundation Special Collection
    • Most Impactful AJNR Articles
    • Photon-Counting CT
    • Spinal CSF Leak Articles (Jan 2020-June 2024)
  • Multimedia
    • AJNR Podcasts
    • AJNR SCANtastic
    • Trainee Corner
    • MRI Safety Corner
    • Imaging Protocols
  • For Authors
    • Submit a Manuscript
    • Submit a Video Article
    • Submit an eLetter to the Editor/Response
    • Manuscript Submission Guidelines
    • Statistical Tips
    • Fast Publishing of Accepted Manuscripts
    • Graphical Abstract Preparation
    • Imaging Protocol Submission
    • Author Policies
  • About Us
    • About AJNR
    • Editorial Board
    • Editorial Board Alumni
  • More
    • Become a Reviewer/Academy of Reviewers
    • Subscribers
    • Permissions
    • Alerts
    • Feedback
    • Advertisers
    • ASNR Home

User menu

  • Alerts
  • Log in

Search

  • Advanced search
American Journal of Neuroradiology
American Journal of Neuroradiology

American Journal of Neuroradiology

ASHNR American Society of Functional Neuroradiology ASHNR American Society of Pediatric Neuroradiology ASSR
  • Alerts
  • Log in

Advanced Search

  • Home
  • Content
    • Current Issue
    • Accepted Manuscripts
    • Article Preview
    • Past Issue Archive
    • Video Articles
    • AJNR Case Collection
    • Case of the Week Archive
    • Case of the Month Archive
    • Classic Case Archive
  • Special Collections
    • AJNR Awards
    • ASNR Foundation Special Collection
    • Most Impactful AJNR Articles
    • Photon-Counting CT
    • Spinal CSF Leak Articles (Jan 2020-June 2024)
  • Multimedia
    • AJNR Podcasts
    • AJNR SCANtastic
    • Trainee Corner
    • MRI Safety Corner
    • Imaging Protocols
  • For Authors
    • Submit a Manuscript
    • Submit a Video Article
    • Submit an eLetter to the Editor/Response
    • Manuscript Submission Guidelines
    • Statistical Tips
    • Fast Publishing of Accepted Manuscripts
    • Graphical Abstract Preparation
    • Imaging Protocol Submission
    • Author Policies
  • About Us
    • About AJNR
    • Editorial Board
    • Editorial Board Alumni
  • More
    • Become a Reviewer/Academy of Reviewers
    • Subscribers
    • Permissions
    • Alerts
    • Feedback
    • Advertisers
    • ASNR Home
  • Follow AJNR on Twitter
  • Visit AJNR on Facebook
  • Follow AJNR on Instagram
  • Join AJNR on LinkedIn
  • RSS Feeds

AJNR is seeking candidates for the AJNR Podcast Editor. Read the position description.

EditorialEDITORIAL

Intrathecal Gadolinium: Its Time Has Come?

W.P. Dillon
American Journal of Neuroradiology January 2008, 29 (1) 3-4; DOI: https://doi.org/10.3174/ajnr.A0884
W.P. Dillon
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Info & Metrics
  • Responses
  • References
  • PDF
Loading

The article in this month's American Journal of Neuroradiology by Albayram et al (“Gadolinium-Enhanced MR Cisternography to Evaluate Dural Leaks in Intracranial Hypotension Syndrome”)1 reviews the authors’ experience with intrathecal gadolinium administration for the detection of CSF fistulas resulting in spontaneous intracranial hypotension (SIH). In their report, the authors reviewed 19 patients with clinical SIH in whom 0.5 mL of gadopentetate dimeglumine diluted with 4 mL of saline was instilled intrathecally 1 hour before fat-suppressed T1-weighted MR imaging. They found CSF fistulas in 17 of 19 patients; 14 of the fistulas were subsequently confirmed, but in 3, the exact site of the fistula was not identified due to the gross extent of leakage by the time the MR imaging was performed. Ten patients had a single fistula, whereas 4 patients had multiple fistulas (2 tears in 3 patients and multiple tears in 1 patient). Of importance, 4 patients, all with meningeal diverticula, showed only paravertebral leakage without prominent epidural leakage. Although the authors did not routinely compare intrathecal MR myelography with CT cisternography, 2 patients did have both studies, and 1 of these showed leakage along a nerve root on MR myelography that was not visible by using CT myelography. Clinically, no patients were found to have an untoward reaction, behavioral changes, or evidence of toxicity at 24 hours and at 6–12 months following the examination.

Di Chiro et al2 first used intrathecal gadolinium to detect intracranial CSF fistulas in Beagle dogs (Beagles apparently occasionally have spontaneous CSF rhinorrhea). Using gadolinium MR cisternography, they identified fistulas in 2 dogs that had been previously found to have CSF rhinorrhea by radioisotope cisternography. In 1999, Jinkins et al3 administered cisternal gadolinium to rabbits, showing no behavioral effects, good cisternal contrast, but “gradual diffusion of the gadolinium into the cranial parenchyma … on the delayed MR studies (45 minutes–6 hours), as revealed by progressive generalized enhancement of the brain.” Zeng et al,4 from the same group, first piloted the technique in humans, showing excellent opacification and no gross behavioral changes following the instillation of 0.2 mL, 0.5 mL, or 1 mL of gadopentetate dimeglumine (500 mmol/L) diluted in 5 mL of CSF. Although long-term safety studies have yet to be performed, histologic studies in animals have shown no changes concerning acute toxicity of intrathecal gadolinium, and a recent international registry study of 95 humans reported no significant toxicity of 0.5–1 mL of intrathecally administered gadopentetate dimegulmine.5 Aydin et al6 reported that gadolinium cisternography demonstrated leaks in 2 patients with negative findings on CT cisternography, and Tali et al7 used gadolinium cisternography to determine the communication between the CSF pathways and intracranial arachnoid cysts. Although the spatial resolution of MR imaging is typically less than that achieved by using CT myelography, the lack of ionizing radiation and better contrast resolution are enticing factors that make MR imaging a viable alternative to CT, especially in children and in those in whom subtle or slow leaks are suspected.8

I have personally used gadolinium cisternography in several patients with SIH who had difficult-to-detect spinal fistulas. After obtaining informed consent from the patients, I diluted 0.5 mL of gadopentetate dimegulmine with 5 mL of iohexol (Omnipaque 180; GE Healthcare, Piscataway, NJ) and slowly injected this mixture intrathecally during a 3-minute period. The patients tolerated this procedure well and had no immediate or subacute side effects, and the technique allowed me to study the patients first with CT myelography, followed by MR myelography. Radioisotopes could also be administered at the same time by using a single spinal puncture.

Obviously gadolinium cisternography brings up concerns regarding the safety of the intrathecal use of gadolinium-based contrast agents. The intrathecal use of gadolinium is not currently FDA-approved. The off-label use of these compounds should be considered carefully and used only in patients with normal renal function and CSF clearance in whom currently accepted techniques for detecting CSF dynamics or leaks are either unrevealing or associated with unacceptable potential consequences or risks. Central nervous system (CNS) toxicity following the intravenous use of gadolinium in a patient with renal failure has been reported.9 In addition, Morris and Miller10 reported that the increased signal intensity in the subarachnoid space detected on fluid-attenuated inversion recovery imaging of the brain in patients following previous intravenous gadolinium injections is secondary to contrast agent crossing the intact blood-brain barrier in both healthy patients as well as those with renal failure. There are, no doubt, differences in the CSF clearance among the various compounds as well among patients with various renal clearances, ages, and underlying CNS disorders. The direct enhancement of brain as observed in rabbits by Jinkins3 (see above) is also a concern that the brain is at risk for toxicity if CSF clearance is impaired or an improper dose is administered. These questions must obviously be addressed before general use of these agents intrathecally.

All that said, gadolinium MR myelography and cisternography may potentially better evaluate obstruction of the subarachnoid space, arachnoid cysts, spontaneous or traumatic intracranial and spinal CSF fistulas, and CSF dynamics. The lack of ionizing radiation, availability of multiplanar views, and the potential to assess dynamics of CSF over time without concern for radiation are appealing aspects of MR imaging–based techniques. However, as we have learned only too clearly from the recent data on nephrogenic systemic sclerosis and its association with gadolinium contrast agents in patients with renal impairment, additional animal and human studies must be performed to further evaluate the long-term safety as well as to prove the clinical efficacy of this procedure in a larger number of human subjects.11 Because the elimination of gadolinium from the CSF compartment has different kinetics than that administered intravenously, the lack of brain and spinal toxicity over the long term must be established before widespread use of this technique is acceptable. Nonetheless, the potential for increased contrast resolution coupled with reduction in radiation exposure is seductive. Its time may have come.

References

  1. ↵
    Albayram S, Kilic F, Ozer H, et al. Gadolinium-enhanced MR cisternography to evaluate dural leaks in intracranial hypotension syndrome. AJNR Am J Neuroradiol 2008;29:117–22
  2. ↵
    Di Chiro G, Girton M, Frank J, et al. Cerebrospinal fluid rhinorrhea: depiction with MR cisternography in dogs. Radiology 1986;160:221–22
    PubMed
  3. ↵
    Jinkins J, Williams R, Xiong L. Evaluation of gadopentetate dimeglumine magnetic resonance cisternography in an animal model: preliminary report. Invest Radiol 1999;34:156–59
    CrossRefPubMed
  4. ↵
    Zeng Q, Xiong L, Jinkins J, et al. Intrathecal gadolinium-enhanced MR myelography and cisternography: a pilot study in human patients. AJR Am J Roentgenol 1999;173:1109–15
    PubMed
  5. ↵
    Tali E, Ercan N, Krumina G, et al. Intrathecal gadolinium (gadopentetate dimeglumine) enhanced magnetic resonance myelography and cisternography: results of a multicenter study. Invest Radiol 2002;37:152–59
    CrossRefPubMed
  6. ↵
    Aydin K, Guven K, Sencer S. MRI cisternography with gadolinium-containing contrast medium: its role, advantages and limitations in the investigation of rhinorrhoea. Neuroradiology 2004;46:75–80. Epub 2003 Nov 13
    CrossRefPubMed
  7. ↵
    Tali E, Ercan N, Kaymaz M, et al. Intrathecal gadolinium (gadopentetate dimeglumine)-enhanced MR cisternography used to determine potential communication between the cerebrospinal fluid pathways and intracranial arachnoid cysts. Neuroradiology 2004;46:744–54
    CrossRefPubMed
  8. ↵
    Muñoz A, Hinojosa J, Esparza J. Cisternography and ventriculography gadopentate dimeglumine-enhanced MR imaging in pediatric patients: preliminary report. AJNR Am J Neuroradiol 2007;28:889–94
    Abstract/FREE Full Text
  9. ↵
    Maramattom BV, Manno EM, Wijdicks EFM, et al. Gadolinium encephalopathy in a patient with renal failure. Neurology 2005;64:1276–78
    Abstract/FREE Full Text
  10. ↵
    Morris JM, Miller GM. Increased signal in the subarachnoid space on fluid-attenuated inversion recovery imaging associated with the clearance dynamics of gadolinium chelate: a potential diagnostic pitfall. AJNR Am J Neuroradiol 2007;28:1964–67
    Abstract/FREE Full Text
  11. ↵
    Chewning RH, Murphy KJ. Gadolinium-based contrast media and the development of nephrogenic systemic fibrosis in patients with renal insufficiency. J Vasc Interv Radiol 2007;18:331–33
    CrossRefPubMed
  • Copyright © American Society of Neuroradiology
PreviousNext
Back to top

In this issue

American Journal of Neuroradiology: 29 (1)
American Journal of Neuroradiology
Vol. 29, Issue 1
January 2008
  • Table of Contents
  • Index by author
Advertisement
Print
Download PDF
Email Article

Thank you for your interest in spreading the word on American Journal of Neuroradiology.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Intrathecal Gadolinium: Its Time Has Come?
(Your Name) has sent you a message from American Journal of Neuroradiology
(Your Name) thought you would like to see the American Journal of Neuroradiology web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Cite this article
W.P. Dillon
Intrathecal Gadolinium: Its Time Has Come?
American Journal of Neuroradiology Jan 2008, 29 (1) 3-4; DOI: 10.3174/ajnr.A0884

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
0 Responses
Respond to this article
Share
Bookmark this article
Intrathecal Gadolinium: Its Time Has Come?
W.P. Dillon
American Journal of Neuroradiology Jan 2008, 29 (1) 3-4; DOI: 10.3174/ajnr.A0884
del.icio.us logo Twitter logo Facebook logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One
Purchase

Jump to section

  • Article
    • References
  • Info & Metrics
  • Responses
  • References
  • PDF

Related Articles

  • No related articles found.
  • PubMed
  • Google Scholar

Cited By...

  • American Society of Regional Anesthesia and Pain Medicine contrast shortage position statement
  • MR Myelography for the Detection of CSF-Venous Fistulas
  • Fatal gadolinium-induced encephalopathy following accidental intrathecal administration: a case report and a comprehensive evidence-based review
  • Crossref (13)
  • Google Scholar

This article has been cited by the following articles in journals that are participating in Crossref Cited-by Linking.

  • Myelographic Techniques for the Detection of Spinal CSF Leaks in Spontaneous Intracranial Hypotension
    Peter G. Kranz, Patrick H. Luetmer, Felix E. Diehn, Timothy J. Amrhein, Teerath Peter Tanpitukpongse, Linda Gray
    American Journal of Roentgenology 2016 206 1
  • The Role of Digital Subtraction Myelography in the Diagnosis and Localization of Spontaneous Spinal CSF Leaks
    Joseph M. Hoxworth, Terrence L. Trentman, Amy L. Kotsenas, Kent R. Thielen, Kent D. Nelson, David W. Dodick
    American Journal of Roentgenology 2012 199 3
  • Imaging of Cerebrospinal Fluid Rhinorrhea and Otorrhea
    Mahati Reddy, Kristen Baugnon
    Radiologic Clinics of North America 2017 55 1
  • Intracranial Hypotension and Intracranial Hypertension
    Esther L. Yuh, William P. Dillon
    Neuroimaging Clinics of North America 2010 20 4
  • Fatal gadolinium-induced encephalopathy following accidental intrathecal administration: a case report and a comprehensive evidence-based review
    David Anthony Provenzano, Zachary Pellis, Leonard DeRiggi
    Regional Anesthesia & Pain Medicine 2019 44 7
  • Spontaneous Intracranial Hypotension: Recommendations for Management
    Farnaz Amoozegar, Darryl Guglielmin, William Hu, Denise Chan, Werner J. Becker
    Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques 2013 40 2
  • Phase-contrast cine MRI versus MR cisternography on the evaluation of the communication between intraventricular arachnoid cysts and neighbouring cerebrospinal fluid spaces
    Oktay Algın, Bahattin Hakyemez, Gokhan Gokalp, Ender Korfalı, Mufıt Parlak
    Neuroradiology 2009 51 5
  • MR Myelography for the Detection of CSF-Venous Fistulas
    J.L. Chazen, M.S. Robbins, S.B. Strauss, A.D. Schweitzer, J.P. Greenfield
    American Journal of Neuroradiology 2020 41 5
  • The Use of Contrast Agents in Interventional Pain Procedures: A Multispecialty and Multisociety Practice Advisory on Nephrogenic Systemic Fibrosis, Gadolinium Deposition in the Brain, Encephalopathy After Unintentional Intrathecal Gadolinium Injection, and Hypersensitivity Reactions
    Honorio T. Benzon, Timothy P. Maus, Hye-Ryun Kang, David A. Provenzano, Anuj Bhatia, Felix Diehn, Ariana Nelson, Zachary L. McCormick, Benjamin P. Liu, Javier de Andres Ares, Magdalena Anitescu, Kristine Blackham, Arun Bhaskar, Silviu Brill, Jeremy Collins, Ashish Gulve, Robert W. Hurley, Young Hoon Jeon, Jee Youn Moon, Richard L. Rauck, Meghan Rodes, Ryan K. Lee, Vinil Shah, Harsha Shanthanna, Jan van Zundert, Marc Huntoon, James P. Rathmell, Mario Sanchez Borges, Steven P. Cohen, Paul A. Greenberger
    Anesthesia & Analgesia 2021 133 2
  • American Society of Regional Anesthesia and Pain Medicine contrast shortage position statement
    Lynn Kohan, Zachary Pellis, David Anthony Provenzano, Amy C S Pearson, Samer Narouze, Honorio T Benzon
    Regional Anesthesia & Pain Medicine 2022 47 9

More in this TOC Section

  • Supporting Imaging Research: A Framework for Equity and Excellence in Neuroradiology
  • Neuroimaging within the Stroke Treatment Paradigm – An Update from the Brain Attack Coalition
  • Introducing the Gene & Cell Therapy Study Group of the ASNR, ASFNR, and ASPNR
Show more EDITORIAL

Similar Articles

Advertisement

Indexed Content

  • Current Issue
  • Accepted Manuscripts
  • Article Preview
  • Past Issues
  • Editorials
  • Editor's Choice
  • Fellows' Journal Club
  • Letters to the Editor
  • Video Articles

Cases

  • Case Collection
  • Archive - Case of the Week
  • Archive - Case of the Month
  • Archive - Classic Case

Special Collections

  • AJNR Awards
  • ASNR Foundation Special Collection
  • Most Impactful AJNR Articles
  • Photon-Counting CT
  • Spinal CSF Leak Articles (Jan 2020-June 2024)

More from AJNR

  • Trainee Corner
  • Imaging Protocols
  • MRI Safety Corner

Multimedia

  • AJNR Podcasts
  • AJNR Scantastics

Resources

  • Turnaround Time
  • Submit a Manuscript
  • Submit a Video Article
  • Submit an eLetter to the Editor/Response
  • Manuscript Submission Guidelines
  • Statistical Tips
  • Fast Publishing of Accepted Manuscripts
  • Graphical Abstract Preparation
  • Imaging Protocol Submission
  • Evidence-Based Medicine Level Guide
  • Publishing Checklists
  • Author Policies
  • Become a Reviewer/Academy of Reviewers
  • News and Updates

About Us

  • About AJNR
  • Editorial Board
  • Editorial Board Alumni
  • Alerts
  • Permissions
  • Not an AJNR Subscriber? Join Now
  • Advertise with Us
  • Librarian Resources
  • Feedback
  • Terms and Conditions
  • AJNR Editorial Board Alumni

American Society of Neuroradiology

  • Not an ASNR Member? Join Now

© 2025 by the American Society of Neuroradiology All rights, including for text and data mining, AI training, and similar technologies, are reserved.
Print ISSN: 0195-6108 Online ISSN: 1936-959X

Powered by HighWire