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MRI's and gadolinium (contrast)
by Lulu54, Nov 07, 2009 02:05PM
, Nov 07, 2009 02:05PM
Today was a wonderful panel discussion with two neuros, one MS RN and the local NMSS president. All of them are women, and it was an open session to discuss whatever topics we wanted. It was absolutely the BEST MS presentation I have been to yet. The one neuro is the head of the Waddell MS Clinic at the university of Cincinnati.
Some of the questions dealt with MRI technology - strength of machines, software development etc.
There was talk about the use of contrast agents in MRIs (gadolinium) and both neuros were emphatic that timing with the contrast is everything .They talked about technicians rushing to finish the MRI's, but it is important to wait long enough for the gad to circulate and enhance active lesions.
When I asked how long that wait should be, the answer was unanimous that it should be 10-15 minutes after the injection before the next series of images are taken.
The techs have NEVER waited more than a minute or two with me - I'll be mentioning that when I go for me next series.
When I get a few quiet moments I will put together a journal entry on the past two MS talk I attended - quite a difference and lots of useful information to share.
be well,
Lulu
Some of the questions dealt with MRI technology - strength of machines, software development etc.
There was talk about the use of contrast agents in MRIs (gadolinium) and both neuros were emphatic that timing with the contrast is everything .They talked about technicians rushing to finish the MRI's, but it is important to wait long enough for the gad to circulate and enhance active lesions.
When I asked how long that wait should be, the answer was unanimous that it should be 10-15 minutes after the injection before the next series of images are taken.
The techs have NEVER waited more than a minute or two with me - I'll be mentioning that when I go for me next series.
When I get a few quiet moments I will put together a journal entry on the past two MS talk I attended - quite a difference and lots of useful information to share.
be well,
Lulu
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The two times I've had contrast, they sure didn't wait like that.
Just got up from my nap and read your post. Thanks for the update - I look forward to reading the info package you are putting together!
I had read that it was important to wait after infusing the gadolineum, but, as with you, that wait never materialized for me. Actually, on my last MRI of the brain (3T) I didn't even feel any gadolineum going in (they had warned that I might have a certain sensation - but I felt nothing). A small amount must have gone in but I don't think it all went in. As with you, imaging after gad infusion was immediate! I'd love for American medicine to actually get back to caring about the patient - rather than just rushing to make the next buck! Good luck trying to get them to wait longer next time!
Maybe you should actually have your next MRI done at Waddell (it would be interesting to see if they actually practice what they preach).
Do you think Waddell Clinic would be a good place to go for a fair and full MS inquiry for those of us still seeking a diagnosis?
WAF
I wouldn't hesitate to switch to her if I want to change - someone asked how to get in touch with her office, and one of her patients pulled out her planner and read a phone number out loud- and the doctor just laughed and said she wasn't supposed to give her cell phone number out publicly like that! That her patients have direct access to her is a good sign.
Crossing state lines for insurance purposes gets impossible with many policies .. and that takes me back to the thought that quality diagnostic care should be available in every state!
my best,
Lu
thanks for sharing that information, My last MRI with the gad he put the needle in and then took the pictures, he certainly didn't wait.
But interestingly enough I had a CT scan done of my kidneys and abdomen a few weeks ago with contrast and the guy made me go out for 15 minutes before he did the next series and the pics are amazing, I have them on a CD but I don't have the results yet.
The things you learn on this forum.
Thanks Lu.
Two different hospital systems.
I thought they were wrong, as I'd read here before that they need to wait a certain amount of time
Thanks, Lulu, I wish I could have been there; sounds like a great presentation. Thanks so much for sharing with us what you learned.
Kathy
LA
I have a spinal MRI coming up soon and I will ask my Neuro at my appointment on the 12th. She admits that she is not as savvy about MRI and the logistics as she should be. Shame on her for NOT being up to date, but glad that she admitted it.
Heather
wobbly
dx
At his previous MS Center in Michigan, he said they were suspicious that in about 4,000 patients who had MRI over a couple year's time, none of them had enhancing lesions. That is zero MS patients with active disease. They re-looked at the imaging technique going on and found that the final set of pics was being taken almost immediately.
He says it takes a minimum of 10 minutes for the gadolinium to breech the blood-brain barrier, and 15 minutes is even better.
beeHe said the protocol was rewritten so there is that waiting time to do those final images and if contrast is given, it is useless unless there is that waiting time.
However, he did also explain (and I wish I had written this down for sure!) that patients are immediately put back in the tube and more pictures are taken.
The T2 weighted (I think that's what he said) images don't enhance, and that series of pictures can be done in this protocol while waiting out the 10-15 minutes for the contrast agent to do its job.
The technician can then take the other images --- but there is no way that any of us should be done with our MRI's almost immediately after getting the contrast agent.
Unfortunately, we can't wear a watch into the MRI to clock the timing!
The best we can do is perhaps talk to our neuros about this and also mention it to the technician and make them aware that you know that this timing is important.
be well,
Lulu
I'll be sure to tell them that they are wasting my time and playing games with MY health....as my very treatment for my MS, could be dependent on that 10 minute wait.
All these people that may have had enhancing blesions to show a breech in the central nervous system,Blood Brain Barrier-BBB) that didn't show, because of immediate return to filiming. This could have resulted in someone NOT being diagnosed with MS, because they do not "meet" the criteria of showing two separate attacks over time. Do you understand what I am trying to say? I shudder when I think about those poor people...
Heather
My neuro is saying because i didn't have 'enough' inflamation (inflammation) in my brain thats why he is 99% sure i dont have MS. I know he cant be that sure when its the only MRI i've ever had and it wasn't following MS protocal to start with but is the consensous (sp) of this topic saying only contrast will show current BBB?
I was under the impression that what my MRI showed was some minimul 'new' inflamation (inflammation) (enhansing lesions) and some minimal but 'old' inflamation (inflammation) (none enhansing) which in my neuro's opinion is all irrelevant and meaningless. TWIT!!!
I cant help but wonder if the thoughts i've had regarding the lack of gadolinium with my only MRI is right thinking, should my brain have lit up like a christmas tree if they had used gadolinium? I'm still confused as to why or how the ones that did enhanse so i'd be greatful for any thoughts on this.
Cheers........JJ
The first explanation I found is here on Medhelp in the neurology forum ....
http://www.medhelp.org/posts/Neurology/Meaning-of-T2-hyperintense-signal-on-MRI/show/296604
"a focus of T2 hyperINTENSITY means that the signal from that area has different tissue characteristics compared to normal brian tissue. Usually this is due to an increased water content of the tissue. Pathological tissue usually has more water than normal brain so this is a good type to scan to pick this up
however it does not reveal any information about what it is although the site and pattern of abnormality does. A few focuses usually does not mean significant pathology and can be due to migraine, hardening of the arteries, high blood pressure or more rarely a demyelinating disease or vasculitis.
A person can have plenty of them and be asymptomatic "
The enhancing of lesions only occur when the lesions are new (less than about 40 days) - I can't explain how gadolinium works, except it targets those new lesions. With the contrast, even smaller, just forming lesions are more likely to be seen (enhancing on MRI).
Old lesions do not enhance. By seeing old and new lesions with the use of contrast, the doctor can track the activity of our MS and also document separation of time, if the patient is still looking to meet the McDonald criteria.
I'm sure Quix can add to this if you need more of an explanation.
I hope this makes sense.
my best,
Lulu
mscare.org/cmsc/images/pdf/mriprotocol2009.pdf
I've never experienced the 10 minute wait either, and though I read it while reviewing the protocols, I didn't include the recommendation on Gad in the protocol HP. I'll work on something simple to add.
Here is the recommendation:
* From the 3 source docs (referenced on the HP) each year 2003, 2006 and 2009 recommend a minimum delay of 5 minutes for post gad T1s. You remembered correctly Lu because it's the FLAIR and T2 can be done DURING the 5 minute minimum delay.
This could very well explain why we all have not experienced the delay. But, they could run the T1s right away too and we'd not know it. I suppose.
-shell
Because when I have had gad, I've been out of the tube pretty quick afterwards.
I'll ask my neuro this week if I remember!
She said ALL scans done after injection of contrast dye, should only be done after ten to fifteen minutes. PERIOD. She did say, that the last of the scans that were being done, WOULD have contrast dye fully in the system, (if they didn't wait to start re-filming after the injection) to show if there was any penetration of the blood brain barrier. She also told me that in cases of her patients with known MS, she relys on the patients reported symptoms and physical exam, to determine if they were in an active attack and paid little to no attention to enhancement of lesions on an MRI.
So with that said, I think we all should ask our MRI tech's to wait at least ten minutes after injection of contrast, to start taking the films again. Hopefully we have a Neurologist that does not depend on seeing enhancement, to know his/her patient is in a full blown attack. What lesions are there are going to show up, no matter if the contrast is given or not. Like I said, she knows if I am in an active attack, but we discover that during my appointment.
I would feel that contrast enhancement would be extremely important to anyone that is going through the diagnostic process. Especially when the doctor is trying to identify 2 distinct relapses to meet the McDonald Criteria evidenced not only by physical exam but followed up by proof on MRI.
Thank you again, for bringing this information to us, Lulu. I now have a third Neurologist that totally agrees with what you have heard the Cincinnati MS conference.
Heather
I like that bathroom excuse - or perhaps everyone just needs to take a copy of the MRI protocol with them and bring up the subject before the MRI even begins .... set the expectation that the scan will be done correctly.
Heather, thanks so much for checking this all out further. Its great to have confirmation from several sources to add to the ammunition.
Lu
What I don't understand is, if the 15 minutes is so important, why isn't it built into the schedule when they have doctor's orders to do it that way? If they have to charge more to cover those 15 minutes, so be it.
She said that she has had cases where she has ordered contrast used and the tech takes it upon himself/herself to NOT administer contrast if they do not see a reason to administer it. She said this has happened when the tech sees NO lesions. She told me that despite that, when she orders something to be done, she expects it to be done. She has had more than one "go-around" with the techs. She complains to the facility's management, but rarely are the techs let go.
I think this is a serious infraction on the tech's part. Not following doctor's orders. They should be fired. The tech's tell their bosses that if no lesions are seen, it is unnecessary to put the patient through an extra set of filming with contrast and wastes their time and the patients time. Since when did they become bosses or doctor's anyway?
If it hadn't been for Lulu reporting this unknown fact among many, I never would have realized that it takes time for the contrast to reach all the necessary areas of the brain. As I said in my first post, they have told me before, that it only takes a few heartbeats for the dye to completely circulate in the body. Although I never knew that there should at least, be a ten minute wait, I always wondered if they gave the contrast enough time to enter the brain, if there WAS a break in the blood brain barrier.
For those of you that do not know, if the blood brain barrier has not been compromised, the contrast dye will not penetrate it at all. The central nervous system is a sealed system, to protect it from germs and infections. In an MS flair up, the blood brain barrier is usually "attacked" or pierced, for the sake of description; so the little "MS Pac-Man can get in there and chew" on the myelin. The entire central nervous system, including the spine, is protected in a sealed membrane. I might be wrong, but I believe it is called the "dura."
The "MS Pac-Man," is the way I have always thought of what MS does, when it attacks our brains and spinal cord. Gobbling away, chewing on the myelin. In fact, that is the way I described it to my grandchildren.
Heather