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572651 tn?1530999357

MRI's and gadolinium (contrast)

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

27 Responses
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405614 tn?1329144114
I find it interesting that the techs run another series of images while the contrast circulates.  If my memory serves me, I was in the tube a long time before I was pulled out, injected with contrast, and then the scanning that followed did not take long at all.

This wasn't totally the case with my 3T, because I had the entire series; head, cervical, and thoracic.  They scanned from my head to thoracic, injected the gad, and put me right back in and scanned back the other way.  The scanning on the way down took longer; I was so tired I actually fell asleep in the tube.

I'll have to remember to ask about this when its time for my next MRIs.  Dr. C. wants to wait until I've been on Avonex longer.

Lulu, too bad you don't get copies of your 7Ts; we like to research these things, too, lol!

Kathy
Helpful - 0
572651 tn?1530999357
Good timing on the bump, Jen.  I just had a 3T done today with/without contrast and I talked to the tech about this.  She told me that there is another series of images she does while the contrast is circulating toward the brain.

I have the files on CD but haven't looked yet to see what's going on in my brain these day.

I also did another 7T for the reseaarch group and they were very happy to have me pumped full of contrast for their scans today.  Unfortunately I don't get copies of the 7T's because it is for research and not clinical use.

my best, Lulu

Helpful - 0
338416 tn?1420045702
Bumpity-bump - this is an interesting thread, and everybody might not have had the chance to read it.
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704043 tn?1298056844
    me neither they rolled me out shot me and run me back in!!!   next time ill insist OH!!  Gotta go  BAD!!!  And stay in bathroom 4 ten min!!!  that will teach them!!!  Thanks lu lu!!!  tick!!
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195469 tn?1388322888
My Neuro told me that even though she has written orders on patients forms to take to the MRI facility to wait for at least 10 full minutes after contrast administration, that the MRI techs, do what they want to do anyway.

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
Helpful - 0
152264 tn?1280354657
The bathroom is a great idea--although when I had an MRI long ago, when I had to leave the machine for the second time to go (it was one of those mornings when my kidneys seemed to be in overdrive, even though I'd very drunk little that morning), they just said, "we'll have to finish early, then," and they didn't let me back into the machine.

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.
Helpful - 0
572651 tn?1530999357
GG,
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
Helpful - 0
738075 tn?1330575844
I brought up waiting at least 5 minutes to the tech last time I was in there, and she said it was not necessary.  I believe it is.  Maybe I'll conveniently excuse myself to the bathroom after the next injection :^))

Helpful - 0
195469 tn?1388322888
I just checked this out with my Neuro.  She said that you and the doctor's that told you this, is EXACTLY the way it is preferred by all Neuro's.  She said that no matter how many times she has instructed for MRI tech's to wait a FULL 10-15 minutes after contrast administration; they seem to do what they want to do.  They are more interested in getting the scan finished, so they can get to the next patient.  

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
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572651 tn?1530999357
My question then would be how long does it take to run the T1 post-gadolinium scans?  
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!
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198419 tn?1360242356
Good solid info here! Thank you Lu!

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
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Avatar universal
Interesting, the techs definitely did not wait, they completed the test immediately after injecting the contrast.
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572651 tn?1530999357
I was posting this for another question on the forum - within the recommended guidelines adopted for 2009 for the MRI protocol there is the reference to waiting after the gad injection - they say a minimum of 5 minutes

mscare.org/cmsc/images/pdf/mriprotocol2009.pdf
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572651 tn?1530999357
Honestly I have to go looking to be able to give you an understandable expalantion of the  difference between hyperintensities (those lesions that appear bright without contrast) and enhancing lesions (lesions that glow because of contrast).

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
Helpful - 0
987762 tn?1671273328
COMMUNITY LEADER
I'm still confused (lol) so why did my MRI done without contrast show at least one marble sized bright glow and another couple of smaller ones, if its only with use of correctly timed gadolinium that they will light up and show them selves? How did some of mine light up or should i say why did anything light up?

My neuro is saying because i didn't have 'enough' inflamation 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 (enhansing lesions) and some minimal but 'old' inflamation (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
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195469 tn?1388322888
The hardest thing for me in all of this will be remembering to MAKE the tech WAIT for that 10-15 minutes, after injection.  If I remember to ask, I will tell them at the beginning of the whole series, about the wait time and if they don't do it, don't bother scanning me.  Period!

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
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572651 tn?1530999357
I actually had a neuro appt yesterday, and was able to ask him this question.  We discussed it in detail.  

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
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293157 tn?1285873439
Thanks Lulu..good info...when I had the Gad admin they did the imagine right away... no waiting for me either...next time I have a MRI...I must remember to ask them to wait..

wobbly
dx
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338416 tn?1420045702
They've done research on lesion imaging, and found that there was 45% improvement in detail when they waited 15 minutes between administering the gadolinium and taking the second set of MRIs.
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195469 tn?1388322888
The MRI technicians that I had, said that with a "few beats of the heart, the contrast dye is totally throughout your body."  Not much waiting necessary.  I am wondering after reading all the replies to this post, if it takes some more time for the 'lesions' to highlight sufficiently, with "just a few beats of the heart?"

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
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233622 tn?1279334905
I have never had them wait.  This last one was very quick.  Interesting.  i will be looking forward to your next post on this issue,
LA
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405614 tn?1329144114
Same here, the two times i've had contrast with MRIs, they've injected and started scanning, with no waiting.  I asked about it , and was told that it goes into the bloodstream so quickly, and crosses the blood brain barrier almost instantly, that there was no need to wait.  

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
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429700 tn?1308007823
I hope all of the radiologists and technicians get this word.  I've never waited for the contrast agent to get into my bloodstream.  I'm wondering what kind of reaction they will have when I ask them if they should wait.  I've had several MRIs now and have never waited for the contrast.

Helpful - 0
Avatar universal
Hi there,
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.
Helpful - 0
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