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Everything you need to know about Computed Tomography (CT) & CT Scanning

Contrast: IV Contrast Imaging Pearls - Educational Tools | CT Scanning | CT Imaging | CT Scan Protocols - CTisus
Imaging Pearls ❯ Contrast ❯ IV Contrast

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  • Purpose To determine if administering IV contrast for CT abdomen and pelvis improves detection of urgent and clinically important non-urgent pathology in patients with urgent clinical symptoms compared to patients not receiving IV contrast, and in turn to determine whether repeat CT exams on the same patient within 72 h were of low diagnostic benefit if the first CT was performed with IV contrast.
    Conclusion In the absence of contraindications, encouraging urgent care physicians to preferentially order IV contrast-enhanced CT AP examinations in adherence with ACR appropriateness criteria may increase detection of urgent pathology and avoid short- term repeat CT.
    Effect of intravenous contrast for CT abdomen and pelvis on detection of urgent and non-urgent pathology: can repeat CT within 72 hours be avoided?
    Lamoureux C et al.
    Emergency Radiology (2019) 26:601–608
  • Methods We evaluated 400 consecutive patients who had CT abdomen and pelvis (CT AP) examinations repeated within 72 h. For each patient, demographic data, reason for examination, examination time stamps, and examination technique were documented. CT AP radiology reports were reviewed and both urgent and non-urgent pathology was extracted.
    Results Of 400 patients, 63% had their initial CT AP without contrast. Administration of IV contrast for the first CT AP was associated with increased detection of urgent findings compared with non-contrast CT (p = 0.004) and a contrast-enhanced CT AP following an initial non-contrast CT AP examination better characterized both urgent (p = 0.002) and non-urgent findings (p < 0.001). Adherence to ACR appropriateness criteria for IV contrast administration was associated with increased detection of urgent pathology on the first CT (p = 0.02), and the second CT was more likely to be performed with IV contrast if recommended by the radiologist reading the first CT (p = 0.0006).
    Effect of intravenous contrast for CT abdomen and pelvis on detection of urgent and non-urgent pathology: can repeat CT within 72 hours be avoided?
    Lamoureux C et al.
    Emergency Radiology (2019) 26:601–608
  • “In our study of patients with duplicate CT abdomen and pelvis within 72 h, the majority of CT exams repeated within the first 6 h were performed first without IV contrast followed by a second CT with IV contrast. Urgent findings were more likely to be detected on the first CT when IV contrast was used. While this may be influenced by patient selection, it could speak to the importance of IV contrast usage in making a rapid definitive ED diagnosis. Furthermore, urgent findings were more likely to be better characterized on the second CT when the first CT was performed without IV contrast followed by IV contrast on the second CT. Our study suggests that in patients with acute abdominal and pelvic symptoms for whom CT abdomen and pelvis is clinically warranted, IV contrast administration should be strongly considered.”
    Effect of intravenous contrast for CT abdomen and pelvis on detection of urgent and non-urgent pathology: can repeat CT within 72 hours be avoided?
    Lamoureux C et al.
    Emergency Radiology (2019) 26:601–608
  • “The results of this study advance our understanding of how administration of intravenous contrast administration for CT of the abdomen and pelvis influence detection of urgent and non-urgent clinically important pathology in the urgent setting. To reduce potentially medically unnecessary redundant imaging within a short timeframe, this information may be useful for optimization of CT examination protocols.”
    Effect of intravenous contrast for CT abdomen and pelvis on detection of urgent and non-urgent pathology: can repeat CT within 72 hours be avoided?
    Lamoureux C et al.
    Emergency Radiology (2019) 26:601–608
  • “Extrinsic warming of room- temperature iodinated contrast material to human body temperature (37°C) is known to reduce contrast material viscosity, and results of some studies have shown that the practice can improve contrast material delivery rates with both hand and power injections through intravenous catheters.”


    Rate of Contrast Material Extravasations and Allergic-like Reactions: Effect of Extrinsic Warming of Low-Osmolality Iodinated CT Contrast Material to 37° C 
Davenport MS et al.
Radiology 2012; 262:475-484
  • “Extrinsic warming of iodinated contrast material to 37°C reduces contrast ma- terial viscosity and has been advocated to decrease the frequency of adverse events related to intravenous administration and to improve iodinated contrast material delivery.”


    Rate of Contrast Material Extravasations and Allergic-like Reactions: Effect of Extrinsic Warming of Low-Osmolality Iodinated CT Contrast Material to 37° C 
Davenport MS et al.
Radiology 2012; 262:475-484
  • STUDY OBJECTIVE: The study objective was to determine whether intravenous contrast administration for computed tomography (CT) is independently associated with increased risk for acute kidney injury and adverse clinical outcomes.

    CONCLUSION: In the largest well-controlled study of acute kidney injury following contrast administration in the ED to date, intravenous contrast was not associated with an increased frequency of acute kidney injury.
Risk of Acute Kidney Injury After Intravenous Contrast Media Administration.


    Hinson JS, Ehmann MR, Fine DM, Fishman EK, Toerper MF, Rothman RE,  Klein EY 
Ann Emerg Med 2017 Jan 19. pii: S0196-0644(16)31388-9 

  • “Rates of acute kidney injury were similar among all groups. Contrast administration was not associated with increased incidence of acute kidney injury (contrast-induced nephropathy criteria odds ratio=0.96, 95% confidence interval 0.85 to 1.08; and Acute Kidney Injury Network/Kidney Disease Improving Global Outcomes criteria odds ratio=1.00, 95% confidence interval 0.87 to 1.16). This was true in all subgroup analyses regardless of baseline renal function and whether comparisons were made directly or after propensity matching. Contrast administration was not associated with increased incidence of chronic kidney disease, dialysis, or renal transplant at 6 months.”
Risk of Acute Kidney Injury After Intravenous Contrast Media Administration.


    Hinson JS, Ehmann MR, Fine DM, Fishman EK, Toerper MF, Rothman RE,  Klein EY 
Ann Emerg Med 2017 Jan 19. pii: S0196-0644(16)31388-9 

  • OBJECTIVE. The objective of our study was to determine the effects of dehydration and oral rehydration on the incidence of acute adverse reactions to iodinated contrast media administered during abdominal and pelvic CT in outpatients.


    CONCLUSION. Dehydration and oral rehydration did not affect the incidence of acute adverse reactions to iodinated contrast material for abdominal and pelvic CT in our randomized prospective trial.

    
Acute Adverse Reactions to Nonionic Iodinated Contrast Media for CT: Prospective Randomized Evaluation of the Effects of Dehydration, Oral Rehydration, and Patient Risk Factors
Utaroh Motosugi et al.
AJR 2016;207: 931-938.
  • “In general, fluid intake is recommended to prevent CIN . However, on the basis of our results, there is no reason to promote fluid intake to prevent acute adverse reactions. Fluid intake does not help patients feel comfortable with the IV contrast injection. On the other hand, fluid intake immediately before CT did not increase the prevalence of adverse reactions. Thus, there is also no reason, to our knowledge, to advise patients to avoid fluid consumption before contrast- enhanced CT.”


    Acute Adverse Reactions to Nonionic Iodinated Contrast Media for CT: Prospective Randomized Evaluation of the Effects of Dehydration, Oral Rehydration, and Patient Risk Factors
Utaroh Motosugi et al.
AJR 2016;207: 931-938.
  • “In conclusion, in our randomized prospective study, neither dehydration nor oral rehydration affected the prevalence of acute adverse reactions to iodinated contrast media administered during abdominal and pelvic CT.”


    Acute Adverse Reactions to Nonionic Iodinated Contrast Media for CT: Prospective Randomized Evaluation of the Effects of Dehydration, Oral Rehydration, and Patient Risk Factors
Utaroh Motosugi et al.
AJR 2016;207: 931-938.
  • “AAA represents a progressive increase in the aortic luminal diameter and is the 10th most common cause of death in the Western world. AAA is usually described by its relationship to renal arteries (ie, suprarenal or infrarenal). The normal diameter of the suprarenal abdominal aorta is up to 3.0 cm, and that of the infrarenal abdominal aorta is 2.0 cm. Aneurysmal dilation of the infrarenal aorta is defined as a diameter ≥3.0 cm or dilation of the aorta ≥1.5 times the normal diameter; on the basis of these criteria, 9% of people aged >65 years have an AAA.”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “Emergency surgery for aortic aneurysm rupture is associated with 46% mortality (as opposed to 4%-6% for elective repair), and rupture occurs with increasing frequency as the aneurysm size exceeds 5 cm. It is therefore valuable to detect AAAs and follow up until elective repair is indicated.”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • When do you followup aneurysms for interval change?
    Aortic Diameter (cm) Imaging Interval
    2.5-2.9                                   5 y
    3.0-3.4                                   3 y
    3.5-3.9                                   2 y
    4.0-4.4                                   1 y
    4.5-4.9                                   6 mo
    5.0-5.5                                   3-6 mo
  • “Aneurysms involve common and internal iliac arteries more commonly than external iliac arteries. Iliac artery aneurysm is defined as a vessel diameter ≥1.5 times the normal iliac artery diameter or ≥2.5 cm in diameter. Iliac artery aneurysms are rare in isolation; Lawrence et al reported a prevalence of 6.58 per 100,000 hospitalized men and 0.26 per 100,000 hospitalized women in the United States. Aneurysms that are <3.0 cm in diameter tend to be asymptomatic, rarely rupture, and expand slowly; those that are 3.0 to 3.5 cm should be followed up with cross-sectional imaging initially at about 6 months. If stable, repeat scanning can be performed annually. Iliac artery aneurysms >3.5 cm have a greater tendency to rupture and should be followed more closely or treated expeditiously.”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “Aneurysms involve common and internal iliac arteries more commonly than external iliac arteries. Iliac artery aneurysm is defined as a vessel diameter ≥1.5 times the normal iliac artery diameter or ≥2.5 cm in diameter. Iliac artery aneurysms are rare in isolation; Lawrence et al reported a prevalence of 6.58 per 100,000 hospitalized men and 0.26 per 100,000 hospitalized women in the United States. Aneurysms that are <3.0 cm in diameter tend to be asymptomatic, rarely rupture, and expand slowly; those that are 3.0 to 3.5 cm should be followed up with cross-sectional imaging initially at about 6 months. If stable, repeat scanning can be performed annually.”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “Splenic artery aneurysms are the most common visceral aneurysms and the third most common intra-abdominal aneurysm, after those occurring in the aorta and iliac arteries . In a series of >300 visceral artery aneurysms, 70.9% were of the splenic artery. The vast majority are true aneurysms, although pseudoaneurysms related to prior inflammation, especially pancreatitis, or infection may occur. The estimates of prevalence of splenic artery aneurysms vary, but a retrospective review of nonselective angiograms suggests that an incidence estimate of 0.8% may be the most accurate .”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “Risk factors for developing these aneurysms are similar to those for other aneurysms. In a review of the clinical features of 217 patients with splenic artery aneurysms, hypertension was present in 50.2%, obesity in 27.6%, coronary artery disease in 23.5%, and hypercholesterolemia in 21.7%. Splenic artery aneurysms occur more frequently in women .”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “Spontaneous rupture of a splenic artery aneurysm is rare, especially for smaller (<2 cm) aneurysms, but may occur, usually with larger aneurysms. Additional risk factors associated with rupture include rapidly increasing size, occurrence in women of childbearing years, cirrhosis (especially associated with α1 antitrypsin deficiency), and symptoms that can be attributable to the aneurysm.”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “The surgical literature suggests a consensus that such an aneurysm should be considered for endovascular therapy when ≥2 cm. Smaller aneurysms probably can be safely followed, although the clinical risk factors for rupture should be carefully assessed. In one review of patients who were followed with small splenic artery aneurysms, the mean aneurysm growth rate was 0.06 cm/y, with the most rapid growth rate noted to be 1 cm over 63 months. In this group of patients, none of the aneurysms ruptured. Given these data, yearly surveillance for small splenic artery aneurysms is recommended, although for the smaller aneurysms among those ≥2 cm, surveillance intervals of >1 year may be reasonable, depending on comorbidities and life expectancy.”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “RAA is uncommon, occurring in about 0.09% of the population . Etiologies include fibromuscular dysplasia (FMD), atherosclerosis, and pseudoaneurysms that may occur after trauma. In a review of 168 patients with 252 RAAs, 34% had FMD, 25% had atherosclerosis, 6.5% had concurrent aneurysms of other vessels, and 73% had hypertension [22]. RAAs are usually detected incidentally at cross-sectional imaging, are small, are asymptomatic, and have uncertain clinical relevance. However, they may rupture, especially if they enlarge, and may be associated with renal arterial hypertension.”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “One approach that has been suggested is to repair all aneurysms ≥1 cm in patients with uncontrolled hypertension. An incidentally discovered RAA measuring 1.0 to 1.5 cm can be safely followed . In a series of 86 RAAs with a mean size of 1.3 cm, none ruptured after an average follow-up of 72 months. We recommend that a reasonable imaging follow-up interval in these asymptomatic individuals is every 1 to 2 years. Larger aneurysms, measuring >1.5 to 2.0 cm, should be considered for surgical or endovascular repair .”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “One approach that has been suggested is to repair all aneurysms ≥1 cm in patients with uncontrolled hypertension. An incidentally discovered RAA measuring 1.0 to 1.5 cm can be safely followed . In a series of 86 RAAs with a mean size of 1.3 cm, none ruptured after an average follow-up of 72 months. We recommend that a reasonable imaging follow-up interval in these asymptomatic individuals is every 1 to 2 years. Larger aneurysms, measuring >1.5 to 2.0 cm, should be considered for surgical or endovascular repair .”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “Outside of the splenic and renal circulations, visceral aneurysms can affect the celiac, hepatic, gastroduodenal, pancreaticoduodenal, gastric, or mesenteric arteries. After splenic and renal arterial aneurysms, the hepatic artery is the next most common location. When discovered incidentally, these aneurysms are typically caused by atherosclerosis and may be associated with aneurysmal disease elsewhere. They can also be mycotic, traumatic (including iatrogenic trauma for hepatic aneurysms after liver biopsy), or, less commonly, related to polyarteritis nodosa, FMD, or visceral inflammatory disease, such as pancreatitis.”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “Treatment is generally recommended for aneurysms >2 cm in diameter, possibly with a smaller threshold for nonatherosclerotic aneurysm. For hepatic aneurysms, Abbas et al  established that multiplicity and nonatherosclerotic origin were linked to increased rupture rate. Criteria for which it is safe to observe visceral arterial aneurysms have not been clearly established. In the study of Abbas et al, of 21 patients with a mean follow-up interval of 68.4 months and mean diameter of 2.3 cm, none required intervention during the follow-up period.”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “Ovarian veins originate from the plexus in the broad ligament near the ovary and fallopian tubes and communicate with the uterine plexus, then course anterior to the psoas muscle and the ureter. The right ovarian vein typically drains into the IVC and the left ovarian vein into the left renal vein. Autopsy studies have shown that valves are absent in the cranial portion of the ovarian vein in 15% of women on the left and 6% on the right . The valves are incompetent on either side in 35% to 43%, with a higher frequency in multiparous women, resulting in dilation >8 mm and incompetence in many asymptomatic patients who undergo CT.”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “Incompetence of the ovarian and draining pelvic veins and venous reflux are considered the main cause of pelvic congestion syndrome in women, symptoms of which include persistent dull pelvic pain lasting >6 months, dysmenorrhea, dyspareunia, postcoital ache, and urinary symptoms. However, dilated pelvic veins are often seen incidentally in asymptomatic multiparous women . If dilated pelvic veins are noted in a woman and are asymptomatic, no further imaging or intervention is recommended..”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “In a CT angiographic study of potential renal donors, dilated ovarian veins were found in 16 (47%) of 34 asymptomatic women . In another CT study of patients with severe ovarian vein reflux, but without PCS, both right and left parauterine veins were tortuous and dilated in all cases, with a mean vein diameter of 5.9 ± 1.6 mm (range, 4.3-8.0 mm). Pelvic varices, and early opacification and dilation of the gonadal veins, may occur without venous reflux, particularly if uterine fibroids or other pelvic abnormalities are present.”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “Gonadal vein thrombosis can be seen in up to 80% of asymptomatic women who undergo routine CT after hysterectomy and lymphadenectomy for neoplasm. When acute, the central thrombus typically demonstrates low attenuation and is associated with mural enhancement. The vessel chronically becomes fibrotic and contracted, and phleboliths may develop.”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • “Pancreaticoduodenal aneurysms are felt to be at higher risk for rupture, and all of these aneurysms should be considered for surgical or endovascular treatment.”

    Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings
    Khosa F et al
    J Am Coll Radiol. 2013 Oct;10(10):789-94
  • Who should get baseline serum creatinine levels before CT?
  • - Age > 60
    - History of renal disease, including:
        - Dialysis
        - Kidney transplant
        - Single kidney
        - Renal cancer
        - Renal surgery
    - History of hypertension requiring medical therapy
    - History of diabetes mellitus
    - Metformin or metformin-containing drug combinations
  • “The major preventive action against CIN is to ensure adequate hydration. The ideal infusion rate and volume is unknown, but isotonic fluids are preferred (Lactated Ringer’s or 0.9% normal saline). One possible protocol would be 0.9% saline at 100 mL/hr, beginning 6 to 12 hours before and continuing 4 to 12 hours after intravascular iodinated contrast medium administration. Oral hydration has also been utilized, but with less demonstrated effectiveness.”
    ACR Manual on Contrast Media
    Version 9 (2013)
  • Contrast Selection for CCTA of Coronary Artery Stents
     - is higher concentration of contrast better for stent opacification
    - what is optimal for stent evaluation?
    - is there a difference between iodixanol-320 and iomeprol-400?
  • Objective: We compared iomeprol-400 with iodixanol-320 to evaluate coronary stents with MDCT-CA
    Conclusions: Iodixanol-320 provides better image quality of coronary stents, allowing higher MDCT-CA evaluability, than iomeprol-400
    Coronary stent evaluation with coronary computed tomographic angiography: Comparison between low-osmolar, high iodine concentration iomeprol-400 and iso-osmolar, lower iodine concentration iodixanol-320
    Andreini D et al.
    J Cardiovasc Comput Tomogr 8(2014) 44-51
  • “ Diminished eGFR is associated with an increased risk of SCr-defined AKI following CT examinations. However, the risk of AKI is independent of contrast material exposure, even in patients with eGFR of less than 30 ml/min/1.73m2.”
    Risk of Intravenous Contrast-mediated Acute Kidney Injury: A Propensity Score-matched Study Stratified by Baseline-estimated Glomerular Filtration Rate
    McDonald JS et al.
    Radiology 2014;271:65-73
  • “ Contrast material induced nephropathy cannot be differentiated from contrast material dependent causes of AKI, in a predominately inpatient cohort, even in patients with severely compromised renal function.”
    Risk of Intravenous Contrast-mediated Acute Kidney Injury: A Propensity Score-matched Study Stratified by Baseline-estimated Glomerular Filtration Rate
    McDonald JS et al.
    Radiology 2014;271:65-73
  • “ In conclusion, our findings provide additional evidence that the administration of intravenous contrast material does not increase the risk of AKI, even in patients with substantially compromised renal function.”
    Risk of Intravenous Contrast-mediated Acute Kidney Injury: A Propensity Score-matched Study Stratified by Baseline-estimated Glomerular Filtration Rate
    McDonald JS et al.
    Radiology 2014;271:65-73
  • BACKGROUND: Previous clinical studies have shown that iso-osmolar iodixanol (Visipaque®) causes less patient discomfort than low-osmolar contrast media (LOCM) when administered via intra-arterial injection. No data are available comparing these agents for patient discomfort when administered intravenously (i.v.) using power injectors.
    PURPOSE:To compare the frequency and intensity of patient discomfort between iodixanol and iopamidol (Isovue®) administered i.v. using a power injector in contrast-enhanced computed tomography (CECT) of the abdomen and pelvis.
    MATERIAL AND METHODS:This was a prospective, randomized, double-blind, multicenter study of iodixanol 320-mg I/mL or iopamidol 370-mg I/mL on patient discomfort. The presence of discomfort (heat, pain, coldness) and intensity was verbally rated by patients on a 0-10 scale and converted into four categories (0, none; 1-3, mild; 4-7, moderate; 8-10, severe). Image quality was evaluated.
    Comparison of patient comfort between iodixanol and iopamidol in contrast-enhanced computed tomography of the abdomen and pelvis: a randomized trial.
    Weiland FL1, Marti-Bonmati L, Lim L, Becker HC.
    Acta Radiol. 2013 Sep 23. [Epub ahead of print]
  • BACKGROUND:Previous clinical studies have shown that iso-osmolar iodixanol (Visipaque®) causes less patient discomfort than low-osmolar contrast media (LOCM) when administered via intra-arterial injection. No data are available comparing these agents for patient discomfort when administered intravenously (i.v.) using power injectors.
    PURPOSE:To compare the frequency and intensity of patient discomfort between iodixanol and iopamidol (Isovue®) administered i.v. using a power injector in contrast-enhanced computed tomography (CECT) of the abdomen and pelvis.
    Comparison of patient comfort between iodixanol and iopamidol in contrast-enhanced computed tomography of the abdomen and pelvis: a randomized trial.
    Weiland FL1, Marti-Bonmati L, Lim L, Becker HC.
    Acta Radiol. 2013 Sep 23. [Epub ahead of print]
  • RESULTS:
    Of the 299 evaluable patients enrolled at nine centers, 151 received iodixanol and 148 received iopamidol. The average age was 58 years. Iodixanol patients experienced significantly less moderate/severe discomfort (35.1% vs. 67.3%; P-<-0.0001) or heat (29.8% vs. 63.9%; P-<-0.0001), and severe discomfort (2.6% vs. 16.3%; P-=-0.0004) or heat (2.6% vs. 15%; P-=-0.0008), but three times more no discomfort (21.2% vs. 7.5%; P-=-0.0008) than iopamidol patients. Excellent image quality was in 95.4% of iodixanol vs. 89.9% of iopamidol patients (P-=-0.0508). Overall, adverse event (AE) rate excluding patient discomfort was 19.9% in the iodixanol group and 14.9% in the iopamidol group (P-=-0.2870), but contrast-related AEs were comparable: 11.3% vs. 10.1% (P-=-0.8522). Delayed skin reactions occurred in 2.6% of patients in the iodixanol group and in no patient in the iopamidol group (P-=-0.1226).
    Comparison of patient comfort between iodixanol and iopamidol in contrast-enhanced computed tomography of the abdomen and pelvis: a randomized trial.
    Weiland FL1, Marti-Bonmati L, Lim L, Becker HC.
    Acta Radiol. 2013 Sep 23. [Epub ahead of print]
  • CONCLUSION:
    Patients receiving iodixanol had significantly lower moderate-to-severe or severe discomfort than patients receiving iopamidol, with heat being the major contributor. Iodixanol use trended towards better image quality but the difference was not statistically significant. No significant differences in incidences of overall or contrast-related AEs or delayed skin reactions were seen between the two groups. These data support that CM osmolality may be a key determinant of patient discomfort.
    Comparison of patient comfort between iodixanol and iopamidol in contrast-enhanced computed tomography of the abdomen and pelvis: a randomized trial.
    Weiland FL1, Marti-Bonmati L, Lim L, Becker HC.
    Acta Radiol. 2013 Sep 23. [Epub ahead of print]
  • “ The safety of iodixanol in routine clinical practice was shown to be similar to the published safety profiles of other non-ionic iodinated contrast agents. Patient discomfort during administration was mild or absent in most patients. Advances in knowledge: The major strength of this study is that it included 20-185 patients enrolled in various types of imaging examinations. The safety profile of iodixanol was comparable to previously published work.”
    Post-marketing surveillance study with iodixanol in 20,185 Chinese patients from routine clinical practices.
    Zhang BC1, Hou L, Lv B Xu YW.
    Br J Radiol. 2014 Feb;87(1034)
  • “ High rate intravenous administration of 80 ml of iopamidol and iodixanol during pulmonary CT angiography slightly increased HR; there was no difference in HR between the contrast agent groups.”
    Comparison of the Effect of Low- and Iso-Osmolar Contrast Agents on Heart Rate during Chest CT Angiography: Results of a Prospective Randomized Multicenter Study
    Chartrand-Lefebvre C et al
    Radiology 2011;258:930-937
  •  “The CT Contrast Protocols application for the iPad and iPhone is one of the first radiology applications in the Apple App Store to focus on radiology education and was designed to address the lack of practical information on contrast media for radiologists, technologists, nurses, and trainees.”
     CT Contrast Protocols Application for the iPad: New Resource for Technologists, Nurses, and Radiologists
    Raman SP, Raminpour S, Horton KM, Fishman EK
    RadioGraphics 2013; 33:913-921
  •  “The developers of the application thought that providing the user with specific questions and answers could be more practically useful on a day-to-day basis than a larger amount of text or information.”
     CT Contrast Protocols Application for the iPad: New Resource for Technologists, Nurses, and Radiologists
    Raman SP, Raminpour S, Horton KM, Fishman EK
    RadioGraphics 2013; 33:913-921
  •  “ We believe that this application, in addition to its educational value, is a clear illustration of the unlimited possibilities that exist in the mobile sphere, particularly on the iPad and iPhone, for radiology educational resource .”
     CT Contrast Protocols Application for the iPad: New Resource for Technologists, Nurses, and Radiologists
    Raman SP, Raminpour S, Horton KM, Fishman EK
    RadioGraphics 2013; 33:913-921
  • “ The three monomeric agents studied (iopamidol 300, iopromide 300, ioxehol 300) and the one dimeric agent (iodixanol 320) were equivalent in terms of lack of a significant effect on measured GFR when administered to patients with normal GFR.”
    Glomerular Filtration Rate in Evaluation of the Effect of Iodinated Contrast Media on Renal Function
    Becker J et al.
    AJR 2013; 200:822-826
  • “ Given the remaining uncertainties about the real incidence of contrast medium-induced nephropathy, how should we practice? It is our recommendation that we be more liberal in our policies in regard to contrast medium administration.”
    Quantitating Contrast Medium-induced Nephropathy: Controlling the Controls
    Newhouse JH, RoyChoudhury
    Radiology 2013; 267:4-8
  • Is it better to use a higher concentration contrast agent for cardiac CT?
  • “We administered 80-100 mL of contrast material [Group 1: Iomeprol, Iomeron 400 mgI/mL, Bracco (Iodine burden = 32-40 grI); Group 2: Iodixanol, Visipaque 320 mgI/mL, GE Healthcare (Iodine burden = 25.6-32 grI)] at an injection rate of 5-6 mL/s [depending on the quality of the venous access; Iodine Delivery Rate (IDR): Group 1 = 2.0-2.4 mgI/s and Group 2 = 1.6-1.92 mgI/s] with an automatic injector (Stellant, MedRad, Pittsburgh, PA, USA) attached to an 18- to 20-gauge needle cannula inserted in an antecubital vein.”
    Plaque imaging with CT angiography: Effect of intravascular attenuation on plaque type classification
    Maffei E et al.
    World J Radiol 2012 Jun 28;4(6):265-272
  • “High intra-vascular attenuation modified significantly the attenuation of non-calcified coronary plaques. As a result, the detection of fibrous vs lipid rich plaques was significantly affected. Image quality was not significantly affected by different settings (i.e., CT scanner and contrast medium used). S/N was significantly better in the Group using lower iodine concentration and with lower intra-vascular attenuation.”
    Plaque imaging with CT angiography: Effect of intravascular attenuation on plaque type classification
    Maffei E et al.
    World J Radiol 2012 Jun 28;4(6):265-272
  • “ Higher intra-vascular attenuation modifies significantly the attenuation of non-calcified coronary plaques. This results in a more difficult characterization between lipid rich vs fibrous type.”
    Plaque imaging with CT angiography: Effect of intravascular attenuation on plaque type classification
    Maffei E et al.
    World J Radiol 2012 Jun 28;4(6):265-272
  • OBJECTIVES:
    To compare vascular and parenchymal contrast enhancement in multidetector computed tomography of the liver using two contrast media with different iodine concentration (Iodixanol 320mgI/mL and Iomeprol 400mgI/mL) and similar viscosity, using fixed total iodine volume (40gI) and iodine delivery rate (1.6gI/s).
    CONCLUSIONS:
    Iodixanol 320 and Iomeprol 400 injected at the same iodine delivery rate (1.6gI/s) and total iodine load (40gI) did not provide statistically significant differences in liver parenchymal and vascular contrast enhancement.
    High concentration (400mgl/mL) versus low concentration (320 mgl/mL) iodinated contrast media in multi detector computed tomography of the liver: A randomized single center, non inferiority study
    Rengo M et al.
    Eur J Radiol 2012 June 8 (Epub ahead of print)
  • Omnipaque-350 vs. Visipaque-320

    - Both work very well for all CT Angiographic studies
    - Despite differences in iodine concentration the opacification of vessels which determine in great part the success of CT angiography are equivalent (Pannu HP, Fishman EK WIP)
  • "Most respondents (75%) perform CT angiography in pregnant patients suspected of having pulmonary embolism, but their policies and practices vary considerably."

    Pulmomary Embolism in Pregnant Patients: A Survey of Practices and Policies for CT Pulmonary Angiography
    Schuster ME et al.
    AJR 2003; 181:1495-1498
  • When is Visapaque always used?

    - Borderline renal function
    - Older patients especially if diabetic
    - Patients who already received one contrast injection in the preceding 24-36 hours
    - All patients premedicated due to prior contrast reaction
    - All pulmonary embolism studies
    - All coronary angiography studies
  • What about saline bolus chasing?

    - Improved use of contrast volume (contrast in IV line and periperal veins (10-15 cc)
    - Ideal in coronary angiography studies to wash dense contrast from the right side of the heart
    - Ideal in patients with borderline renal function to make better use of contrast
    - Decreased volume of contrast needed
  • "Using a saline flush after the contrast material bolus in abdominal CT allows an iodine dose reduction of approximately 6 g, or 17%, without impairing mean parenchymal and vascular enhancement and a cost reduction of $7.30 per patient."

    Abdominal Multidetector Row Computed Tomography: Reduction of Cost and Contrast Material Dose Using Saline Flush
    Schoellnast H et al. J Comput Assist Tomogr 2003;27:847-853
  • "Using 100 ml of contrast material and a saline chaser did not result in a meaningful difference in liver parenchyma attenuation or lesion conspicuity compared with using 150 ml of contrast medium alone.Routine use of a chaser for abdominal CT may yield cost savings and a decreased risk of contrast nephropathy."

    Using a Saline Chaser to Decrease Contrast Media in Abdominal CT
    Dorio PJ et al.
    AJR 2003; 180:929-934
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