When should MRI be performed without contrast (gadolinium-based contrast agents)?

From the Guidelines

MRI without contrast should be performed when the diagnostic goal can be achieved without gadolinium-based contrast agents or when contrast is contraindicated, such as in patients with severe renal impairment, pregnant women, children under 2 years old, and patients with known allergies to gadolinium-based contrast agents. The decision to use contrast should always balance diagnostic benefit against potential risks, with non-contrast MRI being the default when sufficient diagnostic information can be obtained without contrast enhancement 1. This approach minimizes unnecessary exposure to contrast agents while still providing valuable diagnostic information through T1, T2, FLAIR, diffusion-weighted, and other specialized non-contrast sequences. Some specific situations where non-contrast MRI is appropriate include:

• Musculoskeletal imaging (joint injuries, ligament tears)
• Brain imaging for stroke, multiple sclerosis follow-up, hydrocephalus assessment, and screening for certain conditions like pituitary microadenomas
• Patients requiring repeated MRI scans for monitoring chronic conditions should avoid frequent contrast administration to prevent potential gadolinium deposition in brain tissue 1. It's also important to consider the risk of nephrogenic systemic fibrosis (NSF) associated with gadolinium-based contrast agents in patients with renal failure, and to weigh the benefits and risks of contrast administration in these cases 1. In general, the use of non-contrast MRI can provide valuable diagnostic information while minimizing the risks associated with contrast agents, and should be considered as a default option when possible 1.

From the Research

MRI without Contrast: Indications and Considerations

• MRI without contrast (gadolinium-based contrast agents) is recommended in certain situations to minimize the risk of adverse effects, particularly in patients with renal impairment 2, 3.
• Patients with advanced renal failure, characterized by an estimated glomerular filtration rate below 30 ml/min/1.73 m2, should avoid gadolinium-based MR contrast agents unless the diagnostic information is essential and not available with noncontrast magnetic resonance imaging techniques 2.
• The use of gadolinium-based contrast agents in patients with chronic kidney disease or acute kidney injury should be carefully weighed, considering the benefits of MRI and the risk of nephrogenic systemic fibrosis 3.
• In patients with normal renal function, gadolinium-based contrast agents have been considered safe when used at clinically recommended doses, but recent evidence suggests that gadolinium might deposit in the brain, even in patients with intact blood-brain barriers 4.
• Alternative contrast agents, such as gadodiamide, can be used in interventional uroradiologic procedures when iodinated contrast material is contraindicated, including in patients with severe allergic reactions to iodinated contrast or marked renal insufficiency 5.

Special Considerations

• The risk of nephrogenic systemic fibrosis depends on the degree of renal dysfunction, dose of contrast agent, gadolinium contrast agent stability, and severity of concomitant illness 3.
• Changes in practice patterns, including the use of more stable contrast agents and careful screening of patients with renal disease, have largely eliminated nephrogenic systemic fibrosis since 2009 4, 6.
• New emerging safety concerns, such as the potential for gadolinium deposition in the brain, may further impact the use of gadolinium-based contrast agents and practice patterns in the future 4, 6.