When should an MRI be ordered with and without contrast (Magnetic Resonance Imaging)?

When to Order MRI With AND Without Contrast

Order MRI with and without contrast when you suspect infection, inflammation, neoplasm (primary or metastatic), or need to evaluate for enhancement patterns that distinguish pathology from normal tissue—the precontrast images are essential for comparison to confirm areas of abnormal enhancement. 1, 2

Core Principle: Why Both Sequences Matter

The precontrast MRI study is required for comparison to confirm areas of suspected abnormality and assess the presence, extent, or absence of contrast enhancement. 1 MRI performed with IV contrast only (without precontrast images) is not useful because you cannot determine what is truly enhancing without the baseline. 1

Primary Indications for MRI With AND Without Contrast

Suspected Neoplasm

• Brain tumors: Contrast enhancement is crucial for demonstrating leaky tumor vasculature and characterizing tumor extent 2
• Brain metastases screening: Contrast is essential for detecting small metastatic lesions 2
• Posttreatment tumor surveillance: Noncontrast MRI alone cannot distinguish residual/recurrent enhancing tumor from treatment effects 2
• Spinal cord and paraspinal masses: MRI is the primary modality for detection and evaluation, with contrast helping localize masses in relation to neural structures 1
• Soft tissue masses (musculoskeletal): Contrast is recommended for bone and soft tissue lesions to characterize tissue and assess vascularity 3

Suspected Infection

• Spine infection (epidural abscess, discitis-osteomyelitis): MRI without and with IV contrast has 96% sensitivity and 94% specificity, significantly outperforming noncontrast studies 1, 4
• Chronic or complex musculoskeletal infections: Contrast is reserved for these cases, not routine acute infections 3
• Pediatric back pain with red flags: If inflammation, infection, or malignancy is suspected (fever, elevated inflammatory markers, immunocompromised state), use contrast 1

Suspected Inflammation

• Inflammatory arthropathies: Well evaluated with contrast-enhanced MRI 1
• Optic neuritis: Both MRI of orbits and head without and with contrast are primary imaging studies 4
• Cavernous sinus thrombosis: Contrast-enhanced MRI through cavernous sinuses is the test of choice 4

Vascular Pathology

• Arterial thoracic outlet syndrome: MRA without and with IV contrast is usually appropriate 1
• Suspected underlying vascular malformation: After proven parenchymal hemorrhage, MRI head without and with contrast is rated highest (9/9) to evaluate for underlying enhancing mass or vascular malformation 4

Head and Neck Pathology

• Progressive facial asymmetry in children: MRI of head and orbits without and with IV contrast is most appropriate, providing optimal soft-tissue characterization and identifying intracranial/orbital pathology 5
• Sinonasal masses: MRI without and with contrast differentiates soft-tissue masses from postobstructive secretions and evaluates orbital, skull base, or intracranial extension 4

Posterior Fossa Evaluation

• Ataxia workup: Contrast is particularly important for detecting masses, inflammatory processes, or vascular lesions in the posterior fossa 2

When Noncontrast MRI Alone Is Sufficient

Structural/Mechanical Pathology

• Acute trauma: Noncontrast MRI adequately demonstrates bone marrow edema, fractures, and acute soft tissue injuries 1, 6
• Sports injuries: Contrast not recommended for routine evaluation 3
• Degenerative spine disease: Mechanical back pain without red flags 1
• Routine MRI neurography: Noncontrast is sufficient 3

Neurological Conditions

• New-onset seizures: Noncontrast imaging adequately identifies structural lesions and defines the epileptogenic zone 2
• Traumatic brain injury, stroke, dementia: Generally no need for contrast 7
• Multiple sclerosis follow-up: Usually noncontrast is adequate 7

Musculoskeletal

• Rotator cuff tears: MRI shoulder without IV contrast is usually appropriate 1
• Labral tears (acute): Posttraumatic joint effusion provides sufficient visualization without contrast 1
• Chronic ankle pain: MRI without contrast for most indications including osteochondral lesions, tendon abnormalities, impingement 1

Clinical Decision Algorithm

1. Identify the clinical question: Is this trauma/mechanical, or is there concern for infection/inflammation/tumor?

2. Check for red flags suggesting need for contrast:

   • Fever, elevated inflammatory markers, immunocompromised state (infection) 1
   • Known malignancy or high suspicion for metastases 2
   • Progressive neurological deficits unexplained by structural findings 1
   • Postoperative complications or hardware concerns 1
   • Need to evaluate disease extension into adjacent structures 5, 4

3. Assess renal function: GBCAs increase risk for nephrogenic systemic fibrosis (NSF) in patients with GFR <30 mL/min/1.73m² or acute kidney injury—avoid unless diagnostic information is essential and unavailable with noncontrast MRI 8

4. Consider if both sequences are truly needed: If ordering contrast, always include precontrast images for comparison 1

Common Pitfalls to Avoid

• Ordering contrast-only MRI: This is not useful because you cannot assess enhancement without baseline precontrast images 1
• Liberal contrast use without clear indication: Given NSF risk and gadolinium retention in brain/bone/organs, use contrast judiciously only when it provides demonstrable added value 8, 3
• Assuming contrast always improves diagnostic yield: In traumatic spinal cord injuries, noncontrast MRI has comparable efficacy to contrast-enhanced MRI for major injuries (hematoma, edema); contrast only adds value for soft tissue injury detection 6
• Missing renal screening: For patients at risk for reduced renal function (age >60, hypertension, diabetes), estimate GFR through laboratory testing before contrast administration 8

Special Populations

Pediatric patients: The same principles apply—use contrast for suspected infection, inflammation, or neoplasm 1, 5. In pediatric back pain with positive radiographs, contrast is useful if there is concern for inflammation, infection, or neoplasm 1

Pregnancy: Use gadolinium only if imaging is essential during pregnancy and cannot be delayed 8