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Olatunji R, Lim TR, Jones B, Tafur M, Mathur S, Lin AW, Bharatha A, Suthiphosuwan S. Delayed Gadolinium Leakage in Ocular Structures on Brain MR Imaging: Prevalence and Associated Factors. AJNR Am J Neuroradiol 2023; 45:90-95. [PMID: 38123939 PMCID: PMC10756574 DOI: 10.3174/ajnr.a8073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 10/25/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND AND PURPOSE Gadolinium leakage in ocular structures (GLOS) is characterized by hyperintense signal in the chambers of the eye on FLAIR and has been reported in association with blood-ocular barrier breakdown in patients with ischemic strokes. The underlying mechanism of GLOS remains poorly understood; however, some studies suggest it may be part of a physiologic excretion pathway of gadolinium. This study aimed to determine the prevalence of GLOS in an unselected patient population. MATERIALS AND METHODS A retrospective analysis was conducted on 439 patients who underwent brain MR imaging within 7 days of receiving a gadolinium-based contrast agent injection for a prior MR imaging study. Clinical, imaging, and laboratory data were collected. Descriptive and logistic regression analyses were performed. RESULTS GLOS was observed in 26 of 439 patients (6%). The occurrence of GLOS varied with time, with 3 (12%), 14 (54%), 8 (31%), and 1 (4%) patient showing GLOS within 24, 25-72, 73-120, and >120 hours after gadolinium-based contrast agent injection, respectively. Patients with GLOS were older (median age: 72 versus 55 years, P = .001) and had higher median serum creatinine levels (73 versus 64 µmol/L, P = .005) and a lower median estimated glomerular filtration rate (84 versus 101 mL/min/1.73 m2, P < .001). A shorter median time interval between gadolinium-based contrast agent injection and the index brain MR imaging was observed in the group positive for GLOS (62 versus 91 hours, P = .003). Multivariable regression analysis identified the estimated glomerular filtration rate (OR = 0.970; 95% CI, 0.049-0.992; P = .008) and time interval since gadolinium-based contrast agent injection (OR = 0.987; 95% CI, 0.977-0.997; P = .012) as independent factors associated with GLOS. CONCLUSIONS GLOS was observed in only a small percentage of patients receiving gadolinium-based contrast agent within 7 days before brain MR imaging. This phenomenon was noted in patients with normal findings on brain MR imaging and those with various CNS pathologies, and it was associated with lower estimated glomerular filtration rates and shorter time intervals after gadolinium-based contrast agent injection. While GLOS may be a physiologic gadolinium-based contrast agent excretion pathway, the presence of ocular disease was not formally evaluated in the included population. Awareness of GLOS is nonetheless useful for appropriate radiologic interpretation.
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Affiliation(s)
- Richard Olatunji
- From the Division of Diagnostic Neuroradiology (R.O., T.R.L., S.M., A.W.L., A.B., S.S.), Department of Medical Imaging, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
- Department of Radiology (R.O.), University College Hospital, University of Ibadan, Ibadan, Nigeria
| | - Timothy Reynold Lim
- From the Division of Diagnostic Neuroradiology (R.O., T.R.L., S.M., A.W.L., A.B., S.S.), Department of Medical Imaging, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Blair Jones
- Department of Data Science (B.J.), St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Monica Tafur
- Division of Abdominal and Breast Imaging (M.T.), Department of Medical Imaging, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Shobhit Mathur
- From the Division of Diagnostic Neuroradiology (R.O., T.R.L., S.M., A.W.L., A.B., S.S.), Department of Medical Imaging, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
- Medical Imaging Office of Research & Innovation (S.M.), Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
| | - Amy W Lin
- From the Division of Diagnostic Neuroradiology (R.O., T.R.L., S.M., A.W.L., A.B., S.S.), Department of Medical Imaging, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Aditya Bharatha
- From the Division of Diagnostic Neuroradiology (R.O., T.R.L., S.M., A.W.L., A.B., S.S.), Department of Medical Imaging, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Suradech Suthiphosuwan
- From the Division of Diagnostic Neuroradiology (R.O., T.R.L., S.M., A.W.L., A.B., S.S.), Department of Medical Imaging, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
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Ahn SJ, Taoka T, Moon WJ, Naganawa S. Contrast-Enhanced Fluid-Attenuated Inversion Recovery in Neuroimaging: A Narrative Review on Clinical Applications and Technical Advances. J Magn Reson Imaging 2022; 56:341-353. [PMID: 35170148 DOI: 10.1002/jmri.28117] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 02/01/2022] [Accepted: 02/03/2022] [Indexed: 12/15/2022] Open
Abstract
While contrast-enhanced fluid-attenuated inversion recovery (FLAIR) has long been regarded as an adjunct sequence to evaluate leptomeningeal disease in addition to contrast-enhanced T1-weighted imaging, it is gradually being used for more diverse pathologies beyond leptomeningeal disease. Contrast-enhanced FLAIR is known to be highly sensitive to low concentrations of gadolinium within the fluid. Accordingly, recent research has suggested the potential utility of contrast-enhanced FLAIR in various kinds of disease, such as Meniere's disease, seizure, stroke, traumatic brain injury, and brain metastasis, in addition to being used for visualizing glymphatic dysfunction. However, its potential applications have been reported sporadically in an unorganized manner. Furthermore, the exact mechanism for its superior sensitivity to low concentrations of gadolinium has not been fully understood. Rapidly developing magnetic resonance technology and unoptimized parameters for FLAIR may challenge its accurate application in clinical practice. This review provides the fundamental mechanism of contrast-enhanced FLAIR, systematically describes its current and potential clinical application, and elaborates on technical considerations for its optimization. LEVEL OF EVIDENCE: 3 TECHNICAL EFFICACY STAGE: 5.
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Affiliation(s)
- Sung Jun Ahn
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Toshiaki Taoka
- Department of Innovative Biomedical Visualization (iBMV), Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Won-Jin Moon
- Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, South Korea
| | - Shinji Naganawa
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Galmiche C, Moal B, Marnat G, Sagnier S, Schweitzer C, Dousset V, Sibon I, Tourdias T. Delayed Gadolinium Leakage in Ocular Structures: A Potential Marker for Age- and Vascular Risk Factor-Related Small Vessel Disease? Invest Radiol 2021; 56:425-432. [PMID: 33481460 DOI: 10.1097/rli.0000000000000757] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Gadolinium leakage in ocular structures (GLOS) was recently observed in fluid-attenuated inversion recovery (FLAIR) images obtained the day after an initial gadolinium injection in stroke patients. The specificity of GLOS to stroke and its mechanisms remain unclear. OBJECTIVE We investigated the factors associated with GLOS in a cohort of patients presenting with acute neurological deficits. MATERIALS AND METHODS This retrospective study included consecutive patients admitted to our stroke unit for acute neurological deficit between July 2017 and August 2018 who underwent baseline brain magnetic resonance imaging with the injection of a macrocyclic gadolinium agent and another scan without injection within 72 hours. The patients were separated into a stroke group and a stroke mimic group based on diffusion-weighted images. Gadolinium leakage in ocular structures was defined as a bright signal in the vitreous in follow-up FLAIR compared with baseline FLAIR (pregadolinium). Clinical data were collected together with imaging features from the baseline scans, including the volume of the infarct and of hypoperfusion if applicable, white matter hyperintensities, the number of lacunes, and the number of microbleeds, which were combined to yield a small vessel disease (SVD) score. We compared the prevalence of GLOS in both groups using the χ2 test. In the entire cohort, univariate and multivariate regression models were used to test the associations between GLOS and the collected data. RESULTS Among the 467 patients included in the study, GLOS was observed in similar proportions in the stroke group (32.2%, 136/422) and the stroke mimic group (28.9%, 13/45; mean difference, 3.3%; 95% confidence interval, -10.9 to 17.6; P = 0.65). In univariate analysis, GLOS was associated with older age, increased prevalence of vascular risk factors, brain imaging features of SVD (white matter hyperintensities, lacunes, microbleeds), as well as with impairment of renal function and increased dose of gadolinium. No associations were found with factors related to stroke, such as its volume, acute treatment, or rate of recanalization. Multivariate analyses showed that aging (P < 0.001), diabetes (P = 0.010), severe renal failure (P = 0.004), and increased dose of gadolinium (P < 0.001) were independent contributors to GLOS. CONCLUSIONS Gadolinium leakage in ocular structures, which occurs more commonly at higher concentrations of gadolinium, is not specific to stroke and may represent increased permeability of the blood-retinal barrier associated with age- and vascular risk factor-related SVD.
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Affiliation(s)
- Chloé Galmiche
- From the Service de Neuroimagerie Diagnostique et Thérapeutique
| | - Bertrand Moal
- Pôle de Santé Publique, Unité de Soutien Méthodologique à la Recherche Clinique et Epidémiologique
| | - Gaultier Marnat
- From the Service de Neuroimagerie Diagnostique et Thérapeutique
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Gao Y, Wu D, Zhang X. Letter by Gao et al Regarding Article, "Gadolinium Leakage in Ocular Structures Is Common in Lacunar Infarction". Stroke 2019; 50:e114. [PMID: 30869566 DOI: 10.1161/strokeaha.118.024538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Yuan Gao
- Department of Ophthalmology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Di Wu
- Department of Neurology and China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xuxiang Zhang
- Department of Ophthalmology, Xuanwu Hospital, Capital Medical University, Beijing, China
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Hitomi E, Simpkins AN, Luby M, Latour LL, Leigh RJ, Leigh R. Blood-ocular barrier disruption in patients with acute stroke. Neurology 2018; 90:e915-e923. [PMID: 29438039 DOI: 10.1212/wnl.0000000000005123] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 11/13/2017] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE Prompted by the unexpected finding of gadolinium leakage into ocular structures (GLOS) in acute stroke patients, we studied the frequency and nature of this finding in 167 patients. METHODS Patients were selected who had an MRI with gadolinium at baseline and another MRI with fluid-attenuated inversion recovery (FLAIR) imaging at 2 and/or 24 hours later. GLOS was detected as lack of vitreous and/or aqueous fluid suppression on postcontrast FLAIR images. RESULTS GLOS, evident on postcontrast FLAIR MRI, occurred in 127/167 (76%) patients: 86/109 (79%) patients treated with tissue plasminogen activator and 41/58 (71%) who were untreated. At 2 hours after administration of the contrast, GLOS was more common in the aqueous chamber alone, occurring in 67% of patients, compared to the vitreous chamber alone, seen in 6% of patients; it occurred in both chambers in 27% of patients. At 24 hours, GLOS was present in 121/162 (75%) patients, always involving the vitreous chamber, but also affecting the aqueous chamber in 6% of cases. Vitreous GLOS at 24 hours was associated with increasing age (p = 0.002) and a higher burden of cerebral white matter hyperintensities (p = 0.017). Patients with rapid diffuse GLOS, defined as GLOS involving both chambers at 2 hours, had larger infarcts (p = 0.022) and a higher degree of blood-brain barrier permeability (p = 0.025). CONCLUSIONS We found GLOS to be common in patients with acute stroke; delayed GLOS was a marker for chronic vascular disease. The mechanism for acute GLOS remains uncertain but may be a remote effect of acute cerebral injury on the blood-ocular barrier.
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Affiliation(s)
- Emi Hitomi
- From the National Institute of Neurological Disorders and Stroke (E.H., A.N.S., M.L., L.L.L., R.L.), NIH, Bethesda, MD; and Department of Neurology (R.J.L.), Case Western Reserve University, Cleveland, OH
| | - Alexis N Simpkins
- From the National Institute of Neurological Disorders and Stroke (E.H., A.N.S., M.L., L.L.L., R.L.), NIH, Bethesda, MD; and Department of Neurology (R.J.L.), Case Western Reserve University, Cleveland, OH
| | - Marie Luby
- From the National Institute of Neurological Disorders and Stroke (E.H., A.N.S., M.L., L.L.L., R.L.), NIH, Bethesda, MD; and Department of Neurology (R.J.L.), Case Western Reserve University, Cleveland, OH
| | - Lawrence L Latour
- From the National Institute of Neurological Disorders and Stroke (E.H., A.N.S., M.L., L.L.L., R.L.), NIH, Bethesda, MD; and Department of Neurology (R.J.L.), Case Western Reserve University, Cleveland, OH
| | - R John Leigh
- From the National Institute of Neurological Disorders and Stroke (E.H., A.N.S., M.L., L.L.L., R.L.), NIH, Bethesda, MD; and Department of Neurology (R.J.L.), Case Western Reserve University, Cleveland, OH
| | - Richard Leigh
- From the National Institute of Neurological Disorders and Stroke (E.H., A.N.S., M.L., L.L.L., R.L.), NIH, Bethesda, MD; and Department of Neurology (R.J.L.), Case Western Reserve University, Cleveland, OH.
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