Efficacy, Education, Administration, InformaticsE2561. The New Age of Danger in Medical Imaging? A Review of Recent Literature
Swintelski C1, Priamo F1, Concepcion J2, Silberzweig J.1 1. Mount Sinai Beth Israel, New York, NY; 2. Maimonides Medical Center, Brooklyn, NY
Address correspondence to F. Priamo (firstname.lastname@example.org)
Background Information: Recent publications have raised doubts regarding the safety of medical imaging. Specifically, new research and findings have increased concerns regarding the effects of intravenous contrast on radiation burden, the deposition of gadolinium-based contrast agents (GBCA) in the CNS, the use of contrast in pregnancy, and the safety of CT in patients with implanted electronic medical devices. While there are known and well-described risks to medical imaging such as nephrogenic systemic fibrosis and the carcinogenic effects of radiation, the question this exhibit poses is, are we entering a new age of danger in medical imaging?
Educational Goals/Teaching Points: The goals of this exhibit are to discuss the methods, findings, and conclusions of recent studies and reports describing possible risks of medical imaging that have heretofore been unknown or unclear; to discuss previous evidence that may support or contradict these new findings; and to suggest interventions to help reduce the risks of medical imaging in light of these new findings if intervention is needed.
Key Anatomic/Physiologic Issues and Imaging Findings/Techniques: A 2015 study by McDonald et al.  found the concentration of elemental gadolinium in select neural tissue increases in a dose-dependent fashion in patients who have received GBCA despite normal renal function. McDonald et al.’s study could not differentiate between chelated and nonchelated forms of gadolinium given technologic limitations. Furthermore, the study does not indicate what the clinical significance of these findings are. In 2016, Ray et al.  found the use of GBCA at any time during pregnancy was associated with greater morbidity and mortality in exposed fetuses and newborns. Ray’s study lacked data on exposures to other teratogens that may have confounded results. Furthermore, no data was available regarding the types of GBCA used, a factor that may influence the toxicity and chemical stability of GBCA. In 2015, Piechowiak et al.  found evidence of significantly increased DNA damage in patients who had received iodinated contrast material for CT over individuals who had undergone unenhanced examinations. The study did not measure DNA damage in solid organs. Furthermore, bias related to underlying disease was a recognized limitation of the study. In 2016, the U.S. Food and Drug Administration (FDA) updated guidance on potential electronic interference in implanted electronic medical devices by CT radiation, stating the function and operation of medical devices may be affected when directly irradiated. The FDA qualifies that the probability of a significant adverse event secondary to interference is low and is further decreased when dose is reduced. All of the above stated risks may be mitigated or avoided by using the as low as reasonably achievable principle.
Conclusion: Taking into account recent reports and findings that raise questions regarding the safety of medical imaging, it is important to remember there are already many questions that have yet to be answered. However, with a cautious and deliberate approach to prescribing and adapting protocol for medical imaging, many of these risks can still be reduced or avoided. References 1. McDonald RJ, McDonald JS, Kallmes DF, et al. Intracranial gadolinium deposition after contrast-enhanced MR imaging. Radiology 2015; 275:772–782 2. Ray JG, Vermeulen MJ, Bharatha A, Montanera WJ, Park AL. Association between MRI exposure during pregnancy and fetal and childhood outcomes. JAMA 2016; 316:952–961 3. Piechowiak EI, Peter JF, Kleb B, Klose KJ, Heverhagen JT. Intravenous iodinated contrast agents amplify DNA radiation damage at CT. Radiology 2015; 275:692–697