An Initiative to Reduce Unnecessary Gadolinium-Based Contrast in Multiple Sclerosis Patients

Abstract

Objective: Patients with multiple sclerosis (MS) routinely undergo serial contrast-enhanced MRIs. Given concerns regarding tissue deposition of gadolinium-based contrast agents (GBCAs) and evidence that enhancement of lesions is only seen in patients with new disease activity on noncontrast imaging, we set out to implement a prospective quality improvement project whereby intravenous contrast would be reserved only for patients with evidence of new disease activity on noncontrast images.

Methods: To prospectively implement such a protocol, we leveraged our in-house computer-assisted detection (CAD) software and 3-D laboratory radiology technologists to perform real-time preliminary assessments of the CAD-processed T2 fluid attenuated inversion recovery (FLAIR) noncontrast images as a basis for deciding whether to inject contrast. Before implementation, we held multidisciplinary meetings with neurology, neuroradiology, and MR technologists and distributed surveys to objectively assess opinions and obstacles to clinical implementation. We evaluated reduction in GBCA utilization and technologist performance relative to final neuroradiologist interpretations.

Results: During a 2-month trial period, 153 patients were imaged under the new protocol. Technologists using the CAD software were able to identify patients with new or enlarging lesions on FLAIR images with 95% accuracy and 97% negative predictive value relative to final neuroradiologist interpretations, which allowed us to avoid the use of contrast and additional imaging sequences in 87% of patients.

Discussion: A multidisciplinary effort to implement a quality improvement project to limit contrast in MS patients receiving follow-up MRIs allowed for improved safety and cost by targeting patients that would benefit from the use of intravenous contrast in real-time.

Keywords: Brain MRI; IV contrast; gadolinium; multiple sclerosis; precision diagnostics; quality improvement.