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Gadolinium-based contrast agents (GBCAs) are used in up to 35% of magnetic resonance imaging (MRI) examinations and are associated with an excellent safety profile. Nevertheless, two main issues have arisen in the last two decades: the risk of nephrogenic systemic fibrosis and the risk of gadolinium deposition and retention. As a first step, this article reviews the different categories of GBCAs available in neuroradiology, their issues, and provides updates regarding the use of these agents in routine daily practice. Recent advances in MRI technology, as well as the development of new MRI sequences, have made GBCA injection avoidable in many indications, especially in patients with chronic diseases when iterative MRIs are required and when essential diagnostic information can be obtained without contrast enhancement. These recent advances also lead to changes in recommended MRI protocols. Thus, in a second step, this review focuses on consensus concerning brain MRI protocols in 10 common situations (acute ischemic stroke, intracerebral hemorrhage, cerebral venous thrombosis, multiple sclerosis, chronic headache, intracranial infection, intra- and extra-axial brain tumors, vestibular schwannoma and pituitary adenoma). The latter allowing the standardization of practices in neuroradiology. Recommendations were also made concerning the use of GBCAs in neuroradiology, based on evidence in the literature and/or by consensus between the different coauthors., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Background: Diagnosing drug reaction with eosinophilia and systemic symptoms (DRESS) is challenging. Some clinicians reject this diagnosis when the delay of onset is less than 15 days after drug intake., Objectives: To assess the delay of DRESS occurrence and culprit drugs., Methods: All patients hospitalized in 3 dermatology departments with a first occurrence of DRESS for which a drug was highly suspected were included in this retrospective study. Based on the delay in DRESS occurrence, cases were classified into 2 groups: a rapid-onset group (≤15 days after exposure) and a delayed-onset group (>15 days)., Results: A total of 41 patients with DRESS were included: 14 in the rapid-onset and 27 in delayed-onset groups. In the rapid-onset group, antibiotics (n = 6/14) and iodinated contrast media (n = 5/5) were the predominant culprits. Carbamazepine (n = 4/4), lamotrigine (n = 6/6), allopurinol (n = 8/8), and sulfasalazine (n = 2/2) were exclusively found in the delayed-onset group., Limitations: The retrospective nature, limited number of participants, and lack of detailed information on previous exposure to sensitizing drugs in some instances., Conclusions: DRESS is frequently related to drugs introduced 15 or fewer days before the occurrence of cutaneous adverse reactions. The time of onset of DRESS may differ depending on the medications involved., (Copyright © 2019 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Contrast-induced nephropathy (CIN) severely impacts patient morbidity and mortality, especially in patients with ST-segment elevation myocardial infarction treated by primary coronary angioplasty, whose renal function is often unknown at the time of contrast exposure., Aim: We sought the incidence and factors predictive of CIN in patients treated by primary coronary angioplasty in our hospital; we also questioned the relevance of Mehran's risk score in this population., Methods: We considered all patients admitted for primary coronary angioplasty between January 2010 and December 2011, and included 322 patients with complete data on renal function. CIN was defined as a relative (≥25%) or absolute (≥44 μmol/L) increase in serum creatinine following contrast medium administration. We compared patients with or without CIN, to identify predictive factors, and investigated the effectiveness of Mehran's score using a receiver operating characteristic (ROC) curve, Youden's index and a likelihood ratio test., Results: The incidence of CIN was 9.1%. A multivariable analysis identified two independent risk factors for CIN: impaired glomerular filtration rate and cardiogenic shock at admission (P<0.05). An elevated Mehran's score was associated with increased incidence of CIN, but statistical analysis revealed this score to have poor sensitivity, especially in high-risk patients. Youden's index was very low and the area under the ROC curve was 0.59 in our population., Conclusion: Renal failure and cardiogenic shock at admission were independent predictors of CIN in our acute myocardial infarction population. Mehran's score added little to the discrimination of patients undergoing primary coronary angioplasty, particularly high-risk individuals., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Background: Nephrogenic systemic fibrosis (NSF) has been related to the use of gadolinium-based contrast agents (GBCAs) in patients undergoing dialysis. The Prospective Fibrose Nephrogénique Systémique study, a French prospective study supported by the French drug regulatory agency (Agence Nationale de Sécurité du Médicament) and the French Societies of Nephrology, Dermatology, and Radiology, aimed at determining the incidence of NSF in patients undergoing long-term dialysis., Materials and Methods: Adult patients undergoing long-term dialysis receiving a magnetic resonance imaging (MRI) examination prescribed between January 15, 2009 and May 31, 2011, with or without GBCA were included. The methodology was based on a patient form intended to detect any dermatological event (DE) that may occur within 4 months after the examination. Further investigations were planned with their physicians if a DE was reported., Results: A total of 571 patients were included. A total of 50.3% received GBCA. Among them, 93.4% received a macrocyclic GBCA, usually gadoteric acid (88.9%). All in all, 22 patients (3.9%) reported a DE. Dermatological diagnoses did not reveal any evidence of NSF., Conclusions: The incidence of NSF after a single dose of a macrocyclic GBCA is null in our sample of 268 patients undergoing dialysis (hemodialysis and peritoneal dialysis). This incidence is just lower than 0.5%. When contrast-enhanced MRI can be essential, or even decisive, to the diagnosis, these results are important and reassuring if physicians need to perform contrast-enhanced MRI in patients undergoing dialysis.

Objectives: This study sought to assess whether the volume of contrast media (CM) influences the occurrence of acute kidney injury (AKI) following transcatheter aortic valve implantation (TAVI)., Background: The volume of CM has been shown to be associated with increasing risk of AKI; however, in a high-risk elderly TAVI population, the predictive value and optimal threshold of CM dose on AKI remain uncertain., Methods: Data of 415 consecutive transfemoral TAVI patients (age 83.6 ± 6.8 years, logistic EuroSCORE 23.0 ± 12.2%) were analyzed. AKI was defined by Valve Academic Research Consortium criteria. Based on a previous formula, the ratio of CM to serum creatinine (SCr) and body weight (BW) (CM × SCr/BW) was calculated as defining the degree of CM use. The association between CM dose and incidence of AKI, as well as predictive factors and prognosis of AKI, were investigated., Results: AKI occurred in 63 patients (15.2%). Cumulative 1-year mortality showed significant differences between the AKI and non-AKI groups (47.9% vs. 15.7%, p < 0.001). Mean CM × SCr/BW ratio was higher in the AKI group than in the non-AKI group (4.1 ± 2.9 vs. 2.9 ± 1.6, p < 0.001). By multivariate analysis, CM × SCr/BW per 1.0 increase, ejection fraction <40%, and transfusion were associated with the occurrence of AKI (odds ratio [OR]: 1.16; 95% confidence interval [CI]: 1.03 to 1.20; p = 0.017, OR: 3.01; 95% CI: 1.49 to 5.00; p = 0.001, OR: 2.73; 95% CI: 1.54 to 6.15; p = 0.001, respectively). A threshold value of CM × SCr/BW for predicting AKI was statistically identified as 2.7., Conclusions: Although mechanisms of AKI following TAVI are multifactorial, the present study identified a relationship between CM dose increment and high prevalence of AKI. Therapeutic efforts not to exceed the threshold value may reduce the risk of AKI., (Copyright © 2013 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: To assess whether the use of iodinated contrast medium increases the incidence of acute kidney injury in ICU patients, compared with patients not receiving iodinated contrast medium., Design: Prospective observational matched cohort study., Setting: Two ICUs in two tertiary teaching hospitals., Patients: A total of 380 adults were included (20% more than once), before an iodinated contrast medium infusion (contrast inclusions, n=307) or before an intrahospital transfer without iodinated contrast medium infusion (control inclusions, n=170)., Interventions: None., Measurements and Main Results: Among contrast inclusions, iodinated contrast medium-associated acute kidney injury occurred after 23 administrations (7.5%) according to the Acute Kidney Injury Network definition (stage≥1, over 48 hr). As expected, a broader definition (≥25% increase in serum creatinine over 72 hr) yielded a greater incidence (16%). In 146 pairs of contrast and control inclusions, matched on propensity for iodinated contrast medium infusion, the incidence of acute kidney injury was similar (absolute difference in incidence, 0%; 95% confidence interval, -5.2; 5.2%), Acute Kidney Injury Network definition). Hospital mortality was also similar in 71 contrast and 71 control patients included only once and matched the same way. Contrary to iodinated contrast medium infusion (odds ratio, 1.57; 95% confidence interval, 0.69-3.53), the Sequential Organ Failure Assessment score at inclusion (odds ratio, 1.18; 95% confidence interval, 1.07-1.31) and the number of other nephrotoxic agents (odds ratio, 1.38; 95% confidence interval, 1.03-1.85) were independent risk factors for acute kidney injury., Conclusions: The specific toxic effect of monomeric nonionic low-osmolar iodinated contrast medium in ICU patients with multiple renal aggressions seemed minimal. Severity of disease and the global nephrotoxic burden were risk factors for acute kidney injury, regardless of iodinated contrast medium infusion.

Purpose: Data on contrast-induced acute kidney injury (CI-AKI) in intensive care unit (ICU) are scarce and controversial. The objectives of the study were to evaluate the incidence and characteristics of CI-AKI in a surgical ICU., Materials and Methods: We conducted a 13-month prospective observational study. Three definitions were compared to characterize CI-AKI: Barrett and Parfrey criteria; Risk of renal dysfunction, Injury to the kidney, Failure of kidney function, Loss of kidney function and End stage renal disease (RIFLE) classification; and Acute Kidney Injury Network (AKIN) criteria. Patients hospitalized in surgical ICU who had received an injection of contrast medium, who were not on renal replacement therapy, who had stable serum creatinine before injection, and no other etiology for new acute kidney injury were included., Results: One hundred one patients were included. The frequency of CI-AKI was 17%, 19%, and 19% according to Barrett and Parfrey criteria; RIFLE classification; and AKIN criteria, respectively. Diabetes mellitus, creatinine clearance less than 60 mL/min, and concomitant aminoglycoside administration were associated with CI-AKI. Statistically significant associations were found between CI-AKI and renal replacement therapy with all 3 definitions and between CI-AKI and mortality when AKIN criteria were used., Conclusions: These results show that CI-AKI is not inconsequential in critically ill patients. In the present study, AKIN criteria appear to be most relevant to define CI-AKI. Further studies are required to explore CI-AKI prevention in ICU., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Introduction: Contrast-induced nephropathy (CIN) has been extensively studied in the ward but only scarcely in intensive care unit (ICU) patients, even if they may be particularly prone to develop or to worsen acute kidney insufficiency. We aimed to measure the incidence of CIN in a large ICU population using the Acute Kidney Injury Network (AKIN) definition and to investigate its impact on patients' outcome., Methods: In this 3-year retrospective study, we included all patients undergoing, during their stay in our medical ICU, a contrast media-enhanced computed tomographic scan. Change in serum creatinine between baseline (24 hours before to 12 hours after contrast media injection) and its maximum value over the 96 hours after contrast media injection was recorded. Contrast-induced nephropathy was defined as a 44.2-μmol/L absolute or a 25% relative minimal increase in serum creatinine over 48, 72, or 96 hours and according to the stage 1 of the AKIN classification (at least 26.4 μmol/L or 50% increase over 48 hours)., Results: A total of 398 contrast-enhanced computed tomographic scans performed among 299 patients were analyzed. Incidence of CIN was 14% according to the AKIN definition and ranged from 8% (48-hour absolute definition) to 23% (96-hour relative definition). The need for renal replacement therapy and ICU mortality were significantly higher in case of CIN. After adjusting for other variables associated with ICU mortality, the occurrence of at least 1 CIN episode during the ICU stay (AKIN criteria) was independently associated with ICU mortality (odds ratio, 3.85; 95% confidence interval, 1.85-8.00)., Conclusions: Even if incidence varied greatly depending on the definition, CIN appeared frequent in our critically ill patients. The AKIN definition, independently associated with ICU mortality, may allow unifying diagnostic criteria to further evaluate this condition that impacts morbidity and mortality., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Gadolinium (Gd) is used in contrast agents as it enhances magnetic resonance imaging (MRI) signals. To reduce Gd toxicity, it is chelated into linear or macrocyclic complexes. Eight Gd-containing contrast agents have been approved by the European Medicines Agency (EMEA) for use in MRI, and six by the US Food and Drug Administration. Stability depends upon its physicochemical properties. When renal function is normal, the Gd is quickly cleared from the body by the kidneys. For patients with chronic kidney disease, the elimination is greatly reduced and Gd may be released from its chelate and deposit in body tissues, leading to nephrogenic systemic fibrosis (NSF). More than 200 cases of NSF have been reported in the world. NSF is characterized by an extensive fibrosis of skin and tissues, a very severe affection with possible lethal outcome. We propose recommendations to avoid the risk of NSF.

Purpose: To measure and elucidate the mechanisms of presumed mediators of unexpected severe, immediate reactions to iodinated contrast materials., Materials and Methods: In a multicenter study, 20 patients with mild to severe reactions to iodinated contrast material and 20 control subjects without reactions were evaluated. Ionic contrast material was associated with 18 (90%) of 20 reactions. Concentrations of plasma histamine, tryptase, urinary methylhistamine, specific immunoglobulin E (IgE) against ioxitalamate or ioxaglate, and the anaphylatoxins C3a and C4a were measured with radioimmunoassays; complement C3 and C4 levels were measured with nephelometry., Results: Histamine levels were increased in 14 patients; tryptase levels, in 16; and methylhistamine levels, in six. Histamine and tryptase values correlated with the severity of the reaction (P < .02 and P < .004, respectively). Significantly higher levels of specific IgE against ioxaglate (P < .005) and ioxitalamate (P = .045) were found in patients. No differences were found for complement fractions. Skin test results in two patients with life-threatening reactions were positive for the administered contrast material., Conclusion: Histamine release and mast cell triggering are related to severe reactions. An IgE-related mechanism is strongly suspected. Radiologists should be trained to identify and treat anaphylactic shock in patients who react to iodinated contrast material.

Objectives: To evaluate the safety and efficacy of iopentol 350 mg I/ml (Imagopaque/Ivépaque, Nycomed Imaging AS, Oslo, Norway), a monomeric non-ionic contrast medium for computed tomography, in a large population. To identify predictive factors for patient safety., Materials and Methods: One thousand eight hundred and twenty-three (1,823) patients from 48 centres in France were included during a 5-month period. Safety was evaluated by registering adverse events (AEs) reported by the patients, and data were analysed using a multiple factor model., Results: Only 2.6% of the patients experienced AEs other than discomfort. There were no serious AEs. Overall, AEs were more frequent in patients under 50 years of age, in women, and in patients who received contrast medium as a single bolus. Contrast enhancement was considered adequate or better in 98.9% of the patients. A large variation in discomfort (local warmth/chill or pain) frequency was seen between centres, ranging from 0% to 81%. This result implies that factors other than the CM influence the incidence of discomfort., Conclusions: This first study in a large population shows that iopentol 350 mg I/ml is well tolerated and provides CT images of excellent, good or adequate quality in the vast majority of patients. Age, sex and injection procedure were shown to be independent predictors in the AE survey.

French physicians must obtain their patient's consent before carrying out an action that interferes with the patient's corporal integrity. The doctor must use simple, approximate, intelligent, and honest words that help the patient to reach the indispensable decision. Proof of lack of consent lies with the patient. Three lawsuits dealing with contrast media use illustrate the application of the French general principles of medical responsibility and compliance with present standards of information for the patient.