CONTRAST MEDIA :

X-RAY,CT,USG
Shivaprakash.B.H
PG-BIR
• Contrast means act of
distinguishing by comparing
the differences,
 Or is a perceptual effect of
juxtaposition of different colors.
 How do I define?
• A contrast medium (or contrast
agent) is a substance used to
enhance the contrast of
structures or fluids within the
body
 Necessity for use
• The contrast in the imaging is
dependent on the variable
attenuation of the x-ray
beam(number of electrons in
path of beam).
 Factors affecting
• Thickness of the substance
being studied
• Its density
• Number of electrons per atom of
the element
 Where do we use
• Intravascular
 Intravenous
 CT
 DSA
 Intravenous urography
 Venography (phlebography)
 Intra-arterial
 Angiocardiography Computed
tomography Coronary
angiography Pulmonary
angiography Aortography
Visceral and peripheral
arteriography Digital subtraction
angiography
• Intrathecal (Use USFDA-
approved contrast media
only)
 Myelography (myelographic
nonionic only)
 Cisternography (myelographic
nonionic only)

• Other Oral, rectal, or ostomy
– gastrointestinal tract
 Conventional fluoroscopy CT
 Herniography Peritoneography
Vaginography
Hysterosalpingography
Arthrography ERCP
Cholangiography
Nephrostography Pyelography –
antegrade, retrograde
 Urethrography – voiding,
retrograde Cystography
• Miscellaneous
 Sinus tract injection
 Cavity delineation (including
urinary diversions, such as loop
and pouch)
•
 How do we classify
• Water insoluble
 available in form suspensions
of large insoluble particles as
Barium
• Water soluble
 Iodinated contrast materials
Iodinated contrast materials

Classification of No of Osmotic I:P ratioMol.wt Iodine osmolalit
RCM iodine particles content y
Ionic monomer atoms
3 2 3:2 600-800 70 1500-
HOCM 1700
Diatrizoate
Iothalamate
Metrizoate
Non ionic 3 1 3:1 700-800 150 600-700
monomer(LOC
Iohexol
M)
Iomeron
Ionic dimer 6 2 3:1 1269 150 560
LOCM
Ioxaglate
Non ionic 6 1 6:1 1550- 300 300
dimer LOCM 1626
Iodixanol
Iotrolan
 Preference for iodine
• High efficacy in absorbing X-
rays within diagnostic energy
spectrum
• Chemical versatility allowing
allowing stable binding of
multiplicity of atoms to one
organic molecule
• Low toxicity if released from
RCM


•
Physico-chemical properties


• Solubility
• Water content
• Electrolytes
• Calcium binding
• O2 tension
• Viscosity
• Osmolality
• Mixing with other fluids
• pH and buffering capacity
 Does our body react to it?
 The reactions to contrast
material can be classified as
• By systems with various
manifestations
• With intensity of reaction and
treatment essence
• Mode of reaction to the RCM
• On intensity
 Mild reaction
 Signs and symptoms appear
self-limited without evidence of
progression
• Nausea, vomiting, Altered taste,
Sweats Cough, Itching, Rash,
Warmth, Pallor Nasal
stuffiness, Headache, Flushing
Swelling: eyes, face Dizziness
Chills Anxiety Shaking
• Rx-Requires observation
 Moderate
• Signs and symptoms are more
pronounced.
 Tachycardia/bradycardia
Bronchospasm, wheezing,
Hypertension Laryngeal edema,
Generalized or diffuse
erythema, Mild hypotension,
Dyspnea
• Rx-require prompt treatment.
 close, careful observation
for possible progression
• Severe
 Signs and symptoms are often
life-threatening, including:
 Laryngeal edema Convulsions
(severe or rapidly progressing)
Profound hypotension
Unresponsiveness Clinically
manifest arrhythmias
Cardiopulmonary arrest
• Rx-prompt recognition and
aggressive treatment;
manifestations and treatment
To proceed with severe
reaction
• Airway secured, on artificial
ventilation.
• External cardiac massage and
external DC version
• IV fluid infusion to restore blood
volume and IV drug
administration

• a powerful diuretic frusemide
20–40 mg IV slowly or IM for
pulmonary oedema   
•  diazepam and barbiturates for

convulsions   
•  adrenaline   

•  salbutamol (b
2 agonist metered
dose inhaler)   
•  hydrocortisone or methyl

prednisolone (100–1000 mg)   

•  aminophylline (very

slowly,250–500 mg)   
•    chlorpheniramine for allergic
or anaphylactic symptoms   
•    vasopressors, e.g.

noradrenaline (or metaraminol

0.5–5 mg slow IV infusion)   
•    dihydroxyphenylaline (or

dopamine) infusion (2.5–5μg kg-

1 min-1 ) for hypotension with

monitoring of the blood pressure

• Adrenaline is main stay in
treatment of the condition
dosage being 0.3-0.5 ml of
• Who react very often
 Patients with a previous ADR to
RCM Asthmatics
 Allergic and atopic patients
 Cardiac patients with
decompensation, unstable
arrhythmia, recent myocardial
infarction

 Renal patients in failure,
diabetic nephropathy, on
metformin
 Feeble infants and aged
patients
 Patients with various metabolic
and haematological disorders
 Thyrotoxic: goitrous patients
•
Premedications
• 1.Prednisone – 50 mg orally at
13 hours, 7 hours, and 1 hour
before contrast media
injection, plus
 Diphenhydramine – 50 mg
intravenously, intramuscularly,
or by mouth 1 hour before
contrast medium injection.
• 2. Methylprednisolone – 32 mg
orally 12 hours and 2 hours
before contrast media
injection. An antihistamine can
 Patient selection and
preparation strategies
• History – A careful, focused
history is the necessary first
step.
• Hydration – This should be
adequate in all patients and is
especially important in
patients with renal dysfunction
or paraproteinemias & in
others (e.g., neonates, elderly,
& debilitated individuals) who
would be compromised by
• Have equipment and expertise
ready
• Heads up! – Be aware of specific
risks, the patient’s status,
possible reactions & the best
response to them, & where &
how to get help.
•
Special conditions


• Pregnancy-iodinated contrast
can be given.Thyroid function
of the neonate should be
checked in first week of life
• Treatment with beta blockers-
may impair response to
treatment of bronchospasm
induced by RCM
• Lactation-no special precaution
required
• Thyrotoxicosis-IV contrast C/I in
• Avoid thyroid uptake studies &
treatment for two months after
iodinated contrast
administration
• Pheochromocytoma-advised
alpha & beta blockers with
orally administered drugs
before iodinated contrast
• Sickle cell anemia-risk of ppting
crisis,iso-osmolar contrast
indicated
• Myelomatosis-Bence jones
proteins can ppt in the
Why react?
• Inhibition of enzymes such as
cholinesterase, resulting in
increased concentration of
acetylcholine;
• Release of vasoactive
substances such as histamine,
serotonin or bradykinin may
result in vasomotor collapse.
• Activation of physiological
cascade systems including the
complement activation system
 the kinin system with
bradykinin release, the
coagulation system inducing
intravascular coagulation and
the fibrinolytic system causing
lysis of fibrin and blood clots.
• The immune system
disturbances.
• Anxiety, apprehension and fear
of the radiological procedure.
• Chemotoxicity
 depends on intrinsic structure.
Effects on erythrocytes and
endothelium depends on
hyperosmolaltity.
 Due to cation and the anion.
• Hyperosmolar reactions
 Endothelial damage
 Erythrocyte damage
• Blood brain barrier damage
• Vasodilatation & hypervolemia
• Cardiac depression
Contrast induced
nephropathy
• Definition
 CIN is a condition in which an
impairment in renal function
(increase in serum creatinine
>25% or 44 micromol/L) occurs
within 3 days after IV
administration of contrast
medium in the absence of an
alternative cause.
• Markers
• Risk factors
 Increased serum creatinine
levels,particularly secondary to
diabetic nephropathy
 Dehydration
 Congestive heart disease
 Age older than 70 yrs
 Concurrent administration of
nephrotoxic
drugs(e.g,NSAIDS,Aminoglycosides
)
 Hypertension
 Hyperuricemia
• Reducing the risk of CIN
 Identifying pts at risk
 normal serum creatinine
<1.2mg/dl for females &
<1.4mg/dl for males.
 serum creatinine >1.5 mg/dl or
clearance <60ml/min/1.73 m2 is
defined as renal impairment
 patients with clearance
<30ml/min/1.73 m2 are
definitely at risk.

 Choice & dose of contrast media.
 Hydration
 - normal saline iv 4-6 hrs before
and after contrast medium at
rate of ml/kg/hr.
 - isotonic bicarbonate 1 hr
before at the rate of 1 mL/kg/hr
for 6 hrs after infusion

 - isotonic bicarbonate with NAC
(dose of 1200 mg twice a day
for 48 hrs,starting 24 hrs before
contrast administration)
• Outpatients with moderate renal
impairment (GFR 45-60
mL/min) 1000 mL/hr before &
after contrast medium
• Patients receiving larger doses
or with advanced chronic renal
disease ( GFR < 45 mL/min )
better hydrated with IV saline.
• Pharmacological manipulation
 NAC reduces nephrotoxicity
through anti oxidant and
vasodilatory effects
 theophylline fenoldopam &
CCB’s can be used.
• DO’s
 hydrate
 use low/iso-osmolar RCM
 stop nephrotoxic drugs 24 hrs
before RCM
 consider alternatives
• DON’TS
 use of High osmolar RCM
 administer large doses of
contrast
 administer mannitol & diuretics
 perform multiple studies within
72 hrs
Contrast agents & renal
tract
• Intravenous urography
 better delineation
 Average adult dose being 20g
of iodine independent of kidney
function
 - the nephrogram has two

components
 ->vascular blush which is most
prominent in 20-60 sec after
contrast injection
 ->tubular opacification which
• Diagnostic quality is related to
filtered load,amount of the
contrast excreted.
• UV=GFR*P
Contrast agents & the
GIT
• Contrast agents to consider are
• Barium
üPractical properties
 - adherence of barium to

mucosal surface
 - must not flocculate when in

contact with
 the mucosa
 Factors governing
• Particle size & shape
 ranging between 0.1-20 micro
m.
• Density of barium w/v or w/w.
 high density barium >200%w/v
 medium density 100-200%w/v
 low density 50-100%w/v
• Gums for adherence
• Flocculation of barium
 usually negatively
charged,flocculates if positive
ions are added to the
suspension.
• Stabilising agents
• Clinical applications
 for esophagus both single &
double contrast 100%w/v is
adequate
 for stomach high density
barium 240%w/v
• For small bowel
 if follow through
 low density barium 40%w/v
 if small bowel enema
 higher density about 100%w/v
• For large bowel
 moderate density 80-120%w/v
Complications
• Leakage into the pleural or
peritoneal spaces
• Leakage into the mediastinum
• Possible pulmonary aspiration
• Given orally in suspected large
bowel obstruction
Role of iodinated
contrast
• Investigations of possible leaks
from the upper GI tract,
esophagus & duodenum.
• Gastrograffin (75% aqueous
solution of sodium &
methylglucamine diatrizoate
with 0.1% Tween 80)

Uses
• Esophageal tear
• Duodenal perforation
• Small bowel ileus vs mechanical
obstruction
• In CT 3% solutions 1 hr before
the procedure
• Investigation & treatment of
meconium ileus
• Post surgical anastomosis
C/I’s
• Causes severe chemical
pneumonitis so c/i in case of
suspicion that aspiration into
bronchial tree may occur.
• Hyperosmolar effect draws
water into the bowel loops in a
small child & infant may cause
severe electrolyte disturbance
& death.
• In this cases Non ionic contrast
iopamidol with flavouring
agent is used.
Biliary system
• Cholecystographic agents
(iopadate & iopanic acid)
• Cholangiographic agents
(meglumine iotroxate)
 Contraindications & adverse
effects
• Oral agents
 Hepatic dysfunction
 Parotitis skin rash & most
commonly GI symptoms
diarrhoea.
• IV agents
 Acute anaphylactoid reactions
 Bronchospasm &
cardiovascular collapse
• Absolute contraindications
 myeloma & waldenstrom’s
macroglobulinemia
Contrast agents in
Ultrasound
• Requirements
§ Easily introducible
§ Stable in the duration of
examination
§ Low toxicity
§ Modify one or more acoustic
properties of tissues
Blood pool agents
• Free gas bubbles
 normal saline
 indocyanine green
 renograffin
• Limitations
 large in size effectively filtered
by lungs
 unstable,go back into the
solution withinn second or so.
• Encapsulated air bubbles
 Levovist 99.9%
microcrystalline galactose
microparticles & 0.1% palmitic
acid
 microbubble size 3 to 4 micro
m.
 Echovist a galactose agent
with larger bubbles used for
visualisation of non vascular
structures
• Low solubility gas bubbles
 To increase back scatter &
longevity of the bubbles,low
solubility gases as
perfluorocarbons with low
diffusion rate & increased
longevity are used.
 Sonovue with sulfur
hexafluoride & phospholipid
 Optison with perfluoropropane
filled albumin shell
• Selective uptake agents
 Colloidal suspension of liquids
are taken up by the reticulo
endothelial system from where
they are excreted
 Levovist provides late phase of
enhancement in liver
parenchyma & spleen.
Bubble behaviour & incident
pressure
• Microbubbles scatter ultrasound
in a manner dependent on the
sound to which they are
exposed
• At low incident pressures they
produce linear back scatter
enhancement,resulting in
augmentation of the echo from
the blood
• As it increases the beyond 50 to
100 kPa contrast agent back
scatter begins to show non
linear characters,such as
emission of harmonics
• As peak pressure reaches near
100 kPa transient non linear
scattering resulting in
destruction of the bubble
Peak pressure Bubble Acoustic Application
behaviour behaviour

<100 kPa Linear oscillationLinear Doppler signal

backscatter enhancement
enhancement
0.1-0.5 mPa Non linear Harmonic Real time
oscillation backscatter vascular imaging

>0.5 mPa Disruption Transient non Interval delay

linear echoes perfusion
imaging
Thank you