DOI:10.2214/AJR.06.5040.1
AJR 2006; 187:W447
© American Roentgen Ray Society
Reply
Nils Krämer and
Ansgar Berlis
University Hospital Freiburg Freiburg, Germany
WEB—This is a Web exclusive article.
We thank our colleagues for their comments about our case report,
"Intrathecal Gadolinium-Enhanced MR Myelography Showing Multiple Dural
Leakages in a Patient with Marfan Syndrome," which was in the July 2005
issue of AJR [1].
In their letter to the editor, the authors criticize our intrathecal
application of gadobenate dimeglumine (Multihance, Bracco) and mention that
gadopentetate dimeglumine (Magnevist, Schering) has been the better choice for
enhanced imaging of the subarachnoid space and of CSF leakages.
We agree that the intrathecal use of gadopentetate dimeglumine has been
evaluated more frequently in terms of safety and that a clinical trial on the
intrathecal application of this agent has been performed
[2-6].
Moreover, we are aware that gadopentetate dimeglumine is the only MR contrast
agent to have been intrathecally applied to patients before our study
[2,
3,
5,
6]. However, to suggest that we
should have used gadopentetate dimeglumine in our study simply because it has
been applied intrathecally previously, whereas gadobenate dimeglumine had
previously been applied intrathecally in only one animal study
[7], indicates a lack of
understanding of the similarity and differences between gadolinium contrast
agents. We believe that gadobenate dimeglumine provides decisive features that
justify its use in the subarachnoid space. Although previous studies have
reported a gradual diffusion of gadopentetate dimeglumine from the CSF into
the CNS [4,
8], our studies with gadobenate
dimeglumine in animals [7] did
not indicate any visible penetration of intrathecal gadobenate dimeglumine
into the CNS. The absence of penetration might additionally explain why we did
not observe any necrotic lesions histologically, as Ray et al.
[9] did using gadopentetate
dimeglumine intrathecally.
Furthermore, numerous studies have shown that gadobenate dimeglumine
provides higher T1 relaxivity than gadopentetate dimeglumine because of weak,
transient interactions with proteins such as serum albumin
[10]. In extradural CSF, as
observed in our case, high concentrations of proteins can be assumed.
Therefore, another motivation to use gadobenate dimeglumine was to obtain
efficient enhancement of tiny structures and leakages.
In conclusion, we agree that there is a lack of broad safety studies on the
subarachnoid use of gadobenate dimeglumine. However, based on our observations
with intrathecal gadobenate dimeglumine and on other experiences with the high
relaxivity of this agent, we consider gadobenate dimeglumine to be a valuable
contrast agent for the depiction of CSF leakages and for enhanced imaging of
the subarachnoid space. Furthermore, the safety profile of gadobenate
dimeglumine is indistinguishable from that of gadopentetate dimeglumine
[10].
Finally, we should also point out that not even gadopentetate dimeglumine
is approved for intrathecal application, so intrathecal uses of gadopentetate
dimeglumine contrast agent are similarly off-label and at the discretion of
the investigating radiologist.
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