Hi OCADers,
Sorry for the super long email below. This discussion really went down the rabbit hole.
Thanks for all your responses over the past week. Here is a summary:
No one said they would go ahead with the injection as is, if the patient has a verified severe reaction to contrast.
A few said they would pre-medicate (same way as for IV contrast allergy).
Several other comments included using MRI contrast for CT, saline for MRI, no arthrogram or contrast of any kind needed for diagnostic MRI if using a good 3T scanner, and using ultrasound for guidance rather than fluoro. If doing for therapeutic rather than diagnostic purposes, can use feel/lidocaine, or can use air. I’m assuming the comments on air arthrograms are for steroid injections only i.e. folks are not injecting air and then doing a CT for diagnostic purposes, although perhaps that could work for certain things?
A few links that were sent to me:
From my previous awesome attendings at Emory: https://pubmed.ncbi.nlm.nih.gov/31773187/ – saline MRA has similar accuracy as gadolinum MRA
Prior OCAD discussion: https://groups.google.com/g/ocad-msk/c/2Pqc_U_huU0/m/YqE2EDb1CQAJ – good example of using only gadolinium for CT arthrogram
ACR contrast manual: https://www.acr.org/-/media/ACR/Files/Clinical-Resources/Contrast_Media.pdf – doesn’t comment directly on arthrograms / intra-articular contrast, but interesting discussion on potential risk of allergy with GI barium on page 66
"Because anaphylactoid reactions are not considered to be dose related and can occur with less than 1 ml of intravenous (IV) contrast media, it is generally accepted that allergic-like reactions can occur even from the small amounts of contrast medium absorbed from the gastrointestinal tract. Somewhat surprisingly, there are only very rare reports of moderate or severe allergic-like reactions to orally or rectally administered iodinated contrast media"
Case reports: https://pubmed.ncbi.nlm.nih.gov/28497630/ and https://pubmed.ncbi.nlm.nih.gov/17226017/
Survey: https://ajronline.org/doi/10.2214/AJR.15.14507
"There have been two large surveys of radiologists reporting the complications of arthrography with iodinated contrast media. The larger and more recent survey had 134 respondents reporting on approximately 248,680 career studies [26]. They reported 947 (0.4%) occurrences of hives, both immediate and delayed, and eight (0.003%) occurrences of severe anaphylaxis. However, if the patient had a known history of severe reaction to intravascular iodinated contrast media, 23% of the respondents would decline to do the study, and 51% of the respondents would premedicate the patient with a standard protocol and use nonionic contrast agent.
The earlier survey included 57 radiologist respondents who had performed or supervised more than 126,000 arthrograms [27]. They reported only 61 occurrences of hives, which is much lower than the rate in the later study, but five cases of severe anaphylaxis, which is a rate similar to that in the later study. Because the two surveys occurred approximately 13 years apart (1985 and 1998) and the respondents report all career occurrences, there may be overlap of cases."
They also talk about alternatives
UW Madison site: https://radiology.wisc.edu/documents/prophylaxis-policy-for-patients-allergic-to-iv-contrast/
"Arthrograms. Because allergic-like reactions are dose-independent, and arthrograms use a needle and cross the bloodstream, use the same premedication strategy for arthrograms that is used for intravenous media. For patients with known contrast allergies, appropriate to premedicate or switch to US if possible."
Risk of air embolism from arthrogram – should we be considering this when doing air arthrograms (especially in kids)???
A few case reports (there are others also):
https://link.springer.com/article/10.1007/BF00443465
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3981230/
https://pubmed.ncbi.nlm.nih.gov/7466411/
https://journals.lww.com/jbjscc/abstract/2019/03000/hip_arthrography_complicated_by_air_embolism_in.10.aspx
All OCADer comments pasted here for those looking for details:
For MRI in this situation I use saline.
For CT in this situation I use air.
If CT contrast allergy, I’ll perform air arthrogram. Air arthrogram works well. Before injecting contrast (or air) on all my arthrograms, I inject a tiny bit of lidocaine into joint when I think I’m in the joint. If it flows easy, I’m undoubtedly in and air or contrast confirms. If it doesn’t flow easy, I know I’m not in so I readjust. Doing this is especially helpful for the air arthros. So once you’re nearly positive you’re in the joint, you inject the air and look for a flash of it in expected intraarticular location. Pre injection fluoro save image also helpful to compare with post injection if there’s any question.
If gad allergy, can do saline arthrogram (be sure to adjust MR protocol).
I would stay on the safe side and just inject saline/lidocaine. Or perform noncontrast exam maybe with 3T.
If there is a previous documented reaction, I usually protocol the study for a non-arthrogram MRI, or if the referrer still wants it I use saline without contrast, which also makes premedication unnecessary.
We have occasionally replaced Iodinated contrast with gadolinium to check needle position, but not for diagnostic MRI, only for therapeutic fluoroscopic injections. I think we have used gad for the occasional CT arthrogram.
We actually only did saline arthrograms for Mri at my fellowship so that’s what I would do for Mri.I think I do CT arthrograms so in frequently, I would probably try to push for MRI if possible. Beyond that it would depend on their allergy.
Step 1, check if it’s actually indicated and see if an alternative exam might be appropriate (such as 3T)
Step 2 – if proceeding with arthro, just do a saline arthrogram
I have a patient coming in the next few weeks for shoulder MR athrogram who previously developed contrast reaction after MRI hip arthrogram. We do not know which contrast she reacted to and we are not taking any chances so we will be doing a saline arthrogram instead.
I did ask for opinions on the OCAD whatsapp and got some positive responses about it. I can feedback on our case in a next few weeks once we get her scanned.
I would premedicate medrol 12h and 1h prior, and antihis 12 and 1 hour prior procedureI never tried saline only, but should work perfectly
I did use by mistake iodine in arthro MRI and it was a black disaster in the image
Gadolinium for arthro Ct never tried but I think you should inject a higher concentration of gadolinium to see something and might not be feasible
If someone had a severe allergic reaction to contrast, I won’t give them that type of contrast even if they are premeditated. If the patient has a gadolinium contrast allergy, I will just perform an arthrogram without the gadolinium contrast. I really don’t think the contrast adds much anyway, the main benefit of the arthrogram is joint distention. If the patient has an iodine contrast allergy, I will either perform the injection under fluoro without using contrast to confirm intra-articular needle tip position, or I will do the injection under ultrasound. For wrist and elbow arthrograms, I prefer injecting under ultrasound, but for shoulder/hip/knee, either fluoro without iodinated contrast or ultrasound would be fine. I think with the larger joints, you can be pretty confident you are in the joint just based on needle location and feel.
If the patient needs a CT arthrogram and they had a severe allergic reaction to iodinated contrast, I don’t know what I would do. Fortunately, that has not come up in my practice!😅
Saline arthrogram without iodinated contrast for the injection. I run t1 no fs sag and three plane pdfs with te around 40.
Yes, there is definite risk – although anaphylaxis is rare.However you should NEVER use iodinated contrast for IA injection if a previous reaction is proven.
I most commonly will use only saline for an MR arthrogram if there is a Gd allergy. If there is a CT contrast allergy, I’ll drop that and just use Saline/Gd. Some small chance of mistakenly giving an extra-articular injection, especially in very large patients…but I’ve seen extra articular injections even with ‘regular’ contrast and an experienced operator.
Gadolinium agents are quite dense on CT, and I’ve used non-dilute Gd for CT arthrogram on a few occasions with good results.
I think it is also acceptable to do a premedication protocol; there is some data in this regard (if I correctly recall) in the American College of Radiology contrast manual. I prefer to avoid giving steroids and doing it a different way.
I recall there are a few papers that cite reaction data…intra-articular is rather rare, but I’ve had several patients with mild reactions (hives) to our standard saline/isovue/magnavist mix.
I had a case of allergy on a young patient where I injected less than ½ mL of iodine contrast for an injection . so it does happen , i always respect contrast allergy and i would premedicate even for arthrogram.
I used once Gd for a shoulder injection with iodine allergy, not great opacification but it did partially work,
Now i just premedicate and give iodine contrast
Intra articular contrast reactions happen. If the patient had one, even with pre medications and an adverse event happened; how could you defend/justify yourself…. Do no harm…You have alternatives.
I would not put contrast into a patient’s joint that has the history you’ve given.
Saline only; you can "feel" when you’re in the joint… or put in a small amount of air to confirm; you can read past the artifact..
The most important thing is anatomy knowledge. If you don’t know the anatomy without contrast; contrast/fluid isn’t going to help..
I prefer to do non contrast imaging and arthrography for "problem" solving.
Ideally, from our perspective, the patient comes with the equivalent of "nature’s arthrogram."… Fluid in the joint space already.
when I have to perform a CT arthrogram in a patient with CI to MRI (or without) and previous reaction to iodine contrast, I inject within the joint the Gadolinium contrast used for routine IV injection at MRI (undiluted).
it is visible at fluoroscopy during injection and you cannot make the difference from iodine contrast at CT.
it works perfectly well.
Most hospitals would premedicate.
Another option. For an MRI arthrogram, when allergic to CT contrast, you can do it by feel, loss of resistance technique.
For steroid injections when allergic, you can use air contrast.
I have nothing really to add, except that I’ve recently started doing a reasonable number of CT knee arthrograms.
20cc of iodinated contrast into the knee. They do exercises for a few minutes before getting scanned. At the time of their CT arthrogram, you can usually see some opacification of the small genicular veins so in my mind, this is still an IV dose, just a very slow rate, so I would never entertain the concept of giving intra-articular iodine if someone has a documented serious reaction to IV contrast.
I’ve done two transforaminal epidurals/nerve root sleeve injections in patients (well, the one patient on two separate visits, two separate nerve root levels) with anaphylaxis to iodine and used 0.5cc gadovist (to check needle position) and that’s worked fine. I’ve never seen or heard of gadovist being used for a CT arthrogram though – I’m sure it’d be fine
As a trainee I saw an interventionist use gadovist instead of iodine for putting in a nephrostomy in someone with anaphylaxis. That seemed to work ok.
THANKS!
Emad
On Tue, Jan 30, 2024 at 3:41 PM:
Hi folks,
There have been some great responses so far which I will continue to collect and eventually share with everyone. The comments have been a bit variable, and just to steer the conversation: I’m specifically looking for any information on the risk of adverse reaction with intra-articular contrast when someone has a documented reaction to IV contrast. In particular, for CT contrast agents (in situations where the patient has a contraindication to MRI and a CT arthrogram is requested).
Thanks again,
Emad
On Tue, Jan 30, 2024 at 8:00 AM:
Hi OCADers,
Thanks for all the great cases and insight. I wanted to ask the expert OCAD community:
If a patient has a verified history of severe reaction to IV contrast (be it CT or MRI contrast) and you are asked to perform an arthrogram (be it CT or MRI respectively), what do you do? What is the risk of reaction with intra-articular vs IV contrast? Would you premedicate the patient with steroids/anti-histamine? Does anyone just use saline (particularly for MRI), or perhaps interchange the CT and MRI agents in such situations? Any comments, experiences, or literature in this regard would be appreciated.
Thanks!
Emad
