Hepatobiliary MRI contrast agents
Hepatobiliary MRI contrast agents are specialised agents used to aid diagnosis in MRI.
They are separated into three categories: gadolinium-based agents, manganese-based agents and superparamagnetic iron oxide particles.
Gadolinium based agents
Gadolinium (Gd) based contrast agents are classified into:
- non-specific extracellular gadolinium chelates (do not bind to serum proteins)
- high relaxivity agents (bind to serum proteins)
Hepatobiliary specific gadolinium agents include two of the high relaxivity agents: gadobenate disodium (Gd- BOPTA) and gadoxetate disodium (Gd-EOB-DTPA).
Biochemically, these agents are linear ionic molecules and show higher T1 relaxivity (>6.5 L/mmol/s at 1.5 T) as compared to the other Gd chelates (<4.8L/mmol/s at 1.5 T).
These agents initially act like non-specific extracellular gadolinium chelates post bolus injection and show three primary phases of vascular and tissue enhancement (Arterial, Blood pool and Extracellular phases). However, in the delayed (hepatobiliary) phase, they are taken up by the liver as their excretion is not only through the renal but the hepatic route as well.
The absorption by hepatocytes is via OATP1 transporter (polypeptide adenosinetriphosphate-dependent organic anion transporter), the same as the bilirubin transporter. Thus, the enhancement of lesions in the hepatobiliary phase depends on the expression and activity of these transporters, depending on the presence or absence of functioning hepatocytes.
During the hepatobiliary phase, they selectively increase the liver signal intensity and aid the in the detection of small tumours. Additionally, the biliary excretion enables biliary ductal mapping (post-contrast MRCP/ functional MRCP) using 3D T1 weighted fat-saturated GRE images.
a. Gadobenate disodium (Gd- BOPTA): weak and transient protein bonding (<5%) and only 2-4% of it is taken up by the liver cells. It goes by the trade name MultiHance/Bracco. Its delayed imaging time is between 90 to 120 minutes.
b. Gadoxetate disodium (Gd-EOB-DTPA): has protein binding of <10%. It has almost equal biliary and renal excretion (~50% each). Compared to Gadobenate, it has more intense liver parenchymal enhancement. The delayed imaging time is also more convenient (10-20 minutes). It goes by the trade name Primovist, Eovist/Bayer.
Manganese based agents
Mangafodipir trisodium (Mn-DPDP) is specifically taken up by hepatocytes due to its chemical similarity to Vitamin B6. This property results in the increase in signal intensity of normal hepatic parenchyma. Thus, in the presence of a focal liver lesion, the increased signal of normal parenchyma gives a high lesion-to-liver contrast and hence provides improved detection, characterization and evaluation of liver lesions.
During the later phases, mangafodipir trisodium is excreted into bile and provides a post contrast MRCP in the detection of biliary pathologies (~50% biliary excretion). It goes by the trade name Teslascan.
Unlike the gadolinium agents, mangafodipir trisodium readily dissociates to yield free manganese ions. This in vivo instability of the chelate rose concerns about potential toxicity.
Free manganese, in chronic exposure, causes a parkinsonism-like syndrome due to accumulation in the brain. Furthermore, a significant neurological risk is associated with manganese intoxication in subjects with liver dysfunction/hepatic encephalopathy whose ability to eliminate manganese is reduced. It can also have a depressive action on heart function.
Hence, mangafodipir trisodium was effectively withdrawn from the market.
Mn-based nanoparticles are under research for its use as high-performance contrast agents with reduced toxicity.
Superparamagnetic iron oxide particles
Superparamagnetic iron oxide particles such as magnetite (Fe3O4) or maghemite (γ-Fe2O3) contain a crystalline core of iron oxide crystals which are water insoluble with the diameter of its core in the range of 4 to 10 nm.
These crystals are coated with dextran or any other biodegradable polysaccharide which prevents particle aggregation. This modifies their biological behaviour and makes the total size of the iron oxide particle substantially larger.
Superparamagnetic iron oxide particles do not leak into the interstitium. They, therefore, act as intravascular contrast agents or blood pool agents as long as the vessel endothelium is intact and unaltered by any pathological process. Its elimination from the blood is by uptake into the reticuloendothelial system cells in liver, spleen, bone marrow and lymph nodes and are phagocytosed by macrophages throughout the body.
The superparamagnetic iron oxide particles agents are preferentially entrapped by the Kupffer cells in the liver and spleen and reduce their T2 relaxation time. Thus, normal liver appears dark on T2 weighted images. Most liver tumours which are usually deficient in Kupffer cells, do not exhibit superparamagnetic iron oxide particles particle uptake and appear relatively hyperintense. However, well-differentiated tumours which have not lost all their Kupffer cells, will take up superparamagnetic iron oxide particles agents and exhibit reduced signal intensity.
Two superparamagnetic iron oxide particles have been approved for MR imaging:
- Ferumoxide: has a particle size of 50 to 180 nm with a thin, incomplete dextran coating that causes individual particles to form polycrystalline aggregates. These aggregates behave in solutions or within cells as large particles. It is administered as a slow IV infusion over 30-60 minutes with imaging typically performed 1 to 4 hours after infusion. The liver appears darkest on T2*/T2 weighted images in the first 24 hours post infusion. The liver signal intensity returns to normal within 7 to 14 days in most cases; however, complete metabolism requires 14 to 28 days. The most common complication is an acute severe low back pain, which can be minimised with a slow infusion.
- Ferucarbotran: It has a particle size of about 60 nm and is coated with low molecular weight carboxydextran. Ferucarbotran is provided as a ready to use formulation and is administered as a rapid bolus. It is thus used with both dynamic and delayed imaging. Most commonly reported adverse events were vasodilation and paresthesias.
The hepatobiliary phase is prolonged with the hepatobiliary-specific MR contrast agents, therefore no requirement to precisely time imaging in this phase, high-spatial-resolution sequences in separate breath holds can complete imaging and longer imaging time can be used if needed, for example, to study bile leak or contrast agent washout.
These features, combined with advances in MR imaging hardware and software allow high-resolution images of the liver to be obtained.
Preferred MR protocol
- T1-weighted in and opposed-phase GRE
- T2-weighted FS fast SE
- T2-weighted MRCP
Post contrast imaging
- dynamic Imaging (in the case of Gd chelates)
- hepatobiliary phase imaging
- parenchymal assessment: Axial and/or coronal 2D or 3D T1-weighted FS spoiled GRE
- functional MRCP: Axial and oblique coronal 2D or 3D T1-weighted FS GRE
- MRI (introduction)
- MR physics
- MR hardware
- signal processing
MRI pulse sequences (basics | abbreviations | parameters)
- spin echo sequences
- inversion recovery sequences
- gradient echo sequences
- fat-suppressed imaging sequences
- diffusion weighted sequences (DWI)
- derived values
- CSF flow studies
- susceptibility weighted imaging (SWI)
- saturation recovery sequences
- echo-planar pulse sequences
- metal artifact reduction sequence
- T1 rho
- spiral pulse sequences
- MR angiography (and venography)
MR spectroscopy (MRS)
- Hunter's angle
- lactate peak: resonates at 1.3 ppm
- lipids peak: resonate at 1.3 ppm
- alanine peak: resonates at 1.48 ppm
- N-acetylaspartate (NAA) peak: resonates at 2.0
- glutamine-glutamate peak: resonate at 2.2-2.4 ppm
- gamma-aminobutyric acid (GABA) peak: resonate at 2.2-2.4 ppm
- 2-hydroxyglutarate peak: resonates at 2.25 ppm
- citrate peak: resonates 2.6 ppm
- creatine peak: resonates at 3.0 ppm
- choline peak: resonates at 3.2 ppm
- myo-inositol peak: resonates at 3.5 ppm
- functional MRI
- MR fingerprinting
- MR hardware and room shielding
- MR software
- patient and physiologic motion
- tissue heterogeneity and foreign bodies
- Fourier transform and Nyqvist sampling theorem
MR contrast agents
- gadolinium ion
- extracellular MRI contrast agents
- hepatobiliary MRI contrast agents
- intravascular (blood pool) MRI contrast agents
- gastrointestinal MRI contrast agents
- tumor-specific MRI contrast agents
- reticuloendothelial MRI contrast agents
- contrast agent safety
- MR safety
- 1. Seale MK, Catalano OA, Saini S et-al. Hepatobiliary-specific MR contrast agents: role in imaging the liver and biliary tree. Radiographics. 2009;29 (6): 1725-48. doi:10.1148/rg.296095515 - Pubmed citation
- 2. Diagnostic Radiology: Recent Advances and Applied Physics in Imaging (Aiims-Mamc-Pgi Imaging). Jaypee Brothers Medical Pub. ISBN:9350904977. Read it at Google Books - Find it at Amazon
- 3. Gandhi SN, Brown MA, Wong JG et-al. MR contrast agents for liver imaging: what, when, how. Radiographics. 2006;26 (6): 1621-36. doi:10.1148/rg.266065014 - Pubmed citation