Intrathecal gadolinium-based contrast agents (off-label)

Last revised by Frank Gaillard on 9 Apr 2024

Intrathecal use of gadolinium-based contrast agents (GBCAs), for example, in MR cisternography or MR myelography, is not approved by regulatory agencies such as the FDA, and as such, its use is considered off-label.

Nonetheless, its use is relatively widespread, although infrequent, and numerous series have been published demonstrating apparent safety at low doses, typically 0.25 mmol (0.5 mL of 0.5 mmol/mL) 2,3.

At higher doses (over 1 mmol), intrathecal administration of GBCAs can lead to serious adverse events, including but not limited to neurological signs and symptoms (e.g. altered mental state, dysarthria, ataxia, seizures, vertigo) as well as cardiovascular and respiratory symptoms 1,2. Rarely, an particularly at much higher doses, status epilepticus, coma and even death have been reported 1,2.

Healthcare professionals are, therefore, generally advised against using gadolinium-based contrast agents intrathecally, as the safety and efficacy of this route of administration have not been established through rigorous clinical trials. When felt clinically indicated, especially in the absence of conventional alternatives, intrathecal use can be considered after weighing up the pros and cons 5, adhering to published methodologies and gaining informed consent from the patient.

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