CT contrast crisis prompts call for more use of MRI and ultrasound

The dramatic shortage of critical patient care materials requires an immediate and flexible response, wrote a team led by Dr. Timothy Fiori of Fiona Stanley Hospital in Perth, Australia. Healthcare departments and imaging providers there have been quick to evaluate the use of CT contrast agents and take new measures to conserve them.

“Strategies include using alternative imaging modalities to answer clinical questions, weight-based contrast dosing, and lower kVp-CT protocols to improve iodinated contrast media conspicuousness,” the group explained.

The shortage of iodinated contrast media was in large part due to a lockdown in Shanghai, China, in May intended to prevent a COVID-19 outbreak; The lockdown blocked GE Healthcare’s ability to sell its Omnipaque contrast agent. The crisis was mostly resolved by June, but healthcare providers around the world are warning that vulnerabilities in the supply chain for materials like contrast media remain and need to be addressed.

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To this end, Fiori and colleagues outlined the following best practices for head and neck imaging to provide a framework for preserving contrast in acute care.

  • Thyroid: Incidental thyroid nodules can be identified on carotid Doppler ultrasonography, chest CT, or PET/CT; Ultrasound helps doctors determine if a patient would benefit from fine needle aspiration. Hyperthyroidism can be clarified with thyroid scintigraphy, goiter can be visualized by CT without contrast medium.

  • salivary glands: Both blockages and masses in these glands can be assessed with ultrasound, the group wrote. Ultrasound findings may indicate that CT or MRI scans would be beneficial to further investigate larger or malignant lesions. CT provides clinical data on bone involvement in salivary gland disease but can be performed without contrast for this indication.

  • Pediatrics: For neck masses, ultrasound is again the first imaging modality to characterize the mass. If malignancy is suspected, MRI or contrast-enhanced CT can be used. Contrast-enhanced CT is recommended for suspected orbital, temporal, or intracranial pathologies. Finally, in children suffering from stridor, the first diagnostic line is laryngoscopy or bronchoscopy, but in more severe cases, contrast-enhanced CT is recommended.

  • Staging of Head and Neck Cancer: MRI is the preferred modality for staging head and neck cancer, although non-contrast CT is a useful alternative, the researchers wrote. Contrast-enhanced CT is recommended over MRI for staging tumors in the larynx and hypopharynx because patients with these diseases may have compromised airways and CT scans are shorter than MRI scans.

The bottom line is that MRI and ultrasound are useful alternatives to contrast-enhanced CT imaging for head and neck abnormalities, the authors say.

“For the routine assessment of non-acute head and neck presentations in children and adults, the use of contrast-enhanced CT can either be safely minimized or avoided to conserve iodinated contrast media,” they concluded. “This can be achieved by … using alternative modalities [such as] ultrasound and MRI, [which] not only save on iodinated contrast media, but also avoid ionizing radiation.”

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