MRI Patient Information Form

1.         Please describe in detail why your doctor has requested an MRI? ____________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please indicate your symptoms in the diagram:    

2.         List other imaging (Cat Scans, Ultrasound, X-ray) related to today’s examination with date and location? 

____________________________________________________________________________________

3.         Do you have    Tumor:                         NO_____ YES_____              Location:_________  

Cancer                        NO_____ YES_____              Year Diagnosed:_______

High blood pressure:   NO_____ YES_____ 

Stroke:                         NO_____ YES_____ 

MRI Safety Form: model

MRI SAFETY FORM

MRI is simple, safe and painless.  However, because we use strong magnets during the procedure, metal objects in your body may be hazardous or cause interference.  Please provide us with this important information before entering the MRI department.

Name________________________________  Age__________  Weight___________

Have you ever had an MRI?   YES_____  NO_____             Date of last MRI:  ____________

Have you ever had surgery?   YES_____  NO_____ If Yes,  please list all procedures and dates.

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Do you have any of the following items in your body:

Pacemaker                              YES_____  NO_____ Implanted electrical device      YES_____  NO_____

Ear / Cochlear implant             YES_____  NO_____ Neurostimulators                     YES_____  NO_____

Brain / aneurysm clips             YES_____  NO_____ Stents                                      YES_____  NO_____

Metal in eyes                           YES_____  NO_____ Tissue expander                     YES_____  NO_____

Metal fragments or shrapnel   YES_____  NO_____ Magnetic dental implants        YES_____  NO_____

Any other metal objects or implants______________________________________________________________

If known, please give name and date of implant.____________________________________________________

Have you ever had an injection of contrast for an MRI?                                                         YES_____  NO_____

If Yes, did you experience any of the following:          Hives:                                      YES_____  NO_____

                                                                                                Shortness of breath:                YES_____  NO_____

                                                                                                Fainting or collapse:                YES_____  NO_____

                                   

Female patients:          Is there any possibility of pregnancy?             YES_____  NO_____

                                    Are you breast-feeding?                                  YES_____  NO_____

Sometimes MRI requires an injection of contrast.  MRI contrast (gadolinium) is administered through a small needle placed into a vein.  During the administration of MRI contrast (gadolinium), you may experience the sensation of the contrast being injected, which is normal and expected.

MRI contrast (gadolinium) is quite safe, however as with all medications, there is a slight risk of an allergic reaction.  The physicians and staff in the MRI Department are trained to respond to any emergency situation that may develop.  In addition, we use the safest MRI contrast, which our physicians believe is best for you.

I have read and understand the above information. 

Signature_____________________________ Relationship to pt._____________________ Date_____________

Gadolinium MRI side effects

While MRI can create very detailed images on their own, it is a common practice to make use of contrast agents.  This is done to enhance the images of organs and soft tissue after an MRI scanning or to make tissue matter that is hard to detect easier to see.  Contrast agents react strongly to magnetic fields better than the hydrogen atoms from the water molecules in your body.  The most common contrast agent uses gadolinium.

Gadolinium is a metallic element (atomic number 64.)  In its natural form, it is a silvery, ductile material.  Gadolinium exhibits very strong paramagnetic properties.  If a metal is paramagnetic, it does not have any magnetization on its own.  However, in an externally applied magnetic field, it has the ability to align its magnetic moments of the molecules parallel to it.  Because of how easily gadolinium is influenced by magnetic fields (relative to other elements), it is widely used as a contrast agent.

As an ion, gadolinium can be highly dangerous to people.  To make it safe to use for medical applications, it undergoes a process known as chelation.  This will create a bond to a gadolinium atom with other non-metallic compounds.  Some contrast agents that have been approved by the FDA include Magnevist, OptiMARK and Vasovist.

As far as safety goes, there is no need for concern in most cases.  For healthy individuals – more specifically, for people with no kidney problems – the concentrations used in the contrast agents are too low to cause any MRI side effects.  On the other hand, those with renal failure and damaged kidneys do have to worry about possible side effects of gadolinium.

If you suffer from renal failure, then the following information is very important for your safety.

The main cause for concern is a disease known as Nephrogenic Systemic Fibrosis, or NSF for short.  While the exact cause of NSF is still unclear, it has been shown that gadolinium does promote this disease.  People with a working pair of kidneys are able to eliminate the gadolinium contrast agent from the body in time.  Those with renal failure that cannot pump the gadolinium out of their system are at risk of becoming afflicted with this disease.

Nephrogenic Systemic Fibrosis causes fibrosis throughout the body, which is the growth of extra connective tissue in the organs, skin and joints.  As a result, the skin will become hard and feel tight and your joints will be limited and motion and painful to move.  If it affects the internal organs as well, it can be very fatal.

Always consult your radiologist about the risks involved and be sure that any kidney problems you might have are clearly recognized before going through with a contrast agent to prevent the side effects of gadolinium.

Risk of NSF for contrast agents in MRI

The European Medicines Agency has published a report in which they concluded that contrast agents that have a linear molecular structure pose the greatest risk of NSF, while those that have a cyclic molecular structure pose the least.  The types of contrast agents that they included in the report were:

Linear                     Cyclic

Omniscan             ProHance

OptiMARK            Gadovist

Magnevist             Dotarem

MultiHance

Primovist

Vasovist

What MRI contrast agents are associated with NSF?

There are five FDA approved gadolinium contrast agents; however, only three of these contrast agents have been credibly implicated in cases of nephrogenic systemic fibrosis. These three gadolinium MRI contrast agents are Omniscan (GE Healthcare), Optimark (Covidien/Mallinckrodt), and Magnevist (Bayer Healthcare). All three of these contrast agents share a common linear design for their chelator that is intended to bind the gadolinium. Other contrast agents use a safer chelator design that builds a "cage" around the gadolinium. These "macrocyclic" contrast agents have not been linked to cases of NSF. In fact, the only proven cause of NSF is exposure to one of these three contrast agents with the linear design.

Five gadolinium-based contrast agents are approved by the FDA for use during an MRI. The trade names for these products are:

• Omniscan
• OptiMARK
• Magnevist
• ProHance
• MultiHance

None of these agents are approved by the FDA for MRA. The dose of gadolinium-based contrast agent given to patients undergoing an MRA is often higher (up to three times) than the approved dose for MRI.

gadodiamide (OmniScan)*

gadopentetate dimeglumine (Magnevist)*

gadoversetamide (OptiMARK)*

gadobenate dimeglumine (MultiHance)

gadoteridol (ProHance)

* these agents have shown a higher risk association with NSF

Less stable contrast gadolinium agents have shown to have a higher association with NSF. Gadodiamide (OmniScan) is one of the least stable agents. The higher the thermodynamic stability constant for the contrast agent the higher the stability.

- Gadoversetaminde (OptiMARK) 16.6

- Gadodiamide (Omnisan) 16.9

- Gadobutrol (Gadovist) 21.8

- Gd-DTPA (Magnevist) 22.1

- Gadobenate (Multihance) 22.6

- Gadoteridol (Prohance) 23.8

- Gd-DOTA (Dotarem) 25.8