The dynamics of extracellular gadolinium-based contrast agent excretion into pleural and pericardial effusions quantified by T1 mapping cardiovascular magnetic resonance

Introduction Excretion of cardiovascular magnetic resonance (CMR) extracellular gadolinium-based contrast agents (GBCA) into pleural and pericardial effusions, sometimes referred to as vicarious excretion, has been described as a rare occurrence using T1-weighted imaging. However, the T1 mapping characteristics as well as presence, magnitude and dynamics of contrast excretion into these effusions is not known. Aims To investigate and compare the differences in T1 mapping characteristics and extracellular GBCA excretion dynamics in pleural and pericardial effusions. Methods Clinically referred patients with a pericardial and/or pleural effusion underwent CMR T1 mapping at 1.5 T before, and at 3 (early) and at 27 (late) minutes after administration of an extracellular GBCA (0.2 mmol/kg, gadoteric acid). Analyzed effusion characteristics were native T1, ΔR1 early and late after contrast injection, and the effusion-volume-independent early-to-late contrast concentration ratio ΔR1early/ΔR1late, where ΔR1 = 1/T1post-contrast - 1/T1native. Results Native T1 was lower in pericardial effusions (n = 69) than in pleural effusions (n = 54) (median [interquartile range], 2912 [2567–3152] vs 3148 [2692–3494] ms, p = 0.005). Pericardial and pleural effusions did not differ with regards to ΔR1early (0.05 [0.03–0.10] vs 0.07 [0.03–0.12] s− 1, p = 0.38). Compared to pleural effusions, pericardial effusions had a higher ΔR1late (0.8 [0.6–1.2] vs 0.4 [0.2–0.6] s− 1, p < 0.001) and ΔR1early/ΔR1late (0.19 [0.08–0.30] vs 0.12 [0.04–0.19], p < 0.001). Conclusions T1 mapping shows that extracellular GBCA is excreted into pericardial and pleural effusions. Consequently, the previously used term vicarious excretion is misleading. Compared to pleural effusions, pericardial effusions had both a lower native T1, consistent with lesser relative fluid content in relation to other components such as proteins, and more prominent early excretion dynamics, which could be related to inflammation. The clinical diagnostic utility of T1 mapping to determine quantitative contrast dynamics in pericardial and pleural effusions merits further investigation.

A young woman with right upper quadrant pain

Patients with right upper quadrant pain are commonly encountered in the emergency department. The causes of right upper quadrant range from infection or inflammation to malignancy. Thus, prompt and accurate diagnoses are essential in the emergency department. However, vicarious excretion of contrast media via the gallbladder, presenting as right upper quadrant pain, has been rarely reported and is not well known. The present case is instructive because gallbladder opacification is often considered a pathologic condition in patients with right upper quadrant pain. Although vicarious excretion via the gallbladder is uncommon in patients with right upper quadrant pain, inaccurate or delayed diagnoses may prolong hospitalization and increase medical costs due to unnecessary and invasive diagnostic procedures.