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Unlabelled: This paper analyses off-label prescribing of the iodinated organic and magnetic resonance (MR) contrast media used in diagnostic imaging and evaluates the liability profiles and medicolegal issues associated with such use. The term off-label generally indicates the use of known drugs for which new scientific evidence suggests use in a manner and in clinical scenarios not explicitly addressed by the drug data sheet and is outside the indications for which the medication was approved. In addition, the term also indicates the use of drugs with a different route of administration and dosage from those indicated in the information leaflet. Intravascular contrast media used in diagnostic imaging are drugs in the complete sense of the term, even though they have unique characteristics which in many ways distinguish them from other pharmacological agents. The off-label use of contrast media in diagnostic imaging is a little-investigated field and most commonly, but not exclusively, applies to gadolinium-based contrast media used in MR angiography as well as cardiac and paediatric applications. In particular, the off-label use of contrast media mostly concerns deviations from the recommended dose. As contrast media are to all effects pharmaceutical agents, their off-label use can be considered admissible within the limitations laid down by the Italian law in force (Article 3 of Law 94/98) and its interpretation, i.e. the following criteria must be present: the lack of a valid diagnostic alternative; written informed consent by the patient; the presence of scientific publications validated at the international level; assumption of responsibility by the radiologist., Conclusions: The use of contrast media in modern image-guided medicine is essential. In cases in which the information contained in the information leaflet is modified and updated in any way whatsoever (indications, dosage, at others), specifically if restrictions are introduced in accordance with the law in force, the pharmaceutical industry must provide formal and timely notification to radiologists. On their part as prescribers and users of contrast media, radiologists must remain up to date regarding any changes in indications, dosage and route of administration. Lastly, we propose that the radiology report includes not only the type but also the dose of contrast medium used.

Purpose: Perfusion and diffusion Magnetic Resonance Imaging (MRI) studies allow us to quantitatively evaluate the vascularisation and anaplastic grade of glioblastomas based on the regional cerebral blood volume (rCBV) and apparent diffusion coefficient (ADC) values. The aim of our study was to compare these values and enhancement % in order to determine whether enhancement of glioblastomas depends mainly on their vascularisation or anaplastic grade., Materials and Methods: Seventeen patients with brain glioblastomas were studied with perfusion, diffusion and T1-weighted Spin-Echo MR sequences, with and without contrast medium. The quantitative evaluations were made on solid tumour tissue regions of interest (ROI), and the high vascularisation (high rCBV) and low anaplastic grade (high ADC) ROI group was separated from the low vascularisation (low rCBV) and high anaplastic grade (low ADC) group. The mean enhancement % values of the two groups were compared by using statistical METHODS., Results: In 14 patients there were no statistically significant differences between the two groups. In one patient, the enhancement of high anaplastic grade and low vascularisation ROIs was significantly higher, whereas in two patients, the enhancement of high vascularisation and low anaplastic ROIs clearly prevailed., Conclusions: Given that the anaplastic grade is proportional to blood-brain barrier (BBB) impairment, our results show that, in most cases, enhancement of glioblastomas is equally dependent on vascularisation and BBB impairment.

The acronym FLAIR refers to fluid attenuation inversion recovery sequences, which are T2-weighted MR pulse sequences with liquor signal saturation by a long TI. They are characterized by long TR and TE and therefore the acquisition time is very long in the conventional mode, while fast imaging (the Turbo mode) reduces acquisition time to less than 2 minutes. Our study was aimed at codifying the use of this type of sequence in neuroradiologic studies. All the exams were performed with an MR unit with a 1-Tesla magnetic field. We carried out 150 neuroradiologic exams with this pulse sequence on patients with cerebral, medullary or orbital conditions. This technique is very useful to study periventricular or cortical lesions in multiple sclerosis and in other multifocal cerebral conditions (e.g., multiple metastases or lacunar infarcts), but we pointed out the following other advantages: better definition of the extent of infiltrative white matter lesions (i.e., gliomatosis cerebri and lymphomas), better differentiation of cystic from necrotic cavities and exact characterization of cortical damage in cerebral ischemic lesions (useful also for the differential diagnosis). Moreover, FLAIR pulse sequences could diagnose some globe conditions, such as amelanotic uveal melanomas and malformations with no need of contrast agent administration. In contrast, they were useless to study deep ischemic areas, solid neoplasms, hemorrhagic lesions, poroencephalic areas, intrinsic medullary lesions and intra-orbital and extra-ocular conditions. In conclusion, the FLAIR technique is a major diagnostic tool in neuroradiologic MR studies because they overcome such limitations of Turbo SE PD sequences as blurring artifacts; moreover, their acquisition time is always very short. In some cases, FLAIR images are decisive for the diagnosis.

In the last few years, new magnetic resonance (MR) pulse sequences called Fast or Turbo Spin Echo (TSE) sequences have become available. This kind of T2-weighted images is particularly useful for the study of spondylosis and degenerative spinal conditions, because it both reduces involuntary motion artifacts and its acquisition time is shorter than that of conventional SE T2-weighted images. Our study was aimed at assessing the diagnostic gain of this new type of pulse sequences in intrinsic spinal cord conditions. Therefore, we acquired TSE and conventional SE sequences, consequently, in 36 patients with intrinsic spinal cord conditions, which were apparent on T2-weighted images, and then compared the sensitivity, contrast resolution, and depiction of lesion margins and extent in both acquisition techniques. The results of our study follow: even though all lesions were identified with both techniques, contrast resolution was higher with TSE than with conventional SE images. Lesion margins and extent were substantially equally depicted with both techniques. Finally, TSE sequences had the same, and sometimes even higher, diagnostic yield than conventional SE sequences: therefore, TSE can be considered the sequence of choice in the study of intrinsic spinal cord conditions.