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Optimizing Contrast-Enhanced Magnetic Resonance Imaging Characterization of Brain Metastases: Relevance to Stereotactic Radiosurgery

Anzalone, Nicoletta MD*; Essig, Marco MD, PhD; Lee, Seung-Koo MD, PhD§; Dörfler, Arnd MD, PhD; Ganslandt, Oliver MD; Combs, Stephanie E. MD; Picozzi, Piero MD#

doi: 10.1227/NEU.0b013e3182889ddf

Intracranial metastases are the most common form of intra-axial brain tumor. Management approaches to brain metastases include surgical resection, whole-brain radiotherapy, and stereotactic radiosurgery (SRS). The management approach that is selected is based typically on algorithms that incorporate the number, size, and location of lesions. SRS is the treatment of choice when metastases detected on imaging are few (maximum, 3-5) and/or of small size (≤30 mm) and offers the advantages of noninvasiveness and the ability to treat inaccessible lesions compared with surgical resection. Contrast-enhanced magnetic resonance imaging (MRI) is the standard imaging technique for determining the number, size, and location of metastatic lesions. In SRS, the capability of MRI to delineate lesion borders precisely in 3 dimensions helps reduce recurrence rates and minimize radiation necrosis in surrounding tissue. Optimization of the MRI protocol, including selection of the appropriate gadolinium-based contrast agent (GBCA), is paramount for accurate lesion imaging. GBCAs differ in their safety, tolerability, and efficacy because of their diverse physicochemical properties. Gadobutrol and gadobenate dimeglumine are high-relaxivity GBCAs that demonstrate superior efficacy for imaging metastatic lesions compared with other GBCAs, whereas gadobutrol additionally provides macrocyclic stability. This article reviews recent comparative trials of GBCAs and discusses their relevance for optimizing MRI protocols in the management of brain metastases, with particular relevance to SRS.

ABBREVIATIONS: CNR, contrast-to-noise ratio

CNS, central nervous system

GBCA, gadolinium-based contrast agent

NSF, nephrogenic systemic fibrosis

SRS, stereotactic radiosurgery

WBRT, whole-brain radiotherapy

*Department of Neuroradiology, Scientific Institute H. S. Raffaele, Milan, Italy;

Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany;

§Department of Radiology, Yonsei University College of Medicine, Seoul, Korea;

Department of Neurosurgery, University of Erlangen-Nuremberg, Erlangen, Germany;

Abteilung RadioOnkologie und Strahlentherapie, Universitätsklinikum Heidelberg, Heidelberg, Germany;

#Department of Neurosurgery, Scientific Institute H. S. Raffaele, Milan, Italy

Correspondence: Nicoletta Anzalone, MD, Department of Neuroradiology, Scientific Institute H.S. Raffaele, Milan, 20132 Italy. E-mail:

Received June 20, 2012

Accepted January 2, 2013

Copyright © by the Congress of Neurological Surgeons