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Glymphatic Pathway of Gadolinium-Based Contrast Agents Through the Brain

Overlooked and Misinterpreted

Deike-Hofmann, Katerina MD*,†; Reuter, Julia*; Haase, Robert*; Paech, Daniel MD*; Gnirs, Regula MTRA*; Bickelhaupt, Sebastian MD*; Forsting, Michael MD; Heußel, Claus Peter MD†,§,∥; Schlemmer, Heinz-Peter MD*; Radbruch, Alexander MD, JD*,‡

doi: 10.1097/RLI.0000000000000533
Original Articles

Background The “glymphatic system” (GS), a brain-wide network of cerebrospinal fluid microcirculation, supplies a pathway through and out of the central nervous system (CNS); malfunction of the system is implicated in a variety of neurological disorders. In this exploratory study, we analyzed the potential of a new imaging approach that we coined delayed T2-weighted gadolinium-enhanced imaging to visualize the GS in vivo.

Methods Heavily T2-weighted fluid-attenuated inversion recovery (hT2w-FLAIR) magnetic resonance imaging was obtained before, and 3 hours and 24 hours after intravenous gadolinium-based contrast agent (GBCA) application in 33 neurologically healthy patients and 7 patients with an impaired blood-brain barrier (BBB) due to cerebral metastases. Signal intensity (SI) was determined in various cerebral fluid spaces, and white matter hyperintensities were quantified by applying the Fazekas scoring system.

Findings Delayed hT2w-FLAIR showed GBCA entry into the CNS via the choroid plexus and the ciliary body, with GBCA drainage along perineural sheaths of cranial nerves and along perivascular spaces of penetrating cortical arteries. In all patients and all sites, a significant SI increase was found for the 3 hours and 24 hours time points compared with baseline. Although no significant difference in SI was found between neurologically healthy patients and patients with an impaired BBB, a significant positive correlation between Fazekas scoring system and SI increase in the perivascular spaces 3 hours post injection was shown.

Interpretation Delayed T2-weighted gadolinium-enhanced imaging can visualize the GBCA pathway into and through the GS. Presence of GBCAs within the GS might be regarded as part of the natural excretion process and should not be mixed up with gadolinium deposition. Rather, the correlation found between deep white matter hyperintensities, an imaging sign of vascular dementia, and GS functioning demonstrated feasibility to exploit the pathway of GBCAs through the GS for diagnostic purposes.

From the *Department of Radiology, German Cancer Research Center (DKFZ);

Department of Diagnostic and Interventional Radiology With Nuclear Medicine, Thorax Clinic at Heidelberg University Hospital, Heidelberg;

Department of Diagnostic and Interventional Radiology and Neuroradiology, University Essen, Essen;

§Department of Diagnostic and Interventional Radiology, University of Heidelberg; and

Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research (DZL), Heidelberg, Germany.

Received for publication September 5, 2018; and accepted for publication, after revision, October 9, 2018.

Conflicts of interest and sources funding: none declared.

Correspondence to: Alexander Radbruch, MD, JD, Department of Radiology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany. E-mail:

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