Gadolinium-based contrast agent-free (GBCA-free) versus gadolinium-based contrast agent-enhanced (GBCA-enhanced) magnetic resonance imaging as a screening tool for intracranial tumors

Background GBCA-enhanced MRI is considered the gold standard for diagnosing intracranial tumors. However, concerns regarding gadolinium-based contrast agents (GBCAs) and workflow limitations have led to increasing interest in GBCA-free MRI techniques. Objective To compare the diagnostic performance of GBCA-free MRI with GBCA-enhanced MRI for detecting intracranial tumors within a neurological diagnostic pathway. Methods In this retrospective cohort study, 191 patients with 195 tumors (124 intra-axial and 71 extra-axial) and 410 controls were included from a regional brain tumor diagnostic pathway between 2013 and 2022. Three senior neuroradiologists independently assessed anonymized MRI scans. Each scan was first evaluated using GBCA-free sequences and subsequently reassessed using the full GBCA-enhanced protocol. Sensitivity, specificity, and inter-method agreement were calculated. Results GBCA-free MRI demonstrated a sensitivity of 79.6% and a specificity of 96.1%, whereas GBCA-enhanced MRI showed a sensitivity of 73.3% and a specificity of 92.9% ( p = 0.15). Agreement between the two imaging approaches was substantial ( κ = 0.699). Subgroup analyses showed comparable performance for intra-axial tumors, while both imaging approaches demonstrated modest sensitivity for extra-axial tumors. Conclusion GBCA-free MRI demonstrated diagnostic performance comparable to that of GBCA-enhanced MRI for detecting intracranial tumors. These findings suggest that GBCA-free MRI may serve as a reliable first-line screening tool within the neurological diagnostic pathway, reserving GBCA administration for cases requiring further lesion characterization.