Development of an Evidence-based MRI Safety Guide for Risk Stratification of Implanted Devices and Objects

Purpose: Magnetic Resonance Imaging (MRI) is frequently denied to patients with cardiac implantable electronic devices (CIEDs), orthopedic hardware, retained metallic objects, and other implants despite increasing evidence supporting a favorable benefit-to-risk ratio in many scenarios. Mounting data suggest that inappropriate MRI exclusion remains a significant barrier to equitable patient care. This project is developing an interactive evidence-based MRI safety guide to assist radiologists in device-related risk assessment and to increase appropriate MRI access while maintaining safety.

Methods/Materials: We reviewed current guidelines, registries, meta-analyses, product information, and clinical studies focused on MRI safety in patients with implanted and retained devices. Based on contemporary evidence and societal recommendations, we stratified objects into low-, intermediate-, and high-risk categories, with corresponding imaging conditions, monitoring requirements, and decision-making pathways that emphasize individualized risk–benefit assessment rather than blanket contraindications.

Results: Synthesis of contemporary evidence revealed that many devices historically labeled as MRI contraindications can be safely imaged when risk is assessed by device type, configuration, and clinical context rather than by device presence alone. Applying this framework reclassified several commonly encountered scenarios, such as temporary epicardial pacing wires cut at the skin, abandoned intracardiac leads, external fixators, and select retained ballistic fragments, from absolute exclusions to low- or intermediate-risk categories. The guide provides clear pathways for determining when MRI is appropriate, when multidisciplinary input is required, and when alternative imaging should be considered.

Conclusions: MRI safety should be approached as a risk continuum rather than a binary decision. This updateable guide translates contemporary evidence into a practical framework to increase radiologists’ confidence and reduce unnecessary MRI denials. Future work will assess the guide’s impact on radiologists’ efficiency and patients’ MRI access following implementation.