Contrast-associated transient cortical blindness: three cases with MRI and electrophysiology findings

Case Report: Transient cortical blindness following coronary angiography

Temporary blindness, also known as transient cortical blindness, is an uncommon impediment of contrast agent usage during angiography procedures. The occurrence of blindness after a cardiac catheterization procedure is rare and its pathophysiology remains largely speculative. The most probable mechanism seems to be contrast agent-related disruption of the blood–brain barrier, possibly initiated by several predisposing factors. This case reports a 52-year-old man with transient vision loss that occurred following coronary angiography. Brain magnetic resonance imaging (MRI) showed no acute pathology and his vision spontaneously returned within approximately 15 hours post-procedure without any requirement of specific therapy. Suggesting that transient cortical blindness may have occurred following coronary angiography which subsequently self-resolved.

The first two cases of posterior reversible encephalopathy syndrome (PRES) secondary to conventional transcatheter arterial chemoembolization of hepatocellular carcinoma

Background

Posterior reversible encephalopathy syndrome (PRES) is a very rare complication secondary to transcatheter arterial chemoembolization (TACE). Only two patients with liver metastasis have been reported. We report for the first time two cases of hepatocellular carcinoma (HCC) patients occurred PRES secondary toTACE.

Case presentation

The two patients with HCC developed headache, epilepsy, expressive aphasia, visual impairment and loss of consciousness, 11 and 3 h after conventional TACE (c-TACE) surgery. One patient experienced raised blood pressure during and after TACE, accompanied by a significant elevated creatinine. The magnetic resonance imaging (MRI) of the two patients showed multiple abnormal signals in the brain, mainly located in the white matter region. Combined with the clinical symptoms and MRI findings, PRES was diagnosed. Their symptoms and MRI changes improved significantly in the next two weeks.

Conclusion

The PRES in this report is chemoembolization-associated syndrome, which might be related to the use of chemotherapy agents during TACE. And if neurological symptoms occur after TACE, patients should be closely monitored to exclude PRES.

Contrast-enhanced encephalopathy and massive cerebral edema after endovascular coiling of cerebral aneurysm. A case report

Contrast-induced encephalopathy (CIEP) is a rare complication after endovascular therapy. The etiology of CIEP is still a matter of debate. We present a rare occurrence of CIEP in a known hypertensive and type 2 diabetic patient after endovascular coiling of cerebral aneurysm with oculomotor nerve palsy. A 68-year old female presented with seven days history of headache and left ptosis or blepharoptosis with mild mydriasis. The headaches were localized mainly at the left side of the nose, orbit, and upper forehead while the left ptosis was associated with blurred vision. Computed tomography angiography revealed an aneurysm in between the C4 segment of the left internal carotid artery (ICA) and the bifurcation of the left posterior communicating artery. Digital subtraction angiography further confirmed the aneurysm. We used the transarterial approach to assess the aneurysm and subsequent coiling. Iohexol (Omnipaque) contrast agent was used during the endovascular procedure. The patient’s condition deteriorated into acute confusion state with cardinal symptomology of CIEP immediately after the operation. Computed tomography scan revealed cortical contrast enhancement in the vascular territory of the ICA as well as edema. Her symptomatology resolved 48 hours after treated with anticonvulsants, intracranial pressure reduction and hydration. Chronic hypertension as well as type 2 diabetics may be critical predisposing factors to CIEP. CIEP should be suspected in patients presenting with acute confusion state after endovascular therapy. Massive edema with ischemic brain changes in white matter of the brain before endovascular procedure should rise suspicion of CIEP.

Contrast-Induced Encephalopathy following Cerebral Angiography in a Hemodialysis Patient

Contrast-induced encephalopathy (CIE) is a rare complication of contrast media use during angiographic procedures. With the growing use of endovascular interventions, this complication is likely to become more common. We present a case of a 46-year-old woman with hypertension, hypothyroidism, and chronic renal failure. She developed CIE following cerebral angiography for diagnosis of intracranial aneurysm. We had a high index of suspicion for CIE, excluded the most common differential such as stroke, and immediately started hemodialysis with a short course of corticosteroids. The disease runs a benign course, and neurological symptoms resolved completely after five days. We emphasize the need for increased awareness of CIE to make a valid diagnosis and to start supportive therapy as soon as possible.

Risk Factors of Transient Cortical Blindness After Cerebral Angiography: A Multicenter Study

Background: Although transient cortical blindness is a rare complication following cerebral angiography, identification of risk factors for the development of transient cortical blindness after cerebral angiography is an important clinical issue. Material and methods: Between January 2008 and April 2018, 5,126 patients at five high-volume medical centers who underwent cerebral angiography procedures were enrolled in this multicenter cohort study. Patient baseline characteristics and surgery-related factors were analyzed. We used multivariate logistic regression to examine factors associated with transient cortical blindness. Results: Eighteen patients (0.35%) in the total cohort of 5,126 suffered transient cortical blindness. After univariate statistical analysis, no significant differences were determined between the transient cortical blindness group and the control group regarding gender (p = 0.454), age (p = 0.872), smoking (p = 0.170), diabetes (p = 0.800), and hypertension (p = 0.100). Compared with the control group, the transient cortical blindness group weighed less (p = 0.020), and had a larger dose of contrast agent (p = 0.034) and more instances of contrast agent injected into the posterior circulation (p < 0.001). Logistic regression analysis identified contrast agent dose and contrast agent injected into posterior circulation as independent predictive factors for transient cortical blindness (P < 0.05). Conclusion: Larger doses off contrast agent and contrast agent injected into the posterior circulation are potential independent predictive factors for transient cortical blindness following cerebral angiography.

Cortical blindness and not optic neuritis as a cause of vision loss in a Sjögren's syndrome (SS) patient with the neuromyelitis optica spectrum disorder (NMOSD): Challenges of ascribing demyelinating syndromes to SS: a case report

RATIONALE

The conception that multiple sclerosis may be challenging to distinguish from demyelinating manifestations of Sjögren's syndrome (SS) was introduced more than 30 years ago. However, it is now recognized that the neuromyelitis optica spectrum disorder (NMOSD) may occur more frequently in SS as opposed to multiple sclerosis. Characteristic NMOSD features can include severe attacks of optic neuritis, myelitis which is frequently longitudinally-extensive (spanning at least three vertebral segments on magnetic resonance imaging [MRI]), and an association with anti-aquaporin-4 antibodies. In addition, whereas NMOSD was initially thought to spare the brain, it is now recognized that brain lesions occur in a majority of NMOSD patients. Therefore, it is important for the multi-disciplinary team of physicians who care for SS patients to understand this widening spectrum of NMOSD as encompassing brain lesions. In this case-report we describe clinical features, radiographic findings, and treatment of a SS NMOSD patient presenting with severely decreased visual acuity, visual hallucinations, and encephalopathy.

PATIENT CONCERNS

The SS NMOSD patient presented with rapid, bilateral onset of severely decreased visual acuity and was therefore suspected as having bilateral optic neuritis.

DIAGNOSIS

However, the patient lacked stigmata of optic neuritis, instead had visual hallucinations and encephalopathy suggestive of cortical blindness, and was noted to have occipital lobe lesions on brain MRI. Other radiographic findings included simultaneous enhancement of brainstem and periventricular lesions.

INTERVENTIONS

The patient was initially treated with methylprednisolone with no change in her neurological deficits. She was then treated with plasma exchange therapy.

OUTCOMES

The patient had resolution of decreased visual acuity, visual hallucinations, encephalopathy, and contrast-enhancing brain lesions in response to plasma exchange therapy.

LESSON

We provide the first example of severely decreased visual acuity in a NMOSD patient due to cortical blindness and not bilateral optic neuritis. This finding expands the spectrum of central nervous system syndromes and brain lesions which may occur in NMOSD. The synchronous enhancement of a brainstem lesion (known to occur in NMOSD) with occipital lobe lesions also suggests that our patient's occipital lobe findings were due to NMOSD. All of our patient's findings had an excellent clinical and radiographic response to plasma exchange therapy.