Nickel-Related Adverse Reactions in the Treatment of Cerebral Aneurysms: A Literature Review

Safety of intracranial venous stenting in patients with nickel allergy

BACKGROUND

Nickel hypersensitivity is the most common metal related allergy. Nickel containing alloys are frequently used in endovascular devices. The use of intracranial stents in patients with nickel hypersensitivity appears to be safe, but these small series only evaluated arterial stent placement. This case series aimed to assess the safety of intracranial venous stent placement in patients with documented nickel allergy.

METHODS

In this retrospective multicenter case series, patients with idiopathic intracranial hypertension and documented nickel allergy underwent treatment with a permanently implanted nickel containing stent in the dural venous sinuses.

RESULTS

Nine patients with nickel allergy were included. All patients reported clinical improvement in their idiopathic intracranial hypertension symptoms. Of the five patients who had follow-up intracranial venous imaging, all stents remained patent. No patients experienced intraoperative, postoperative, or long term procedure related complications, with follow-up ranging from 1.8 weeks to 49.1 months.

CONCLUSION

In this limited case series, the use of nickel containing stents in intracranial venous sinuses in patients with nickel allergy did not result in any allergic reaction or adverse outcome.

Metal allergy and neurovascular stenting: A systematic review

BACKGROUND

Intracranial stents and flow diverters contain significant amounts of metals, notably nickel, which can cause allergic reactions in a considerable portion of the population. These allergic responses may lead to complications like in-stent stenosis (ISS) and TIA/Stroke in patients receiving stents or flow diverters for intracranial aneurysms.

METHODS

We conducted a systematic review of studies from inception until July 2023, which reported outcomes of patients with metal allergy undergoing neurovascular stenting. The skin patch test was used to group patients into those with positive, negative, or absent patch test results but with a known history of metal allergy.

RESULTS

Our review included seven studies with a total of 39 patients. Among them, 87% had a history of metal allergy before treatment. Most aneurysms (89%) were in the anterior circulation and the rest (11%) were in the posterior circulation. Skin patch tests were performed in 59% of patients, with 24% showing positive results and 33% negative. Incidental ISS was observed in 18% of patients, and the rate of TIA/Stroke was reported in 21%. The pooled rates of ISS and TIA/Stroke were higher in the first group (43% and 38%) compared to the second (18% and 9%) and third groups (15% and 15%), but these differences were not statistically significant.

CONCLUSIONS

The current neurosurgical literature does not provide a conclusive association between metal allergy and increased complications among patients undergoing neurovascular stenting. Further studies are necessary to gain a more comprehensive understanding of this topic.

Overt nickel and cobalt hypersensitivity after pipeline embolization device placement: A case report

Nickel and cobalt are frequently found in metallic alloys used in the manufacture of aneurysm clips and endovascular prostheses, such as the pipeline embolization device (PED). Nickel hypersensitivity can affect up to 15% of the population, however, it is very rarely overt in patients who undergo endovascular stent placement. Here, we present the case of a 35-year-old woman who developed allergic symptoms after PED placement and was later confirmed to be allergic to both nickel and cobalt by patch testing. Fortunately, she responded well to pharmacologic treatment, rendering surgical intervention unnecessary. To the best of our knowledge, this is the first report of symptomatic nickel hypersensitivity, and the second report of symptomatic cobalt allergy caused by the PED. Despite its low prevalence, we believe that surgeons should actively inquire patients in the postoperative period about allergic symptoms, to facilitate early diagnosis and treatment.

Possible Delayed Foreign Body Reactions against Titanium Clips and Coating Materials after Unruptured Cerebral Aneurysm Surgery

Delayed foreign body reactions to either or both clipping and coating materials have been reported in several small series; however, studies in the titanium clip era are scarce. This study aims to survey the contemporary status of such reactions to titanium clips and coating materials. Among patients who received a total of 2327 unruptured cerebral aneurysmal surgeries, 12 developed delayed intraparenchymal reactions during outpatient magnetic resonance imaging (MRI) follow-up. A retrospective investigation was conducted. The patients' average age was 58.6 (45-73) years, and 11 were women. The aneurysms were located in the middle cerebral artery (n = 7), internal carotid artery (n = 4), or anterior communicating artery (AComA, n = 1). In 10 patients, additional coating with tiny cotton fragments was applied to the residual neck after clipping with titanium clips; however, only the clipping with titanium clips was performed in the remaining two. The median time from surgery to diagnosis was 4.5 (0.3-60) months. Seven (58.3%) patients were asymptomatic, and three developed neurological deficits. MRI findings were characterized by a solid- or rim-enhancing lobulated mass adjacent to the clip with surrounding parenchymal edema. In 11 patients, the lesions reduced in size or disappeared; however, in one patient, an AComA aneurysm was exacerbated, necessitating its removal along with optic nerve decompression. In conclusion, cotton material is a strongly suspected cause of delayed foreign body reactions, and although extremely rare, titanium clips alone may also induce such a reaction. The prognosis is relatively good with steroid therapy; however, caution is required when the aneurysm is close to the optic nerve, as in AComA aneurysms.

Nickel-related hypersensitivity reactions following endovascular interventions: A review of current evidence

INTRODUCTION

Nickel is a principal alloying agent in the production of vascular endoprostheses, despite persisting as the most habitually identified allergen. Variable nickel-related hypersensitivity manifestations following endovascular intervention were reported, challenging established paradigms in treatment and accuracy of prognostic assessments. The objective of this review is to critically evaluate current metrics to maximise patient-related outcomes.

METHODS

A literature review was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009 statement. Patients indicative of nickel hypersensitivity reaction following endovascular intervention were discerned. A positive reaction was defined by patch testing, histological analysis, or anamnesis indicative of nickel hypersensitivity. Morphology of implicating prostheses, adverse events and postoperative complications, clinical course, diagnostic and therapeutic strategies alongside patient prognosis were recorded.

RESULTS

Nickel-related hypersensitivity reactions following endovascular repair were identified in 36 patients with a median age of 44.5 years. 20 patients received nitinol-containing intervention. 28 (77.8%) patients are female. Multi-organ adverse reactions occurred in 21 (58.3%) patients with variable latency. 14 (38.9%) patients were presented with neurological adverse reactions manifesting mainly as unilateral hemiparesis. Dermatological reactions implicated 16 (44.4%) patients. Miscellaneous manifestations include suicidal ideation. 13 (36.1%) patients displayed previous metal intolerance and 32 (88.9%) patients had positive patch testing for nickel. Histological analysis of lesions and prostheses indicated lymphocytic infiltration. 5 (13.9%) patients experienced device-specific reactions as in-stent restenosis or auxiliary distal vessel stenosis. 11 (30.1%) patients received solely medical therapy and 5 (13.9%) patients received solely surgical therapy. 19 (52.7%) patients underwent both medical (oral corticosteroid) and surgical therapy (device retrieval). 26 (77.1%) patients achieved symptomatic cessation, 6 (16.7%) patients exhibited symptomatic persistence and 0 patients died.

CONCLUSION

Prophylactic pre-assessment for a history of metal allergy and consideration of prostheses alternatives is recommended to minimise reaction risk and severity. Despite nickel's predominant usage, information paucity urges additional studies to emphasise its implications and maximise patient outcomes.

Endovascular Treatment of Cerebrovascular Lesions Using Nickel- or Nitinol-Containing Devices in Patients with Nickel Allergies

Nickel is used in many cerebral endovascular treatment devices. However, nickel hypersensitivity is the most common metal allergy, and the relative risk of treatment in these patients is unknown. This retrospective analysis identified patients with nickel or metal allergies who underwent cerebral endovascular treatment with nickel-containing devices. Seven patients with nickel and/or other metal allergies underwent treatment with 9 nickel-containing devices. None experienced periprocedural complications. No patient received treatment with corticosteroids or antihistamines. At a mean clinical follow-up for all patients of 22.8 months (range, 10.5-38.0 months), no patients had symptoms attributable to nickel allergic reactions. The mean radiographic follow-up for all patients at 18.4 months (range, 2.5-37.5 months) showed successful treatment of the targeted vascular pathologies, with no evidence of in-stent stenosis or other allergic or hypersensitivity sequelae. The treatment of cerebrovascular lesions with a nickel-containing device resulted in no adverse outcomes among these patients and was safe and effective.

Urinary Nickel Was Associated with the Prevalence of Diabetes: Results from NHANES

The study aimed to investigate the association between nickel exposure and the presence of diabetes (DM). The participants were analyzed from the National Health and Nutrition Examination Surveys (NHANES) 2017-2018. Urinary nickel exposure was measured using inductively coupled-plasma mass spectrometry. DM was diagnosed based on the WHO standards. The association between nickel and DM or fasting glucose was examined using multivariable linear regression models and logistic regression models. A total of 1899 participants (933 men and 966 women) were included in our study, of whom 342 (18.0%) were diagnosed with DM. There was a significant positive association between nickel level and DM (OR: 1.27, 95%CI: 1.04-1.56) after adjusting for potential confounding factors. Comparing with the lowest quartile, the highest quartile independently increased a 0.66-fold higher risk of DM (OR: 1.66, 95%CI: 1.13-2.44]). In addition, nickel exposure was independently related to the level of fasting glucose. The exposure to nickel was associated with a higher risk of DM in general population.

"Gingival Soft Tissue Integrative" Lithium Disilicate Glass-Ceramics with High Mechanical Properties and Sustained-Release Lithium Ions

Due to their good mechanical performances and high biocompatibility, all-ceramic materials are widely applied in clinics, especially in orthopedic and dental areas. However, the "hard" property negatively affects its integration with "soft" tissue, which greatly limits its application in soft tissue-related areas. For example, dental implant all-ceramic abutments should be well integrated with the surrounding gingival soft tissue to prevent the invasion of bacteria. Mimicking the gingival soft tissue and dentine integration progress, we applied the modified ion-exchange technology to "activate" the biological capacity of lithium disilicate glass-ceramics, via introducing OH^- to weaken the stability of Si-O bonds and release lithium ions to promote multi-reparative functions of gingival fibroblasts. The underlying mechanism was found to be closely related to the activation of mitochondrial activity and oxidative phosphorylation. In addition, during the ion-exchange process, the larger radius sodium ions (Na⁺) replaced the smaller radius lithium ions (Li⁺), so that the residual compressive stress was applied to the glass-ceramics surface to counteract the tensile stress, thus improving the mechanical properties. This successful case in simultaneous improvement of mechanical properties and biological activities proves the feasibility of developing "soft tissue integrative" all-ceramic materials with high mechanical properties. It proposes a new strategy to develop advanced bioactive and high strength all-ceramic materials by modified ion-exchange, which can pave the way for the extended applications of such all-ceramic materials in soft tissue-related areas.

Association between the nickel exposure and lipid profiles in general population from NHANES

This study is to investigate the association between nickel exposure and serum lipid profiles. We analyzed the population from the National Health and Nutrition Examination Surveys (NHANES) 2017-2018. Urinary nickel exposure was measured using inductively coupled-plasma mass spectrometry. Serum lipid profiles, including triglyceride (TG), total cholesterol (TC), high-density lipoprotein-cholesterol (HDL-C), and low-density lipoprotein-cholesterol (LDL-C), were measured using the standard biochemistry assays. The association between urinary nickel and lipid profiles was examined using multivariable linear regression models and restricted cubic spine plots. There was a significant negative relationship between nickel level and TC (β, - 9.67; 95% CI, - 13.58 to - 5.76), HDL-C (β, - 1.57; 95% CI, - 2.98 to - 0.16), and LDL-C (β, - 5.88; 95% CI, - 11.04 to - 0.71) after adjusting for potential confounding factors. Furthermore, restricted cubic spines showed that only HDL-C was nonlinearly associated with nickel (p for nonlinearity 0.004). However, nickel exposure was not related to the level of triglyceride. The exposure to nickel was linearly associated with serum total cholesterol and LDL-C while nonlinearly associated with HDL-C in general population.

Influences of Stent Design on In-Stent Restenosis and Major Cardiac Outcomes: A Scoping Review and Meta-Analysis

Thanks to the developments in implantable biomaterial technologies, invasive operating procedures, and widespread applications especially in vascular disease treatment, a milestone for interventional surgery was achieved with the introduction of vascular stents. Despite vascular stents providing a solution for embolisms, this technology includes various challenges, such as mechanical, electro-chemical complications, or in-stent restenosis (ISR) risks with long-term usage. Therefore, further development of biomaterial technologies is vital to overcome such risks and problems. For this purpose, recent research has focused mainly on the applications of surface modification techniques on biomaterials and vascular stents to increase their hemocompatibility. ISR risk has been reduced with the development and prevalent usage of the art technology stent designs of drug-eluting and biodegradable stents. Nevertheless, their problems have not been overcome completely. Furthermore, patients using drug-eluting stents are faced with further clinical challenges. Therefore, the bare metal stent, which is the first form of the vascular stent technology and includes the highest ISR risk, is still in common usage for vascular treatment applications. For this reason, further research is necessary to solve the remaining vital problems. In this scoping review, stent-based major cardiac events including ISR are analyzed depending on different designs and material selection in stent manufacturing. Recent and novel approaches to overcome such challenges are stated in detail.

Incidence, clinical spectrum, and immunotherapy of non-ischemic cerebral enhancing lesions after endovascular therapy

Background:

Symptomatic and asymptomatic delayed non-ischemic cerebral enhancing (NICE) lesions in magnetic resonance imaging (MRI) have been reported as a rare complication after endovascular therapy (EVT) in recent years with incidence rates between 0.05% and 0.9% in most studies. Information on long-term clinical course and immunotherapies is scarce or has not been reported in detail in the literature. Objective: Aims of our study were to assess the incidence of NICE lesions in patients after cerebral EVT over a period of more than 12 years, describe clinical and EVT characteristics, and immunotherapies applied.

Methods:

A retrospective chart review of all patients treated by endovascular therapy for symptomatic or asymptomatic aneurysms at the University Hospital of Augsburg from May 1, 2008 to December 31, 2020 was performed. Patients were identified retrospectively and followed-up prospectively where appropriate. In addition, one case treated at another institution was included.

Results:

Five out of 746 patients, 0.67%, developed NICE lesions after EVT, all with non-ruptured aneurysms and all symptomatic upon detection of NICE lesions by MRI. In total, the disease course of 6 female patients is reported. Symptoms occurred after a mean time of 15 days (±13.42, SD) after EVT with headache (6/6 patients), focal neurological signs (6/6 patients), epileptic seizures (2/6 patients) and cognitive deficits (3/6 patients). All 6 patients received glucocorticosteroids (GCS), 1/6 azathioprine (AZA), 4/6 mycophenolate mofetil (MMF), 1/6 methotrexate (MTX), 1/6 rituximab (RTX), 2/6 cyclophosphamide (CYC) and 3/6 tocilizumab (TCZ). A treatment response could be observed for GCS, TCZ and MMF (in two of four cases), RTX and AZA did not result in disease stabilization.

Conclusions:

Delayed NICE lesions are a rare complication after EVT, requiring immunotherapies in all patients reported here. Physicians should be aware of this disorder in case of new symptoms or contrast enhancing lesions after EVT.

Nickels and tines: the myth of nickel allergy in intracranial stents

BACKGROUND

Most intracranial stents contain nickel alloy, and nickel allergy or hypersensitivity is common. Neurological injury following endovascular treatment with a nickel containing intracranial stent has been reported in patients with purported nickel allergy, but it is unclear whether these reactions represent true nickel hypersensitivity. We quantified nickel release from commonly used intracranial stents to investigate whether such stents should be avoided in patients with nickel allergy.

METHODS

We examined nickel release from seven commonly used intracranial stents: Enterprise, LVIS Jr, Neuroform, Wingspan, Zilver, Pipeline Flex Embolization Device, and Surpass Evolve. We incubated each stent in human plasma-like media for 30 days. Dimethylglyoxime (DMG) spot testing was performed on each stent to detect released nickel at 0 and 30 days. Inductively coupled plasma-optical emission spectroscopy (ICP-OES) was then used to quantify the nickel concentration of the media at 30 days. Nickel currency and nickel standard for atomic absorption spectrometry were used as positive controls.

RESULTS

DMG spot tests indicated nickel release only from nickel currency at 0 and 30 days of incubation. No nickel release was detected from any stent at 30 days using ICP-OES.

CONCLUSIONS

Nickel release from commonly used intracranial stents is negligible. These results suggest that previously reported hypersensitivity to these stents may be misattributed to nickel allergy, and that patients with nickel allergy may be safely treated with select nickel-containing stents.

Nickel in terrestrial biota: Comprehensive review on contamination, toxicity, tolerance and its remediation approaches

Nickel (Ni) has been a subject of interest for environmental, physiological, biological scientists due to its dual effect (toxicity and essentiality) in terrestrial biota. In general, the safer limit of Ni is 1.5 μg g^-1 in plants and 75-150 μg g^-1 in soil. Litreature review indicates that Ni concentrations have been estimated up to 26 g kg^-1 in terrestrial, and 0.2 mg L^-1 in aquatic resources. In case of vegetables and fruits, mean Ni content has been reported in the range of 0.08-0.26 and 0.03-0.16 mg kg^-1. Considering, Ni toxicity and its potential health hazards, there is an urgent need to find out the suitable remedial approaches. Plant vascular (>80%) and cortical (<20%) tissues are the major sequestration site (cation exchange) of absorbed Ni. Deciphering molecular mechanisms in transgenic plants have immense potential for enhancing Ni phytoremediation and microbial remediation efficiency. Further, it has been suggested that integrated bioremediation approaches have a potential futuristic path for Ni decontamination in natural resources. This systematic review provides insight on Ni effects on terrestrial biota including human and further explores its transportation, bioaccumulation through food chain contamination, human health hazards, and possible Ni remediation approaches.

Microcatheter Originating Debris during Neuroendovascular Procedures: Mechanism of Dislodgement and Its Prevention

Embolic material dislodgement from microcatheters can potentially induce subclinical brain damage as evidenced by a delayed enhanced or other type of lesions. Some of the most frequently used microcatheters were investigated in vitro in different setups and combinations with different port insertions and rotating hemostatic valves. It was found that side port application increases injury to the catheter surface and debris dislodgement by conflicting with internal ledges in rotating hemostatic valves. This initial observation suggests the need for measures to remove the produced debris during such procedures.

Nickel: Human Health and Environmental Toxicology

Nickel is a transition element extensively distributed in the environment, air, water, and soil. It may derive from natural sources and anthropogenic activity. Although nickel is ubiquitous in the environment, its functional role as a trace element for animals and human beings has not been yet recognized. Environmental pollution from nickel may be due to industry, the use of liquid and solid fuels, as well as municipal and industrial waste. Nickel contact can cause a variety of side effects on human health, such as allergy, cardiovascular and kidney diseases, lung fibrosis, lung and nasal cancer. Although the molecular mechanisms of nickel-induced toxicity are not yet clear, mitochondrial dysfunctions and oxidative stress are thought to have a primary and crucial role in the toxicity of this metal. Recently, researchers, trying to characterize the capability of nickel to induce cancer, have found out that epigenetic alterations induced by nickel exposure can perturb the genome. The purpose of this review is to describe the chemical features of nickel in human beings and the mechanisms of its toxicity. Furthermore, the attention is focused on strategies to remove nickel from the environment, such as phytoremediation and phytomining.

Real-world Case Series of iStent or iStent inject Trabecular Micro-Bypass Stents Combined with Cataract Surgery

INTRODUCTION

This real-world retrospective case series assessed 12-month effectiveness and safety following implantation of iStent® or iStent inject® trabecular micro-bypass with cataract surgery.

METHODS

Consecutive patients were implanted with either iStent (comprising 1 stent) or iStent inject (comprising 2 stents), together with cataract surgery. Most patients had primary open-angle glaucoma. Effectiveness outcomes through 12 months included intraocular pressure (IOP) and glaucoma medications. Proportional analyses were completed for eyes achieving IOP ≤ 18 mmHg, IOP ≤ 15 mmHg, or IOP reduction ≥ 20% from preoperative; and eyes on 0 medications or ≥ 2 medications. Safety outcomes included adverse events, secondary surgeries, visual acuity, and visual fields.

RESULTS

This analysis included 137 eyes (67 iStent, 70 iStent inject) with cataract and mild to moderate glaucoma or ocular hypertension. Over 73% of eyes in both groups had early disease, and ~ 22% had prior glaucoma surgery. At 12 months postoperatively, mean IOP decreased from 18.4 ± 4.2 mmHg to 14.2 ± 2.5 mmHg in iStent eyes (p < 0.0001), and from 20.4 ± 5.6 mmHg to 14.4 ± 2.1 mmHg in iStent inject eyes (p < 0.0001). The IOP reduction was significantly greater for iStent inject eyes than iStent eyes (6.0 mmHg versus 4.2 mmHg reduction, p = 0.034). Both groups had high proportions of patients achieving the 12-month IOP endpoints, although consistently greater proportions reached these endpoints after iStent inject than iStent: 95.7% versus 92.5% had IOP ≤ 18 mmHg, respectively; 74.3% versus 71.6% had IOP ≤ 15 mmHg, respectively; and 68.6% versus 62.7% had IOP reduction ≥ 20% from baseline, respectively. Mean medication burden at 12 months decreased from 1.8 ± 0.7 to 0.3 ± 0.5 medications in iStent eyes (84.0% reduction, p < 0.0001), and from 1.3 ± 0.9 to 0.1 ± 0.3 medications in iStent inject eyes (94.7% reduction, p < 0.0001). Significantly more iStent inject eyes were medication-free at 12 months than iStent eyes (92.9% versus 76.1% medication-free, respectively; p = 0.0068). Favorable safety included few adverse events, no secondary glaucoma surgeries, and stable visual acuity and visual fields in both groups.

CONCLUSION

Significant and safe IOP and medication reductions were achieved through 12 months after iStent or iStent inject implantation with cataract surgery. iStent inject eyes had greater absolute IOP reduction and more eyes medication-free versus iStent eyes.

FUNDING

Glaukos Corporation.