Persistent neurological deficit from iodinated contrast encephalopathy following intracranial aneurysm coiling. A case report and review of the literature

Transient cortical blindness after diagnostic cerebral angiography - A single center report

Background

Transient cortical blindness (TCB) has been reported as a complication after diagnostic cerebral angiography in 0.3-1% of cases. Our aim was to observe the frequency of TCB after diagnostic cerebral angiography over a period of 11 years using only hypo-osmolar, nonionic contrast agents and following a protocol to reduce both the total volume of injected contrast agent and the number of angiography series obtained.

Methods

We retrospectively included all 2431 patients who received diagnostic cerebral angiographies at our institution. Primary outcome measure was the occurrence of TCB after diagnostic cerebral angiography, hypothesizing that the occurrence of TBC depends on the volume of contrast agent and angiography of the vertebrobasilary arteries.

Results

Over the analyzed time period of 11 years, we did not observe a single case of TCB following diagnostic cerebral angiography. The median contrast volume used was 100 ml (IQR, 100-200), ranging from 15 ml to 500 ml. In our cohort, 61.5% of patients received a selective catheterization of the vertebrobasilary territory. In 99.8% of angiographies iopamidol was used a contrast agent.

Conclusion

Our results indicate that following to certain aspects of the angiography protocol (using the hypoosmolar, non-ionic contrast agent iopamidol and reducing the number of catheterized vessels and angiography series to a diagnostic minimum) the frequency of transient cortical blindness as a complication of diagnostic cerebral angiography considerably can be very low.

Contrast-Induced Encephalopathy and the Blood-Brain Barrier

BACKGROUND

Contrast-induced encephalopathy (CIE) is an adverse event associated with diagnostic and therapeutic endovascular procedures. Decades of animal and human research support a mechanistic role for pathological blood-brain barrier dysfunction (BBBd). Here, we describe an institutional case series and review the literature supporting a mechanistic role for BBBd in CIE.

METHODS

A literature review was conducted by searching MEDLINE, Web of Science, Embase, CINAHL and Cochrane databases from inception to January 31, 2022. We searched our institutional neurovascular database for cases of CIE following endovascular treatment of cerebrovascular disease during a 6-month period. Informed consent was obtained in all cases.

RESULTS

Review of the literature revealed risk factors for BBBd and CIE, including microvascular disease, pathological neuroinflammation, severe procedural hypertension, iodinated contrast load and altered cerebral blood flow dynamics. In our institutional series, 6 of 52 (11.5%) of patients undergoing therapeutic neuroendovascular procedures developed CIE during the study period. Four patients were treated for ischemic stroke and two patients for recurrent cerebral aneurysms. Mechanical stenting or thrombectomy were utilized in all cases.

CONCLUSION

In this institutional case series and literature review of animal and human data, we identified numerous shared risk factors for CIE and BBBd, including microvascular disease, increased procedure length, large contrast volumes, severe intraoperative hypertension and use of mechanical devices that may induce iatrogenic endothelial injury.

Contrast-induced encephalopathy after an embolization procedure for a cerebral aneurysm in a female with subarachnoid hemorrhage: a case report

BACKGROUND

Contrast-induced encephalopathy (CIE) is a rare complication during or after angiography, usually transient and reversible. CIE diagnosis is challenging due to the absence of no formal diagnostic criteria. CIE can mimic stroke symptoms, including visual disturbances, seizures, confusion, coma, and focal neurological deficits. This case reports neurological deficit reversal in a CIE patient due to the embolization of an intracranial aneurysm, the second angiographic procedure in six days.

CASE PRESENTATION

A 77-year-old woman was admitted to the hospital for headaches. The cerebral computed tomography (CT) scan indicated a subarachnoid hemorrhage. The first digital subtraction angiography (DSA) identified an aneurysm of 4 mm ∗ 3 mm in size in the M1 segment of the right middle cerebral artery (MCA). Then, embolization surgery was performed for the cerebral aneurysm, which was successful. However, the patient had post-operative headaches, slurred speech, epilepsy, limb weakness, and delirium post-procedure. The non-contrast cerebral CT indicated widespread edema in the right cerebral hemisphere. The patient was diagnosed with CIE and treated with symptomatic supportive therapy. Eventually, the patient's neurological deficits and cerebral edema improved significantly.

CONCLUSIONS

The current case emphasized the importance of early diagnosis and symptomatic treatment of CIE. Thus, CIE should be the first consideration during the differential diagnosis of a patient having acute neurological impairment after repeated DSA.

Risk factor analyses of contrast leakage and contrast-induced encephalopathy following coil embolization for unruptured intracranial aneurysm

BACKGROUND

Contrast-induced encephalopathy (CIE) following endovascular interventions is a rare but serious complication. This study aimed to investigate the risk factors of contrast leakage (CL) and CIE in patients who underwent coil embolization of unruptured intracranial aneurysms (UIAs).

METHODS

Patients with UIAs who underwent coil embolization at a single tertiary institute between January 2019 and January 2022 were enrolled retrospectively. CL was defined as cortical or subcortical contrast enhancement with effacement of the cortical sulci. CIE was defined as the new onset of neurological deficits associated with CL. Following the procedure, all patients underwent CT scans, and MRI scans were performed on those with symptoms. Patient and procedural risk factors were investigated.

RESULTS

In total, 459 patients were analyzed. The median procedure time and contrast dose were 69 min and 96 mL, respectively. CL was evident in 35 patients. In the multivariate analysis, hypertension, large aneurysm, longer procedure time, and greater contrast dose were associated with CL. CIE was diagnosed in 19 patients, and the risk factors included large aneurysm, longer procedure time, and greater contrast dose. The procedure time was predictive of both CL (P<0.001) and CIE (P=0.01). The optimal cut-off value for procedure time was 81.5 min. All CIE patients recovered completely within 8-96 hours.

CONCLUSIONS

A large aneurysm and prolonged procedure time may increase the patient's risk of CL and CIE due to increased contrast exposure. Patients who underwent a procedure that exceeded 1.5 hours necessitate post-procedure evaluation and monitoring.

Pathophysiology of Contrast-Induced Neurotoxicity: A Narrative Review of Possible Mechanisms

BACKGROUND

Contrast-induced neurotoxicity (CIN) is an increasingly observed event following the administration of iodinated contrast. It presents as a spectrum of neurological symptoms that closely mimic ischaemic stroke, however, CIN remains a poorly understood clinical phenomenon. An appreciation of the underlying pathophysiological mechanisms is essential to improve clinical understanding and enhance decision-making.

METHODS

A broad literature search of Medline (1946 to December 2022) and Embase (1947 to December 2022) was conducted. Articles discussing the pathophysiology of CIN were reviewed.

SUMMARY

The pathogenesis of CIN appears to be multifactorial. A key step is likely blood-brain barrier (BBB) breakdown due to factors including ischaemic stroke, uncontrolled hypertension, and possibly contrast agents themselves, among others. This is followed by passage of contrast agents across the BBB, leading to chemotoxic sequelae on neural tissue.

KEY MESSAGES

This review provides a clinically oriented review on the pathophysiology of CIN to enhance knowledge and improve decision-making among clinicians.

Contrast-Induced Encephalopathy after Endovascular Treatment: Two Case Reports

Contrast-induced encephalopathy (CIE) is a rare neurological complication that occurs after the use of contrast medium in various angiographic procedures. Symptoms can be different, from headache to severe neurological deficit and coma. In the articles published to date, symptoms appeared immediately after application of contrast agent or within 24 hours. Here we present two cases of patients in whom CIE developed delayed after endovascular treatment.

Current knowledge and perspectives of contrast-induced neurotoxicity: A survey of Australian clinicians

BACKGROUND

Contrast-induced Neurotoxicity (CIN) is an increasingly recognised complication following endovascular procedures. It remains a relatively unexplored clinical entity, and we sought to characterise clinician perspectives towards CIN, as well as identify gaps in knowledge and provide directions for future research.

METHODS

An online survey was distributed to members of the Australian and New Zealand Society of Neuroradiology, as well as several Australian tertiary hospitals. Questions related to clinical exposure to CIN, diagnosis, management and pathophysiology were explored. Descriptive analysis was conducted on survey responses, and statistical analysis was performed using Chi-square and Fisher's exact test as appropriate.

RESULTS

A total of 95 survey responses were recorded (26.8% response rate). Only 28.4% of respondents were comfortable in diagnosing CIN, and even fewer (24.2%) were comfortable in independently managing CIN patients. Based on clinician opinion, symptoms including impaired consciousness and cortical blindness were thought to be most associated with CIN, whilst the radiological findings of parenchymal oedema and cortical enhancement were considered to be most indicative of CIN. Most clinicians agreed that further investigation is required related to pathophysiology (86.3%), diagnosis (83.2%), and treatment (82.1%).

CONCLUSION

CIN is a poorly understood complication following endovascular procedures. Significant gaps in clinical understanding are evident, and further investigation is vital to improve diagnosis and management.

Prognostic value of contrast staining on dual-energy CT after endovascular therapy in acute ischemic stroke: a meta-analysis

BACKGROUND

Contrast staining (CS) on dual-energy CT (DECT) is common after endovascular therapy (EVT) in acute ischemic stroke (AIS). We performed a meta-analysis to investigate the prognostic significance of CS detected by DECT after EVT in AIS.

METHOD

MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science and Scopus databases were searched from inception to July 2023 for publications on the prognostic significance of CS on DECT after EVT in patients with AIS. Prognostic outcomes were hemorrhage transformation (HT) and poor functional outcome (modified Rankin Scale [mRS] Score of 3-6 at the 90-day follow-up). Data are presented as odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

Eleven studies including 1123 cases of AIS were included. Pooled results indicated a higher risk of HT in patients with CS than in those without CS (OR = 2.22; 95% CI 1.41-3.51, P = 0.001; I2 = 45.4%). No association between CS and symptomatic HT was observed (OR = 2.10; 95% CI 0.64-6.95, P = 0.223; I2 = 67.3%). Moreover, there was also higher odds of poor functional outcome in patients with CS than in those without CS (OR = 2.76; 95% CI 1.53-4.97, P = 0.001; I2 = 44.9%).

CONCLUSIONS

The presence of contrast staining on DECT after EVT is associated with a higher risk of hemorrhage transformation and poor functional outcome. However, further high-quality studies with standardized processes are required to confirm these results.

Contrast Injection from an Intermediate Catheter Placed in an Intradural Artery is Associated with Contrast-Induced Encephalopathy following Neurointervention

BACKGROUND AND PURPOSE

Contrast-induced encephalopathy can result from neurotoxicity of contrast medium in the affected area. The development of intermediate catheters has allowed guidance of catheters to more distal arteries. This study focused on the association between contrast-induced encephalopathy and contrast injection from an intermediate catheter guided into a distal intradural artery during neurointervention for cerebral aneurysms.

MATERIALS AND METHODS

We retrospectively reviewed 420 consecutive aneurysms in 396 patients who underwent neurointervention for extracranial aneurysms and unruptured intracranial aneurysms at our institution from February 2012 to January 2023. Patients were divided into a group with contrast-induced encephalopathy and a group without. To identify risk factors for contrast-induced encephalopathy, we compared clinical, anatomic, and procedural factors between groups by multivariate logistic regression analysis and stepwise selection.

RESULTS

Among the 396 patients who underwent neurointervention for cerebral aneurysms, 14 (3.5%) developed contrast-induced encephalopathy. Compared with the group without contrast-induced encephalopathy, the group with contrast-induced encephalopathy showed significantly higher rates of patients on hemodialysis, previously treated aneurysms, intradural placement of a catheter for angiography, nonionic contrast medium, and flow-diversion procedures in univariate analyses. Stepwise multivariate logistic regression analysis revealed intradural placement of a catheter for angiography (OR = 40.4; 95% CI, 8.63-189) and previously treated aneurysms (OR = 8.20; 95% CI, 2.26-29.6) as independent predictors of contrast-induced encephalopathy.

CONCLUSIONS

Contrast injection from an intradural artery and retreatment of recurrent aneurysms were major risk factors for contrast-induced encephalopathy. Attention should be paid to the location of the intermediate catheter for angiography to avoid developing contrast-induced encephalopathy.

Association between general anesthesia and contrast-induced encephalopathy after endovascular treatment on neurovascular diseases

Objective

Contrast-induced encephalopathy (CIE) is a rare neurological complication that can occur in the context of various endovascular procedures. Although many potential risk factors for CIE have been reported, it is still unclear whether anesthesia is a risk factor for the occurrence of CIE. The goal of this study was to investigate the incidence of CIE in patients who underwent endovascular treatment under different anesthesia methods and anesthetics administration and to explore whether general anesthesia was a potential risk factor for CIE.

Methods

We retrospectively reviewed available clinical data from 1,043 patients with neurovascular diseases undergoing endovascular treatment between June 2018 and June 2021 in our hospital. A propensity score-based matching strategy and logistic regression were used to analyze the association between anesthesia and the occurrence of CIE.

Results

In this study, we implemented the embolization of intracranial aneurysm in 412 patients, stent implantation of extracranial artery stenosis in 346, stent implantation of intracranial artery stenosis in 187, embolization of cerebral arteriovenous malformation or dural arteriovenous fistula in 54, endovascular thrombectomy in 20, and other endovascular treatments in 24. A total of 370 patients (35.5%) received treatment under local anesthesia, while the remaining 673 (64.5%) underwent treatment under general anesthesia. In total, 14 patients were identified as CIE, resulting in a total incidence rate of 1.34%. After propensity score-based matching of anesthesia methods, the occurrence of CIE was significantly different between the general anesthesia and local anesthesia group (P = 0.007). After propensity score-based matching of CIE, the anesthesia methods were significantly different between the two groups. Pearson contingency coefficients and logistic regression showed a significant correlation between general anesthesia and the risk of CIE.

Conclusion

General anesthesia might be a risk factor for CIE, and propofol might be associated with the increased occurrence of CIE.

Ioversol Induced Microglia Proinflammatory Activation and Oxidative Stress in Rats

Contrast-induced encephalopathy (CIE) following angiography, though not often and reversible, can in some cases lead to permanent neurological dysfunction. To identify how neuroinflammation is involved in CIE, we investigated microglia responses to a bolus injection of ioversol in the internal carotid artery (ICA) in rats. MicroCT scanning indicated that the injected ioversol was cleared from the rat's brain within 25 min. However, proinflammatory activated and significantly increased microglia were found in the rat occipital cortex at 1 day, and the number of blood vessel-associated microglia was still significantly higher at 3-day post-injection, compared with sham- and PBS-treated rats. Moreover, significantly upregulated malondialdehyde (MDA), downregulated superoxide dismutase (SOD) levels, and elevated proinflammatory cytokines were observed in the brain of rats treated with ioversol. Ioversol administration decreased cell viability of primarily cultured microglia and induced significant proinflammatory activation. Furthermore, ioversol remarkably upregulated astrocytic aquaporin (AQP) 4 expression in the rats brain, and transwell cultures showed significantly enhanced microglia migrating to ioversol-treated endothelial cells. Immediate injection of edaravone dexborneol, a novel antioxidative drug, after ioversol injection effectively rescued ioversol-induced neuroinflammation. Together, these findings suggest that ioversol induced neuroinflammation and oxidative stress in the brain via microglia activation in a direct and indirect manner, which might contribute to the pathogenesis of CIE.

Contrast-induced encephalopathy following endovascular treatment for intracranial aneurysms-risk factors analysis and clinical strategy

PURPOSE

Contrast-induced encephalopathy (CIE) was defined as new onset of neurological deficits after exposure to contrast media, which could be observed after the endovascular treatment for intracranial aneurysms.

METHODS

We enrolled a consecutive cohort of patients who underwent endovascular treatment for unruptured intracranial aneurysms. CIE was defined as a reversible neuropathic syndrome that occurred after interventional therapy, accompanied by imaging abnormalities and excluding other diseases. Multivariable Poisson regression analysis was performed to show risk factors by incidence rate ratio (IRR) and a clinical strategy was proposed.

RESULTS

Among the 579 patients who underwent interventional therapy for intracranial aneurysms, the crude incidence rate of CIE was 2.4% (95% CI, 1.2-3.6%) at our center. Headache, hemiplegia, and disorientation could be initial symptoms, and cortical blindness was the most common localized deficit. Cerebral edema and sulci effacement on CT were observed, and re-revaluation after treatments on CT/MRI showed absent lesions. The risk factors were history of stroke (IRR, 7.752; P = 0.007), history of hypertension (IRR, 1.064; P = 0.042), posterior circulation aneurysms (IRR, 9.412; P = 0.004) and higher dosage of contrast agents (IRR, 1.018; P = 0.007). After the strategy of accelerating excretion of contrast agents, reduction of intracranial pressure and anti-inflammation/vasospasm therapy, the prognosis was favorable with most patients fully recovered within 72 h.

CONCLUSION

History of stroke and posterior circulation aneurysms were main risk factors for CIE. A higher dosage of contrast agents might induce CIE, and the history of hypertension should be considered as well.

Fully Reversible Contrast-Induced Encephalopathy Mimicking Stroke after Flow Diverter Treatment of Carotid Cave Aneurysm

Contrast-induced encephalopathy (CIE) is a rare complication of coronary and neurointerventional procedures. The condition is believed to arise from endothelial damage secondary to exposure to iodinated contrast media. A wide spectrum of clinical manifestations has been reported including seizures, cortical blindness, and focal neurological deficits. This report details the case of fully reversible CIE mimicking severe anterior circulation stroke in a 55-year-old female following elective endovascular treatment with a flow diverter of a carotid cave aneurysm. The patient was managed conservatively with intravenous hydration and steroids and showed an excellent prognosis with supportive management.

Contrast-induced encephalopathy and permanent neurological deficit following cerebral angiography: A case report and review of the literature

Contrast-induced encephalopathy (CIE) is an uncommon complication associated with contrast exposure during angiographic procedures that is usually transient but occasionally leads to permanent complications or death. Due to the low incidence of CIE, there are still insufficient reports. This study was used to summarize the clinical features of CIE through a case report and systematic review. We summarized and reviewed 127 patients with CIE, and we found that the total incidence of CIE between men and women had no difference (49.61 and 50.39%, respectively), but the average age in female patients with CIE was older than that in male patients (62.19 and 58.77 years, respectively). Interestingly, the incidence of female patients with CIE in the poor prognosis group was significantly higher than that in the good prognosis group (62.50 and 36.51%, respectively), and the average age of these female patients in the poor prognosis group was younger than that in the good prognosis group (61.39 and 62.82 years, respectively). The contrast medium types were mainly nonionic (79.69 and 73.02%, respectively) and low-osmolar (54.69 and 71.43%, respectively) in both groups. Importantly, the total contrast media administrated in patients with poor prognoses was greater than that administrated in patients with good prognoses (198.07 and 188.60 ml, respectively). In addition, comorbidities in both groups included hypertension (55.91%), diabetes mellitus (20.47%), previous contrast history (15.75%), renal impairment (11.81%), and hyperlipidemia (3.15%). The percentage of patients with cerebral angiography was significantly higher in the poor prognosis group than that in the good prognosis group (37.50 and 9.52%, respectively), whereas the percentage of patients with coronary angiography in both groups had the opposite results (35.94 and 77.78%, respectively). In conclusion, CIE may not always have a benign outcome and can cause permanent deficits. Female gender, younger age, the higher dose of contrast medium, and the procedure of cerebral angiography may be related to the patient's poor prognosis.

Posterior reversible encephalopathy syndrome following coronary angiography

Posterior reversible encephalopathy syndrome (PRES) is a relatively rare neurotoxic disorder. A 56-year-old male underwent elective coronary angiography. A Few hours postprocedure, the patient developed bilateral painless vision loss, headache, vomiting and hypertension and was subsequently diagnosed with PRES. Possible trigger factors could be contrast agent used, or hypertension. Contrast agent-induced PRES in hypertensive patients is benign and reversible, and a high-grade suspicion about this possibility is critical for precise management. Our patient was successfully treated with supportive management and was doing well on follow-up.

Contrast-Induced Encephalopathy Presenting With Fever After Coronary Angiography: A Case Report

Contrast-induced encephalopathy (CIE) is a rare complication that occurs after exposure to contrast media, and it usually manifests with transient neurological deficits that include cortical blindness, altered mental status, and paralysis. It is self-limited, and symptoms usually resolve within 48-72 hours. It requires a high index of suspicion and must be taken into consideration in every patient developing a neurological manifestation after the administration of radiocontrast media. We report a case of post-coronary angiography contrast-induced encephalopathy with low-grade fever and negative imaging.

Contrast Media Adverse Drug Reactions in Highly Polluted Environment

Iodinated- (ICM) and gadolinium-based (GCM) contrast media are used in radiology imaging techniques, such as computer tomography (CT) and magnetic resonance (MR), respectively. The paper aims to analyze the adverse drug reactions of ICM and GCM on different sites of the body in a highly polluted environment. We analyzed the pharmacovigilance in contrast media on the basis of reports submitted to the Regional Center for Monitoring of Adverse Drug Reactions (ADR) at the Department of Clinical Pharmacology in Wrocław. Safety profiles were compared between different ICM and GCM and at the system organ level using the proportional reporting ratio (PRR). We analyzed 124 reports of adverse reactions related to contrast agents between 2006 and 2021. Our findings revealed that ADR combinations occurred more frequently after the use of iodinated contrast agents (72.08%) than gadolinium contrast agents (27.92%). Iomeprol and Iopromide were identified as the most frequently reported media. Each medium presented a different safety profile. Skin disorders are the most common adverse drug reactions among patients using both iodine- and gadolinium-based contrast media. Gadolinium-based contrast agents are characterized by similar organ toxicity. Conversely, iodine-based contrast agents are more diverse—some of which show tissue specificity, such as Iodixanol for the gastrointestinal system or Iohexol for the respiratory tract. This study shows relatively high occurrence of respiratory tract related ADRs in Wrocław. We also prove that it is possible to choose the most optimal contrast agent for patients with specific organ site problems to omit the possible complications.

Contrast-induced encephalopathy following cerebral angiography: A case report

The present study describes the case of patient with contrast-induced encephalopathy following cerebrovascular angiography, and presents the clinical and imaging features, as well as the treatment and prognosis of this patient. Following digital subtraction angiography, cortical blindness and cognitive dysfunction were the main complaints of the patient. The emergency craniocerebral CT scan revealed hyperdense areas in the bilateral cerebellum, thalamus, sulcus and cistern, and a review of the CT scan 24 h following the procedure revealed that the hyperintense lesions were reduced or resolved in these areas. The patient obtained a good prognosis following treatment anti-inflammatory and intracranial pressure reduction treatment. On the whole, the present study demonstrates that cognitive dysfunction may be a clinical manifestation of contrast-induced encephalopathy. Thus, the earlier diagnosis and earlier treatment are crucial for the prognosis of patients.

Contrast‐Induced encephalopathy following diagnostic coronary angiography

Contrast‐induced encephalopathy (CIE) is a rare, reversible complication of coronary angiography that can mimic acute strokes. This case illustrates the diagnostic challenges for a patient presenting with confusion following coronary angiography and raises awareness for CIE as diagnosis of exclusion.

Contrast-induced encephalopathy-neuroimaging findings and clinical relevance

Contrast-induced encephalopathy (CIE) is a rare encephalopathic condition after the administration of a contrast agent. The diagnosis of CIE is challenging because of the heterogeneity and non-specificity of the clinical presentation. The clinical course is usually favorable with full recovery within 48–72 h in most patients, although comorbidity is of relevance and contributes to the clinical outcome. It is expected that the incidence of CIE is currently increasing, due to an increase in endovascular and diagnostic imaging procedures using iodinated contrast. It is important to include CIE in the differential diagnosis when patients deteriorate during, or immediately after, contrast administration, even when only a small amount of non-ionic contrast agent is used. When CIE is considered to be the most likely explanation for the clinical symptoms, it is advised to refrain from unnecessary additional contrast studies such as angiography or perfusion CT.

Contrast-induced encephalopathy mimicking stroke after a second cerebral DSA: an unusual case report

Background

Contrast-induced encephalopathy (CIE) is a rare complication of the angiography process. CIE may mimic stroke symptoms clinically and subarachnoid hemorrhage radiologically. Previous CIE cases occurred after the initial digital subtraction angiography (DSA) scan. Here, we encountered an unusual case of CIE mimicking a stroke with an internal carotid artery (ICA) aneurysm and ipsilateral ICA stenosis that occurred after a second DSA procedure.

Case presentation

A 77-year-old female with a history of hypertension and coronary heart disease underwent two cerebral DSA procedures over 1 week. She was given the same nonionic and iso-osmolar Visipaque agent (smaller than 200 ml) for both procedures. However, neurological complications only occurred after the second DSA procedure. On the first diagnostic cerebral DSA, she was diagnosed with an intracranial aneurysm of the left ICA with moderate stenosis (approximately 50%) in the initial part of the ipsilateral ICA. However, after the second aneurysm embolization procedure by DSA, she developed right hemiplegia, aphasia, and epilepsy, mimicking left middle cerebral artery occlusion. An emergency CT showed a diffuse hyperdensity in the left subarachnoid space, mimicking SAH. MRI demonstrated that the lesion was hyperintense on T2WI, FLAIR imaging, and DWI but was normal on ADC mapping. On postoperative Day 6, her neurologic deficits had completely resolved after initial fluid restriction, corticosteroid treatment, and rehydration.

Conclusion

This case indicates that clinicians should consider the occurrence of CIE following any angiography procedure, even if the initial cerebral DSA procedure is successful and without complications.

Contrast Medium-Induced Encephalopathy After Coronary Angiography- Case Report

Introduction

Contrast-induced encephalopathy represents a rare, reversible complication that appears after intravenous or intra-arterial exposure to contrast agents. There is no consensus in the literature regarding the mechanism of action. However, the theoretical mechanism is set around the disruption of the blood-brain barrier and the contrast agents’ chemical properties.

Case report

The case of a 70-year-old patient, known to have hypertension and type 2 diabetes mellitus is reported. The patient had undergone a diagnostic coronary angiography during which he received 100ml of Ioversol (Optiray 350™). Soon after the procedure, the patient began experiencing a throbbing headache, followed by intense behavioural changes and aggressive tendencies. He was transferred to the Neurology Clinic. The neurological examination was without focal neurological signs; however, the patient was very aggressive and uncooperative. The CT scan revealed a mild hyper-density in the frontal lobes. MRI scan revealed no pathological changes. Conservative treatment with diuretics and hydration was administered, and the patient experienced a complete resolution of symptoms in 72 hours.

Conclusion

Contrast-induced encephalopathy is a possible secondary complication to contrast agents and a diagnostic challenge, and it should not be overlooked, especially following procedures that use contrast agents.

A Case Report of Contrast-Induced Encephalopathy after Repeated Percutaneous Transluminal Angioplasty for Acute Middle Cerebral Artery Occlusion

Objective

We report a case of contrast-induced encephalopathy (CIE) after repeated percutaneous transluminal angioplasty (PTA) for acute middle cerebral artery (MCA) occlusion.

Case Presentation

An 88-year-old woman with left hemiparesis was transferred to our hospital by ambulance. MRI revealed acute MCA M1 occlusion. We performed intravenous tissue plasminogen activator therapy and PTA for right MCA occlusion, leading to complete recanalization and improvement in hemiparalysis. After approximately one week, restenosis of right MCA developed and PTA was performed again on day 11. However, her left hemiparesis exacerbated shortly thereafter. CT demonstrated leakage of contrast medium, and an extensive high-intensity area (HIA) on the white matter in the right cerebral hemisphere was noted on MRI FLAIR. The HIA on MRI and neurological deficits gradually improved after conservative treatment, but diffuse atrophy of the right cerebral hemisphere occurred and higher brain dysfunction remained.

Conclusion

Repeated ischemia and reperfusion, and the frequent use of contrast media were considered the causes of CIE.

Case Report: A 62-Year-Old Woman With Contrast-Induced Encephalopathy Caused by Embolization of Intracranial Aneurysm

Contrast-induced encephalopathy (CIE) is a rare complication of endovascular treatment and is extensively reported as a transient and reversible phenomenon. This report describes a 62-year-old woman for embolization of an internal carotid artery (ICA) aneurysm. The operation was successful, but postoperation the patient suffered unconsciousness, blindness, hemiplegia, ophthalmoplegia, fever, and seizures. CT of the brain without the contrast showed widespread edema in the right cerebral hemisphere, which is involved in the frontal, parietal, temporal, and occipital lobes. She was diagnosed with CIE in time and treated with supportive management as soon as possible, and fortunately, the patient improved a benign course and was discharged without any neurological deficits. This study emphasizes the prevention of the CIE and the importance of early diagnosis and symptomatic treatment.

Reversible contrast-induced encephalopathy after coil embolization of epistaxis

A 37-year-old woman (35 weeks pregnant) was admitted to a local hospital due to severe epistaxis resulting in shock and the need for emergency cesarean section. After failure to tamponade the bleeding, angiographic treatment was provided. After the procedure, she was admitted to the neurocritical intensive care unit and was confused and agitated, requiring sedation and endotracheal intubation. In the intensive care unit, diagnostic investigations included brain magnetic resonance imaging, lumbar puncture with viral panel, electroencephalogram, tests for autoimmunity, and hydroelectrolytic and metabolic evaluations. Magnetic resonance imaging showed a puntiform restricted diffusion area on the left corona radiata on diffusion weighted imaging and mild cortical posterior edema (without restricted diffusion), and an electroencephalogram showed moderate diffuse slow activity and fronto-temporal slow activity of the left hemisphere with associated scarce paroxysmal components. The other exams did not show any relevant alterations. Due to the temporal relationship, the clinical history and the magnetic resonance imaging results, a diagnosis of contrast-induced encephalopathy was made. After 2 days in the intensive care unit, sedation was withdrawn, the patient was extubated, and total neurological recovery was verified within the next 24 hours.

Contrast-induced encephalopathy and permanent neurological deficit: A case report and literature review

Background:

Contrast-induced encephalopathy (CIE) is a rare condition that occurs after intravenous or intra-arterial contrast agent administration. Patients generally show different ranges of neurological deficits, which generally resolve themselves spontaneously within 24–48 h or in rare cases within 2 weeks.

Case Description:

We report a case of CIE in a 54-year-old woman during retreatment for recanalization of communicating anterior artery aneurysm and with no history of allergic reaction to contrast agent. After the procedure, the patient developed right hemiplegia and complete aphasia; an MRI performed at 6 days excluded any signs of new ischemia and revealed a hyperintense signal on FLAIR sequences in the left cortical precentral gyrus corresponding to a hyperintense signal on DWI, suggesting a vasogenic edema. After 6 months, she clinically improved even if her previous neurological status was never restored while radiological findings did not change.

Conclusion:

According to the literature, many risk factors may play a role in the pathogenesis of CIE: we hypothesized that, among all of them, chronic hypertension and previous cerebral ischemic lesions were the most important in our case. Further studies are necessary to find the correlation between possible risk factors and neurotoxicity.

Unusual Magnetic Resonance Imaging Findings Contrast-induced Encephalopathy following Cerebral Angiography

<p>Contrast-induced encephalopathy (CIE) following cerebral angiography has similar clinical presentations to ischemic complications of cerebral angiography. Neurologic deficits in CIE are mostly transient, but those caused by acute cerebral infarction (ACI) as ischemic complications of cerebral angiography may be permanent. Therefore, distinguishing CIE from ACI is important. Diffusion restriction on magnetic resonance imaging (MRI) implies ACI, while hyperintensity on diffusion weighted imaging (DWI) without correlation on the apparent diffusion coefficient (ADC) map implies CIE. We reported a rare case of CIE with diffusion restriction on MRI following cerebral angiography that mimicked MRI findings of ACI. The mechanism of this phenomenon remains unknown and requires further investigation.

Contrast-Induced Encephalopathy after Cerebral Angiogram: A Case Series and Review of Literature

Contrast-induced encephalopathy (CIE) is a rare complication that arises from exposure to iodinated contrast medium and can result in a range of symptoms, including cortical blindness, aphasia, focal neurological deficits, and altered mental status. We present 4 individual cases of CIE who presented with stroke-mimic symptoms following surgery with localized iodixanol or ioversol injection. We outline a clinical timeline of all patients, showing that CIE follows a general pattern of delayed onset, worsening symptomology, and ultimately full recovery. All patients received IV hydration, corticosteroids, or both as part of their treatment protocol.

Transient oculomotor paralysis after cerebral angiography: A case report

RATIONALE

A special case of transient oculomotor nerve palsy after cerebral angiography.

PATIENT CONCERNS

A 55-year-old man developed oculomotor nerve dysfunction after right radial artery puncture angiography.

DIAGNOSES

Cerebral angiography-induced oculomotor nerve palsy.

INTERVENTIONS

According to the patient's disease state, intravenous drip of dexamethasone 10 mg/d.

OUTCOMES

Magnetic resonance imaging (MRI) showed no abnormalities, and the patient recovered completely after 48 hours of hormone therapy.

LESSONS

Transient eye palsy caused by contrast agent encephalopathy is a clinically rare neurological dysfunction caused by adverse effects of contrast agents. Early prevention and correct treatment are critical.

[Iopromide-Induced Encephalopathy: A Case Report and Literature Review]

A 42-year-old male was admitted for paroxysmal syncope for 10 + months, chest tightness for 20 + days and chest pain for 10 + days. The patient was diagnosed with hypertrophic cardiomyopathy. The patient did not have a history of hypertension or diabetes. Coronary angiography and left ventricular cardiac catheterization were done in order to examine the coronary artery and the pressure gradient of the left ventricular outflow tract. The cardiac catheterization was performed via a right radial artery approach and a total of 200 mL of 370 mg I/mL iopromide was injected. The patient developed contrast-induced encephalopathy following the cardiac catheterization procedure, displaying severe headache, cortical blindness and neuropsychiatric symptom as the main clinical manifestations. The patient was then given symptomatic and supportive treatment, including decreasing intracranial pressure, analgesics and sedatives, and the patient recovered.

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.

Low-dose Contrast-induced Encephalopathy During Diagnostic Cerebral Angiography

Contrast-induced encephalopathy (CIE) is a rare complication of contrast agent use. We herein report a case of acute lacunar infarction in a 70-year-old woman. During diagnostic cerebral angiography for asymptomatic common carotid stenosis, she experienced transient drowsiness. After angiography, generalized tonic-clonic seizures occurred in her left arm and leg, with eye deviation to the left. The patient was diagnosed with CIE due to the acute onset of symptoms during angiography and characteristic computed tomography findings of high-density signaling in the cortex. Our findings suggest that it is important to pay close attention to acute neurological symptoms during and immediately after examinations, even with small amounts of contrast agents.

Cardiorespiratory arrest after iso-osmolar iodinated contrast injection: A case report of contrast-induced encephalopathy following contrast-enhanced computed-tomography

RATIONALE

Contrast-induced encephalopathy (CIE) is a rare complication caused by administration of intravascular contrast media and characterized by acute reversible neurological disturbance. Most of the CIE cases are reported after arterial administration of contrast media such as during cerebral or coronary angiographies, yet only a few articles have reported CIE secondary to intravenous contrast. A case of CIE secondary to intravenous contrast administration is reported here.

PATIENT CONCERNS

A 68-year-old man was admitted to our hospital for contrast-enhanced chest computed-tomography (CT) examination due to suspected pulmonary nodules. After CT examination, the patient lost consciousness and experienced a cardiorespiratory arrest. An emergency plain brain CT was done immediately which showed abnormal cortical contrast enhancement and cerebral sulci hyperdensity.

DIAGNOSES

After excluding other differential diagnoses such as electrolytes imbalance, hypo/hyperglycemia, cardiogenic pathologies and other neurological emergencies such as cerebral hemorrhage, cerebral infarction, the final diagnosis of CIE was made.

INTERVENTIONS

The patient was admitted to the intensive care unit for further management. A series of supportive treatments were arranged.

OUTCOMES

Follow-up visits at the outpatient clinic showed no lasting neurological deficits.

LESSONS

CIE should be considered as 1 of the differential diagnoses for a patient with acute neurologic symptoms after iodinate contrast administration. Neuroradiological imaging examinations are essential to rule out other etiologies such as acute cerebral infarction or intracranial hemorrhage.

Case Report and Literature Review on Low-Osmolar, Non-Ionic Iodine-Based Contrast-Induced Encephalopathy

Contrast-induced encephalopathy (CIE) is a rare complication following percutaneous carotid and coronary interventions, and important diagnostic radiological signs include brain edema and cortical enhancement. In this report, we detail a case of probable CIE in an 84-year-old woman following a normal diagnostic coronary angiography (CAG) that involved 20 mL of the low-osmolar, non-ionic monomeric, iodine-based contrast agent iopromide (Ultravist 370). The patient was unconscious and presented with hemiparesis, hemianopia, recurrent seizures, and cardiac and respiratory arrest within minutes to hours following the procedure. Non-contrast computed tomography (CT) of the head showed increased subarachnoid density, cortical enhancement, and brain edema in the right hemisphere. Three days of rehydration, reduction in cranial pressure, and treatment with an anticonvulsant and dexamethasone resulted in a gradual recovery with no neurological deficits. This case highlights that severe neurotoxic symptoms may occur in response to low doses of low-osmolar, non-ionic, monomeric contrast agents. This finding is of importance to interventional cardiologists for diagnostic considerations and development of treatment plans.

Contrast-induced neurotoxicity related to neurological endovascular procedures: a systematic review

Contrast-induced neurotoxicity (CIN) is an adverse reaction to contrast agents which can occur in the context of diagnostic and therapeutic neurological endovascular procedures. Our goal was to conduct a systematic review of patients reported in the literature diagnosed with CIN after neurological endovascular procedures. A systematic search of EMBASE and MEDLINE databases was conducted. Inclusion criteria were age ≥ 18 years; neurological endovascular procedure performed ≤ 24 h before ictus; new manifestations compatible with encephalic dysfunction; imaging performed < 7 days after ictus; exclusion of other causes and manifestations attributed to pre-existing conditions. Forty-eight patients were included, of which 60.4% were female and 60.4% had arterial hypertension; median age was 63 years. The most frequent procedure was diagnostic cerebral angiography (n = 24, 50.0%) and non-ionic contrast agents were more frequently used (n = 40, 83.3%). Twenty-six patients (54.2%) developed clinical manifestations compatible with CIN during or immediately after the procedure, and the most frequent manifestations were encephalopathy, cortical blindness and motor deficit. The most frequent imaging findings were cortical contrast enhancement on CT (n = 23/42), and cortical sulci effacement (n = 18/48). Most patients presented complete clinical recovery (89.6%) at a median time of 3 days. Among patients with neuroimaging changes who underwent follow-up, complete regression of the abnormalities was shown in 81.5% at a median time of 5 days. CIN is a rare adverse reaction in the context of neurological endovascular procedures. Recognition of clinical manifestations and typical imaging abnormalities, while excluding other causes, is essential for diagnosis.

Iodine levels in different regions of the human brain

BACKGROUND

Iodine is a key component of the thyroid hormones thyroxine (T4) and triiodothyronine (T3), which are crucial for proper growth and development of the human body. In particular, a great body of literature has been published on the link between thyroid hormones and brain development and functioning. However, there is a lack of knowledge on the iodine levels in the human brain. The aim of this work was to determine the brain iodine levels and to contribute to the establishment of "reference" levels for iodine in the different anatomical and functional regions of normal (i.e., subjects without neurological or psychiatric diseases) human brain.

METHODS

The iodine levels were determined in 14 brain regions of 52 dead subjects without evidence of neurological or psychiatric disease (n = 728 samples). Iodine was extracted from brain samples using a standard procedure and determined by inductively coupled plasma - mass spectrometry (ICP-MS).

RESULTS

Four subjects presented abnormally high brain iodine levels (26.0 ± 14.2 μg/g) and were excluded from the overall data analysis. The average brain iodine levels for the remaining 48 subjects was 0.14 ± 0.13 μg/g dry weight. Iodine showed very heterogeneous distribution across the different brain regions, with the frontal cortex, caudate nucleus and putamen showing the highest levels. Interestingly, these brain regions are closely related to cognitive function. Iodine levels also showed a tendency to increase with age. The high levels observed in four subjects seemed to be related to previous exposure to iodine-based contrast agents widely used in radiology and computed tomography exams.

CONCLUSIONS

This paper provides important data on iodine levels at different brain regions in "normal" people, which can be used to interpret eventual imbalances in subjects with mental disorders and neurodegenerative diseases.

Application of spectral CT in the diagnosis of contrast encephalopathy following carotid artery stenting: a case report

BACKGROUND

Contrast encephalopathy is a rare complication of carotid artery stenting (CAS). Contrast encephalopathy is a diagnosis of exclusion that often needs to be distinguished from high perfusion syndrome, cerebral haemorrhage, subarachnoid haemorrhage (SAH), cerebral infarction and so on.

CASE PRESENTATION

In this study, we report on a 70-year-old man who was admitted to the hospital with transient ischaemic attacks presenting paroxysmal weakness of limbs in the previous 2 years. He had severe stenosis of the left internal carotid artery diagnosed by digital subtraction angiography (DSA) and underwent CAS. Two hours after the operation, the patient developed paralysis of the right upper limb, unclear speech, fever and restlessness. Emergency skull computed tomography (CT) showed swelling and a linear high-density area in the left cerebral hemisphere. To clarify the components of this high-density area in the traditional CT, the patient had spectral CT, which made the diagnosis of the leakage of contrast clear. After 1 week of supportive treatment, the patient improved.

CONCLUSIONS

Spectral CT can easily distinguish the components of high-density areas on traditional CT, which is haemorrhage, calcification or iodine contrast leakage. Therefore, spectral CT is worth consideration for the differential diagnosis of complications of vascular intervention.

Greater intraprocedural systolic blood pressure and blood pressure variability are associated with contrast-induced neurotoxicity after neurointerventional procedures

BACKGROUND

Contrast-induced neurotoxicity (CIN) is a rare complication of neurointerventional procedures and its understanding remains limited. We evaluated the association of CIN with systemic hemodynamics in patients undergoing neuroendovascular interventions.

METHODS

We conducted a 1:2 matched case-control study from a prospectively collected database of 2510 neurointerventional patients. We defined CIN as new neurological deficits presented ≤24 h post-operation after excluding other possible etiologies. We obtained demographic, clinical and imaging data, and baseline and intraprocedural blood pressures (BP) from medical records. The area between baseline and intraprocedural BP was used to measure sustained variability of BP over time. A generalized linear mixed model and generalized estimating equation were used to analyze the BP difference between groups over time.

RESULTS

We evaluated 11 CIN cases and 22 controls. 2746 and 5837 min of continued BP data were analyzed for cases and controls, respectively. CIN cases had higher measurements and greater variability for: Systolic BP (SBP) [median 125 (IQR:121-147) vs. 114 (IQR:107-124) mmHg], median area above baseline [median 350 (IQR:25-1328) vs. 52 (IQR:0-293) mmHg*minutes] and mean arterial pressure (MAP) [median 85 (IQR:79-98) vs. 80 (IQR:74-89) mmHg]. CIN cases demonstrated a significant mean increase in SBP and MAP of 23.41 mmHg (p < 0.01) and 13.79 mmHg (p < 0.01) when compared to controls, respectively, over the perioperative time.

CONCLUSION

Sustained hypertension and high BP variability may contribute to the pathophysiology of CIN. Acute hypertension can increase blood-brain barrier permeability and potentially allow contrast to leak into the brain parenchyma causing direct toxicity and CIN symptoms.

Contrast-induced encephalopathy mimicking total anterior circulation stroke: a case report and review of the literature

INTRODUCTION

Contrast-induced encephalopathy is a rare and usually reversible entity due to the administration of iodinated contrast. Clinical manifestations include cortical blindness, encephalopathy, seizures and focal neurological deficits.

METHODS

We report the case of a 56-year-old woman who developed global aphasia and right hemiplegia after a cerebral angiography performed for a subarachnoid haemorrhage. A prompt brain MRI resulted negative, while CT scan revealed left cerebral oedema with the cerebral sulci effacement. Complete recovery was observed in 10 days.

DISCUSSION

Diagnosis of contrast-induced encephalopathy requires a temporal correlation between neurological dysfunction and administration of iodinated contrast. Usually, the symptomatology is transient with a full recovery within 48-72 h. The most common symptom is cortical blindness, while other symptoms have been rarely reported. Only 20 cases previously reported global aphasia and/or hemiplegia or mimed anterior circulation strokes. Prompt brain neuroimaging is essential in order to exclude an alternative diagnosis that requires a distinct therapeutic approach.

Rare Cases of Contrast-Induced Encephalopathies

Cortical blindness (CB) due to contrast-induced encephalopathy is a rare complication in endovascular procedure. Although exact mechanism is not known, disruption of blood–brain barrier (BBB) by contrast agent is supposed to be caused. We report two cases of contrast-induced encephalopathies after coil embolization of unruptured aneurysm. A 68-year-old woman with unruptured basilar artery aneurysm was treated with endovascular stent-assisted coil embolization. The procedure was successfully accomplished within 172 min using about 160 ml of contrast medium (iopamidol). However, she manifested with CB 3 h after the procedure and seizure on the next day. Immediate computed tomography revealed the cortical enhancement in both occipital lobes. Diffusion-weighted imaging–magnetic resonance imaging and fluid-attenuated inversion recovery sequence 1 day after the procedure revealed edema in both occipital lobes with no findings of ischemia or hyperperfusion. Electroencephalography showed sharp and slow waves in both occipital lobes. She required endotracheal intubation on day 2 to maintain airways and breathing. Her sensorium improved 4 days after the procedure with administration of steroid and anticonvulsant. She was extubated on day 4 after the procedure. She was discharged with persisting CB as a sequel.

Does Systemic Lupus Erythematosus Increase the Risk of Procedure-Related Complication in Endovascular Treatment of Intracranial Aneurysm?

Cerebral aneurysms associated with systemic lupus erythematosus (SLE) are more likely to grow rapidly and rupture, compared to those found in the general population. The main underlying pathology of intracranial aneurysm and its rupture is presumed to be SLE-related intracranial vasculitis and fragility of blood vessels due to prolonged use of steroid. For these reasons, both surgical and endovascular options are challenging. On the other hand, given the possibility that SLE may predispose to growth and rupture of intracranial aneurysm, early intervention for cerebral aneurysms associated with SLE may be more necessary and beneficial than other cerebral aneurysms in the general population. Here we would like to report on the unexpected complications that occurred during or after endovascular treatment of an SLE patient with multiple aneurysms. The complications include intraprocedural rupture of unruptured aneurysm, coil stretching, contrast-induced encephalopathy, and delayed ipsilateral intraparenchymal hemorrhage after stent-assisted coiling. Our unique case highlights that the SLE patient with multiple intracranial aneurysms had a higher risk of endovascular procedure-related complications, which might be due to the increased bleeding tendency and fragility of blood vessels.