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Heemelaar JC, van der Hoeven NW, Muller FF, Appelman Y. Acute-onset coma after iso-osmolar iodinated contrast injection: a case report of contrast-induced encephalopathy after elective coronary angiography. Eur Heart J Case Rep 2019; 2:yty132. [PMID: 31020208 PMCID: PMC6426011 DOI: 10.1093/ehjcr/yty132] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 10/24/2018] [Indexed: 12/16/2022]
Abstract
Background Contrast-induced encephalopathy (CIE) is a rare complication of coronary angiography (CAG) caused by a direct neurotoxic reaction to iodinated contrast medium. Contrast-induced encephalopathy can result in a variety of neurological symptoms following within minutes to hours after contrast injection. It manifests most frequently as transient cortical blindness, headache, or confusion. In the majority of known cases, symptoms completely resolve solely with supportive care. We present a case where CIE takes a more dramatic course. Case summary A 67-year-old woman was scheduled for elective CAG, due to progressive typical chest pain. Within minutes after injection of iso-osmolar iodinated contrast medium, the patient showed a sudden decline in consciousness while all other vital functions remained normal. Shortly, after the patient was admitted to the intensive care unit due to acute-onset coma and respiratory insufficiency. A computed tomography scan of the brain showed bilateral cerebral oedema, which in combination with the development of symptoms after contrast injection led to the diagnosis of CIE. Remarkable decrease of cerebral oedema was observed 1 day later and slowly clinical recovery ensued. After 23 days, the patient was discharged from the cardiology ward. Follow-up at the outpatient clinic showed no lasting neurological deficits. Discussion While most symptoms of CIE are relatively mild and transient in nature, we describe a more devastating course that occurred with the use of only a low quantity of iso-osmolar contrast medium. We emphasize that even the more severe manifestations of CIE can develop at any dosage, and with all types of iodinated contrast medium.
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Affiliation(s)
- Julius C Heemelaar
- Department of Cardiology, VU University Medical Center, De Boelelaan 1117, HV Amsterdam, The Netherlands
| | - Nina W van der Hoeven
- Department of Cardiology, VU University Medical Center, De Boelelaan 1117, HV Amsterdam, The Netherlands
| | - Fenna F Muller
- Department of Neurology, VU University Medical Center, De Boelelaan 1117, HV Amsterdam, The Netherlands
| | - Yolande Appelman
- Department of Cardiology, VU University Medical Center, De Boelelaan 1117, HV Amsterdam, The Netherlands
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Narata AP, Janot K, Bibi R, Herbreteau D, Perrault C, Marzo A, Cottier JP. Reversible Brain Edema Associated with Flow Diverter Stent Procedures: A Retrospective Single- Center Study to Evaluate Frequency, Clinical Evolution, and Possible Mechanism. World Neurosurg 2018; 122:e569-e576. [PMID: 30394357 DOI: 10.1016/j.wneu.2018.10.103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 10/14/2018] [Accepted: 10/16/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Hemorrhage and ischemia after flow diverter stent (FDS) procedures for intracranial aneurysms are the most common complications and have been extensively described. Temporary brain edema (TBE) is an unknown complication that could be associated with particular FDS procedures. OBJECTIVE To estimate the frequency, clinical presentation, imaging findings, and possible mechanisms associating TBE with FDS. METHODS Unruptured aneurysms treated with FDS implantation performed in our service from June 2015 to March 2018 were reviewed. Medical antecedents, endovascular procedure, clinical assessments before and after treatment, aneurysm characteristics, and image records were collected. Artery diameters of patients in whom TEB developed were also calculated to investigate any correlation between TBE and anatomic descriptors. RESULTS A total of 179 FDS procedures in 176 patients were reviewed. Six patients (3.4%) presented with symptomatic TBE, and all TBE patients had undergone FDS implantation from the middle cerebral artery (MCA) to the internal carotid artery (ICA). A Pearson product-moment correlation coefficient (PPCC) found smaller MCA diameters and MCA/ICA ratios in these 6 patients (respectively PPCC = -0.619, P < 0.04; PPCC = -0.647, P < 0.03). Hemorrhagic and ischemic complications were less frequent than TBE (2.3% and 1.1% vs. 3.4%). CONCLUSIONS TBE was more frequent than ischemic or hemorrhagic complications after FDS in this study. TBE seemed to be associated with a particular FDS positioning in small arteries, inducing flow changes and disruption of the blood-brain barrier.
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Affiliation(s)
- Ana Paula Narata
- Department of Radiology and Neuroradiology, University Hospital of Tours, France.
| | - Kevin Janot
- Department of Radiology and Neuroradiology, University Hospital of Tours, France
| | - Richard Bibi
- Department of Radiology and Neuroradiology, University Hospital of Tours, France
| | - Denis Herbreteau
- Department of Radiology and Neuroradiology, University Hospital of Tours, France
| | - Cecile Perrault
- Mechanical Engineering Department, University of Sheffield, United Kingdom
| | - Alberto Marzo
- Mechanical Engineering Department, University of Sheffield, United Kingdom
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53
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Eleftheriou A, Rashid AS, Lundin F. Late Transient Contrast-Induced Encephalopathy after Percutaneous Coronary Intervention. J Stroke Cerebrovasc Dis 2018; 27:e104-e106. [DOI: 10.1016/j.jstrokecerebrovasdis.2017.12.051] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 12/18/2017] [Accepted: 12/31/2017] [Indexed: 10/18/2022] Open
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54
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Pokersnik JA, Liu L, Simon EL. Contrast-induced encephalopathy presenting as acute subarachnoid hemorrhage. Am J Emerg Med 2018; 36:1122.e3-1122.e4. [DOI: 10.1016/j.ajem.2018.03.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 03/02/2018] [Indexed: 11/27/2022] Open
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55
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Spina R, Simon N, Markus R, Muller DWM, Kathir K. Author reply. Intern Med J 2018; 48:605-606. [DOI: 10.1111/imj.13783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 02/03/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Roberto Spina
- Department of Cardiology; St Vincent's Hospital; Sydney New South Wales Australia
| | - Neil Simon
- Department of Neurology; St Vincent's Hospital; Sydney New South Wales Australia
- University of New South Wales; Sydney New South Wales Australia
| | - Romesh Markus
- Department of Neurology; St Vincent's Hospital; Sydney New South Wales Australia
| | - David W. M. Muller
- Department of Cardiology; St Vincent's Hospital; Sydney New South Wales Australia
- University of New South Wales; Sydney New South Wales Australia
| | - Krishna Kathir
- Department of Cardiology; St Vincent's Hospital; Sydney New South Wales Australia
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56
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Schilling C, Weilenmann D, Diener S, Hundsberger T. [A Rare Cause for Transient Aphasia after Conorary Angiography]. PRAXIS 2018; 107:531-534. [PMID: 29690845 DOI: 10.1024/1661-8157/a002977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Zusammenfassung. Wir berichten über eine 72-jährige Patientin, die nach einer elektiven Koronarangiografie über plötzlich einsetzende stärkste Kopfschmerzen klagte. Klinisch bestand eine dysphasische Aphasie, die sich rasch progredient zu einer globalen Aphasie und einem deliranten Zustandsbild entwickelte. Nach dem Ausschluss alternativer Differenzialdiagnosen gingen wir von der seltenen Komplikation einer kontrastmittelinduzierten Enzephalopathie nach Koronarangiografie aus.
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Affiliation(s)
- Carin Schilling
- 1 Klinik für Allgemeine Innere Medizin, Kantonsspital St. Gallen
| | | | - Suzie Diener
- 3 Klinik für Neurologie, Kantonsspital St. Gallen
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57
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Montejo C, Rodríguez A, Pascual-Vicente M, Renú A. Transient contrast-induced encephalopathy after internal carotid artery embolisation prior to surgery for nasopharyngeal carcinoma. Neurologia 2018. [PMID: 29530435 DOI: 10.1016/j.nrl.2018.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Affiliation(s)
- C Montejo
- Servicio de Neurología, Hospital Clínic de Barcelona, Barcelona, España
| | - A Rodríguez
- Servicio de Neurología, Hospital Clínic de Barcelona, Barcelona, España
| | - M Pascual-Vicente
- Servicio de Neurología, Hospital Clínic de Barcelona, Barcelona, España
| | - A Renú
- Servicio de Neurología, Hospital Clínic de Barcelona, Barcelona, España.
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58
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A Seizure and Hemiplegia following Contrast Exposure: Understanding Contrast-Induced Encephalopathy. Case Rep Med 2018; 2018:9278526. [PMID: 29686712 PMCID: PMC5857315 DOI: 10.1155/2018/9278526] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 02/06/2018] [Indexed: 12/27/2022] Open
Abstract
Contrast-induced encephalopathy is a rare, reversible phenomenon known to occur after intravenous or intra-arterial contrast exposure. This report describes a case involving a 73-year-old female admitted for an elective thoracic aortic aneurysm repair. During the procedure, a large volume of nonionic iodinated contrast was necessary for arteriography. Postoperatively, the patient developed seizure activity followed by left-sided hemiplegia. Computed tomography (CT) of the brain without contrast and magnetic resonance imaging (MRI) were negative for acute stroke but did show residual contrast surrounding the brain. Antiepileptic medications were administered with resolution of the seizure activity. The patient was treated with supportive management and improved to baseline over the next seven days. This case demonstrates a rare, nonionic iodinated contrast-induced encephalopathy with seizure activity and transient hemiplegia. The unique imaging findings differentiate it from other neurologic conditions.
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59
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Contrast-induced encephalopathy after coronary angioplasty in a patient with ST-elevation myocardial infarction. HEART ASIA 2018; 10:e010987. [DOI: 10.1136/heartasia-2017-010987] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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60
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Suthiphosuwan S, Hsu CCT, Bharatha A. HARMless: Transient Cortical and Sulcal Hyperintensity on Gadolinium-Enhanced FLAIR after Elective Endovascular Coiling of Intracranial Aneurysms. AJNR Am J Neuroradiol 2018; 39:720-726. [PMID: 29472303 DOI: 10.3174/ajnr.a5561] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 12/15/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND PURPOSE Cortical and sulcal hyperintensity on gadolinium-enhanced FLAIR has been increasingly recognized after iodinated contrast medium exposure during angiographic procedures. The goal of this study was to assess the relationship of cortical and sulcal hyperintensity on gadolinium-enhanced FLAIR against various variables in patients following elective endovascular treatment of intracranial aneurysms. MATERIALS AND METHODS We performed a retrospective review of 58 patients with 62 MR imaging studies performed within 72 hours following endovascular treatment of intracranial aneurysms. Patient demographics, aneurysm location, and vascular territory distribution of cortical and sulcal hyperintensity on gadolinium-enhanced FLAIR were documented. Analysis of cortical and sulcal hyperintensity on gadolinium-enhanced FLAIR with iodinated contrast medium volume, procedural duration, number of angiographic runs, and DWI lesions was performed. RESULTS Cortical and sulcal hyperintensity on gadolinium-enhanced FLAIR was found in 32/62 (51.61%) post-endovascular treatment MR imaging studies, with complete resolution of findings in all patients on the available follow-up studies (27/27). Angiographic iodinated contrast medium injection and arterial anatomy matched the vascular distribution of cortical and sulcal hyperintensity on gadolinium-enhanced FLAIR. No significant association was found between cortical and sulcal hyperintensity on gadolinium-enhanced FLAIR with iodinated contrast medium volume (P = .56 value) and the presence of DWI lesions (P = .68). However, a significant association was found with procedural time (P = .001) and the number of angiographic runs (P = .019). No adverse clinical outcomes were documented. CONCLUSIONS Cortical and sulcal hyperintensity on gadolinium-enhanced FLAIR is a transient observation in the arterial territory exposed to iodinated contrast medium during endovascular treatment of intracranial aneurysms. Cortical and sulcal hyperintensity on gadolinium-enhanced FLAIR is significantly associated with procedural time, and the frequency of angiographic runs suggesting a potential technical influence on the breakdown of the BBB, but no reported adverse clinical outcome or association with both iodinated contrast medium volume and DWI lesions was found. Recognition of cortical and sulcal hyperintensity on gadolinium-enhanced FLAIR as a benign incidental finding is vital to avoid unnecessary investigation.
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Affiliation(s)
- S Suthiphosuwan
- From the Division of Diagnostic and Interventional Neuroradiology, Department of Medical Imaging (S.S., C.C.-T.H., A.B.)
| | - C C-T Hsu
- From the Division of Diagnostic and Interventional Neuroradiology, Department of Medical Imaging (S.S., C.C.-T.H., A.B.)
| | - A Bharatha
- From the Division of Diagnostic and Interventional Neuroradiology, Department of Medical Imaging (S.S., C.C.-T.H., A.B.).,Division of Neurosurgery, Department of Surgery (A.B.), St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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61
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Transient trochlear nerve palsy following percutaneous angioplasty. ACTA ACUST UNITED AC 2018; 93:398-401. [PMID: 29398228 DOI: 10.1016/j.oftal.2017.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 11/06/2017] [Accepted: 11/09/2017] [Indexed: 11/22/2022]
Abstract
CASE REPORT A case is presented of a 63-year-old man who suffered a unilateral isolated trochlear nerve palsy with vertical diplopia following an elective radial coronary angiography and percutaneous coronary intervention, which resolved spontaneously within 2 months. DISCUSSION Ophthalmoplegia following coronary percutaneous angioplasty is rare. Only internuclear ophthalmoplegia, III and VI cranial nerve palsy have been previously reported following percutaneous angioplasty. This is the first reported case of unilateral isolated trochlear nerve ophthalmoplegia following this procedure.
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62
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Dattani A, Au L, Tay K, Davey P. Contrast-Induced Encephalopathy following Coronary Angiography with No Radiological Features: A Case Report and Literature Review. Cardiology 2018; 139:197-201. [DOI: 10.1159/000486636] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Accepted: 12/31/2017] [Indexed: 12/17/2022]
Abstract
Contrast-induced encephalopathy (CIE) following coronary angiography (CAG) is a very rare complication. Radiological signs such as cerebral oedema and cortical enhancement are of great importance in the diagnosis. We report a case of probable CIE in a 76-year-old gentleman following a normal diagnostic CAG that involved 120 mL of the iodinated contrast agent iohexol (Omnipaque 300). At 90 min postprocedure he became acutely confused with a normal non-contrast CT of the head. After 9 days of conservative treatment, the patient recovered spontaneously with no neurological deficits. This case and a review of the literature highlights that contrast-induced neurotoxicity may not always present with the typical radiological signs that are described in association with CIE. Given the excellent prognosis with supportive management only, interventional cardiologists should be well aware of this condition despite the absence of radiological features.
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63
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Shi F, Shen L, Shi Y, Shi L, Yang X, Jin Z, Liu W, Wu D. Posterior reversible encephalopathy syndrome after postpartum hemorrhage and uterine artery embolization: A case report. Medicine (Baltimore) 2017; 96:e8973. [PMID: 29245268 PMCID: PMC5728883 DOI: 10.1097/md.0000000000008973] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
RATIONALE Posterior reversible encephalopathy syndrome (PRES) is characterized by clinical and radiological features, including headache, disturbed consciousness, seizures, and cortical blindness associated with findings indicating posterior leukoencephalopathy on imaging studies. Ours is the first case of PRES developing after postpartum hemorrhage and uterine artery embolization. PATIENT CONCERNS An 18-year-old patient had postpartum hemorrhage after a normal delivery. She required uterine artery embolization to stop the bleeding; however, she developed PRES 2 hours after the surgery. DIAGNOSES Brain computed tomography suggested subarachnoid hemorrhage or cerebral venous sinus thrombosis. However, findings on magnetic resonance imaging were highly indicative of PRES. INTERVENTIONS The patient received diazepam and midazolam to prevent seizures. OUTCOMES Seizures were controlled on the first day. The patient's visual acuity returned to normal on the fourth day of admission. Thirteen days after admission, her neurological signs and symptoms were completely managed. LESSONS PRES may be related to postpartum hemorrhage, blood pressure fluctuation, inflammation, and contrast agents. Collectively, they cause a breakage in the blood-brain barrier and endothelial cell damage, eventually leading to PRES. We also found PRES had many features similar with contrast-induced encephalopathy.
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64
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Piršić A, Šipić T, Štambuk K, Budinčević H. Acute ischemic stroke mimicking subarachnoid hemorrhage after coronary angioplasty. ROMANIAN JOURNAL OF INTERNAL MEDICINE = REVUE ROUMAINE DE MÉDECINE INTERNE 2017; 55:175-177. [PMID: 28306544 DOI: 10.1515/rjim-2017-0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Indexed: 11/15/2022]
Abstract
Use of non-ionic contrast media (CM) in coronary arteriography has been reported to cause transient cortical blindness, confusion, amnesia and very rare focal deficits. We report a 69-year old patient with stable angina pectoris who underwent coronary angioplasty with stent placement due to in-stent thrombosis of the right coronary artery and developed stroke symptoms with radiological suspicion of subarachnoid hemorrhage. No vascular malformations were detected on CT cerebral angiography. Dual antiplatelet treatment was continued. Complete neurological recovery was observed within 48 hours post angiography. As observed with repeated CT scans, sulcal hyperdensities mostly faded after 24 hours and totally disappeared within 7 days when she was discharged home. Our case shows transient neurological symptoms and rapid disappearing of sulcal hyperdensities, suggesting temporary blood brain barrier disruption, consequential cerebral infarction and contrast media extravasation as the main mechanisms which allowed us to treat the patient with dual antiplatelet treatment.
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65
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Hamra M, Bakhit Y, Khan M, Moore R. Case report and literature review on contrast-induced encephalopathy. Future Cardiol 2017. [PMID: 28621151 DOI: 10.2217/fca-2016-0075] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Contrast-induced encephalopathy (CIE) is a rare neurological complication following the administration of injectable intravascular contrast media. Patients with CIE present a wide spectrum of symptoms such as headache, transient cortical blindness, seizure and focal neurological deficits. The diagnosis of CIE requires a high index of suspicion. Its early recognition is of paramount importance in instituting the appropriate supportive treatment in the form of intravenous fluids and also in avoiding unnecessary potentially harmful treatment such as intravenous thrombolysis for suspected ischemic stroke. Here, we report the case of a 62-year-old male patient with a typical presentation of CIE immediately following coronary angiography. We then continue to briefly review the relevant literature on CIE to date.
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Affiliation(s)
- Mardi Hamra
- Cardiology Department, Royal Infirmary of Edinburgh, 51 Little France Cres, Edinburgh, Scotland, EH16 4SA, UK
| | - Yasir Bakhit
- Cardiology Department, Freeman Hospital, Freeman Rd, Newcastle upon Tyne, NE7 7DN, UK
| | - Mahboob Khan
- Department of Stroke Medicine, Cumberland Infirmary, Newtown Rd, Carlisle, CA2 7HY, UK
| | - Roger Moore
- Cardiology Department, Cumberland Infirmary, Newtown Rd, Carlisle, CA2 7HY, UK
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66
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Pagani-Estévez GL, Nasr DM, Brinjikji W, Perry A, Fugate JE. Dual-Energy CT to Diagnose Pseudoedema in Contrast-Induced Encephalopathy Following Cerebral Angiography. Neurocrit Care 2017; 27:261-264. [DOI: 10.1007/s12028-017-0394-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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67
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Chien CF, Huang P, Hsieh SW. Reversible global aphasia as a side effect of quetiapine: a case report and literature review. Neuropsychiatr Dis Treat 2017; 13:2257-2260. [PMID: 28894370 PMCID: PMC5584915 DOI: 10.2147/ndt.s141273] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Quetiapine is an atypical antipsychotic agent which is also prescribed for delirium due to its anti-dopaminergic effects; aphasia is an unusual side effect associated with the drug. Here, we report the case of an 83-year-old woman who was prescribed quetiapine (50 mg per day) for delirium. Unexpected, global aphasia occurred 3 days after treatment began. Complete recovery occurred following discontinuation of the drug. A brain computed tomography scan excluded intracranial hemorrhage and the laboratory results confirmed that no exacerbation of infection or electrolyte imbalances were present. During the aphasic episode, the patient's condition did not deteriorate and no new neurological symptoms occurred. We suspect that the occurrence of aphasia was directly due to an adverse reaction to quetiapine. To our knowledge, this is the first case report of reversible, global aphasia as a side effect of quetiapine. We propose that this occurrence of aphasia may be due to the action of quetiapine as a dopamine receptor antagonist. Clinicians should use quetiapine with caution, especially in elderly patients. On observation of aphasia, a review of the patient's medical history is required to assess for the usage of quetiapine.
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Affiliation(s)
- Ching-Fang Chien
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Poyin Huang
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Department of Neurology, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan
| | - Sun-Wung Hsieh
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Department of Neurology, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan
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