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Vaishnav D, Essibayi MA, Toma A, Liriano G, Perkash RS, Stock A, Holland R, Dmytriw AA, Wolfe SQ, Al Kasab S, Spiotta A, Haranhalli N, Altschul DJ. Metal allergy and neurovascular stenting: A systematic review. Interv Neuroradiol 2024:15910199231226283. [PMID: 38225179 DOI: 10.1177/15910199231226283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2024] Open
Abstract
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.
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Affiliation(s)
- Dhrumil Vaishnav
- Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Muhammed Amir Essibayi
- Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Aureliana Toma
- Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Genesis Liriano
- Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Raja Sandeep Perkash
- Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ariel Stock
- Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ryan Holland
- Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Neurovascular Centre, Departments of Medical Imaging & Neurosurgery, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Stacey Q Wolfe
- Department of Neurosurgery, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Sami Al Kasab
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - Alejandro Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - Neil Haranhalli
- Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - David J Altschul
- Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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Martio AE, Kieling DM, Manzato LB, Vanzin JR. Overt nickel and cobalt hypersensitivity after pipeline embolization device placement: A case report. Brain Circ 2024; 10:85-88. [PMID: 38655437 PMCID: PMC11034441 DOI: 10.4103/bc.bc_85_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 09/19/2023] [Accepted: 09/28/2023] [Indexed: 04/26/2024] Open
Abstract
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.
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Affiliation(s)
- Artur Eduardo Martio
- Division of Interventional Neuroradiology, Passo Fundo Clinics Hospital, Passo Fundo, RS, Brazil
| | - Daniel Marchi Kieling
- Division of Interventional Neuroradiology, Passo Fundo Clinics Hospital, Passo Fundo, RS, Brazil
| | - Luciano Bambini Manzato
- Division of Interventional Neuroradiology, Passo Fundo Clinics Hospital, Passo Fundo, RS, Brazil
| | - José Ricardo Vanzin
- Division of Interventional Neuroradiology, Passo Fundo Clinics Hospital, Passo Fundo, RS, Brazil
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3
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Tjen VH, Yang PZ. Nickel-related hypersensitivity reactions following endovascular interventions: A review of current evidence. Sci Prog 2023; 106:368504231200626. [PMID: 37872684 PMCID: PMC10594965 DOI: 10.1177/00368504231200626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
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.
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Affiliation(s)
| | - Paul Zichu Yang
- School of Medicine, University of Glasgow, Glasgow, UK
- Department of Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, UK
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Baranoski JF, Catapano JS, Rutledge C, Cole TS, Majmundar N, Winkler EA, Srinivasan VM, Jadhav AP, Ducruet AF, Albuquerque FC. Endovascular Treatment of Cerebrovascular Lesions Using Nickel- or Nitinol-Containing Devices in Patients with Nickel Allergies. AJNR Am J Neuroradiol 2023; 44:939-942. [PMID: 37474263 PMCID: PMC10411833 DOI: 10.3174/ajnr.a7936] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 06/11/2023] [Indexed: 07/22/2023]
Abstract
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.
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Affiliation(s)
- J F Baranoski
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - J S Catapano
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - C Rutledge
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - T S Cole
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - N Majmundar
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - E A Winkler
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - V M Srinivasan
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - A P Jadhav
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - A F Ducruet
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - F C Albuquerque
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Levitt MR, Vanent KN, Federico EM, Bass DI, Barros G, Keen J. Response to: Correspondence on "Nickels and tines: the myth of nickel allergy in intracranial stents" by Apostolos et al. J Neurointerv Surg 2022; 14:1287-1288. [PMID: 35236769 DOI: 10.1136/neurintsurg-2022-018859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 02/24/2022] [Indexed: 11/03/2022]
Affiliation(s)
- Michael R Levitt
- Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA .,Radiology, University of Washington, Seattle, Washington, USA.,Mechanical Engineering, University of Washington, Seattle, Washington, USA
| | - Kevin N Vanent
- Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Emma M Federico
- Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA.,Stroke & Applied Neuroscience Center, University of Washington, Seattle, Washington, USA
| | - David I Bass
- Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Guilherme Barros
- Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Jade Keen
- Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA.,Stroke & Applied Neuroscience Center, University of Washington, Seattle, Washington, USA
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6
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Vanent KN, Federico EM, Bass DI, Barros G, Keen J, Levitt MR. Nickels and tines: the myth of nickel allergy in intracranial stents. J Neurointerv Surg 2022; 14:1244-1247. [PMID: 34987071 DOI: 10.1136/neurintsurg-2021-018365] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 12/18/2021] [Indexed: 11/04/2022]
Abstract
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.
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Affiliation(s)
- Kevin N Vanent
- School of Medicine, University of Washington, Seattle, WA, USA
| | - Emma M Federico
- Neurological Surgery, University of Washington, Seattle, Washington, USA.,Stroke & Applied Neuroscience Center, University of Washington, Seattle, Washington, USA
| | - David I Bass
- Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Guilherme Barros
- Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Jade Keen
- Neurological Surgery, University of Washington, Seattle, Washington, USA.,Stroke & Applied Neuroscience Center, University of Washington, Seattle, Washington, USA
| | - Michael R Levitt
- Neurological Surgery, University of Washington, Seattle, Washington, USA .,Stroke & Applied Neuroscience Center, University of Washington, Seattle, Washington, USA.,Radiology, University of Washington, Seattle, WA, USA.,Mechanical Engineering, University of Washington, Seattle, WA, USA
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7
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Pan Z, Yang Y, Zhang L, Zhou X, Zeng Y, Tang R, Chang C, Sun J, Zhang J. Systemic Contact Dermatitis: The Routes of Allergen Entry. Clin Rev Allergy Immunol 2021; 61:339-350. [PMID: 34338976 DOI: 10.1007/s12016-021-08873-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2021] [Indexed: 01/19/2023]
Abstract
Systemic contact dermatitis (SCD) is a generalized reactivation of type IV hypersensitivity skin diseases in individuals with previous sensitization after a contact allergen is administered systemically. Patients with SCD may consider their dermatitis unpredictable and recalcitrant since the causative allergens are difficult to find. If a patient has a pattern of dermatitis suggestive of SCD but fails to improve with conventional treatment, SCD should be taken into consideration. If doctors are not familiar with the presentations of SCD and the possible routes of allergen sensitization and exposure, the diagnosis of SCD may be delayed. In this work, we summarized all of the routes through which allergens can enter the body and cause SCD, including oral intake, local contact (through skin, inhalation, nasal spray and anal application), implants, and other iatrogenic or invasive routes (intravenous, intramuscular, intraarticular, and intravesicular). This will provide a comprehensive reference for the clinicians to identify the culprit of SCD.
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Affiliation(s)
- Zhouxian Pan
- Allergy Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Yongshi Yang
- Allergy Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Lishan Zhang
- Allergy Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Xianjie Zhou
- Allergy Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Yueping Zeng
- Dermatology Department, Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, PekingBeijing, 100730, China
| | - Rui Tang
- Allergy Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China.
| | - Christopher Chang
- Division of Rheumatology, Allergy and Clinical Immunology, University of California, Davis, Davis, CA, 95616, USA. .,Division of Pediatric Immunology and Allergy, Joe DiMaggio Children's Hospital, Hollywood, FL, USA.
| | - Jinlyu Sun
- Allergy Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China.
| | - Jing Zhang
- Beijing Synchrotron Radiation Facility, Institute of High Energy Physics, Chinese Academy of Sciences, Beijing, 100049, China
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Wallace AN, Delgado Almandoz JE, Kayan Y, Fease JL, Scholz JM, Milner AM, Thomas M. Pipeline Treatment of Intracranial Aneurysms Is Safe and Effective in Patients with Cutaneous Metal Allergy. World Neurosurg 2019; 123:e180-e185. [DOI: 10.1016/j.wneu.2018.11.115] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 11/12/2018] [Accepted: 11/13/2018] [Indexed: 10/27/2022]
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