A Case of Unusual Presentation of Contrast-induced Encephalopathy after Cerebral Angiography Using Iodixanol

Contrast-induced encephalopathy with significantly elevated levels of cerebrospinal fluid protein

Contrast-induced encephalopathy (CIE) is a rare complication of angiography. According to our knowledge, the majority of CIE reports is imaging observations and rarely includes results of cerebrospinal fluid (CSF) tests. Furthermore, among the cases reporting the data for CSF testing, most of the results were normal. Here, we report a case of CIE presenting with significantly elevated levels of CSF protein. We found that the course of improvement in brain imaging findings was not consistent with the severity of clinical manifestations. The diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) sequences were normal. Considering the lack of convenient direct indicators to observe blood-brain barrier (BBB) function, changes in the levels of CSF protein may be related to BBB permeability and recovery and may serve as a potential prognostic marker.

Neuroradiological features of contrast-induced neurotoxicity: A systematic review and pooled analysis

BACKGROUND

Contrast-induced neurotoxicity (CIN), is an increasingly recognised complication of endovascular procedures, presenting as a spectrum of neurological symptoms that mimic ischaemic stroke. The diagnosis of CIN remains a clinical challenge, and stereotypical imaging findings are not established. This study was conducted to characterise the neuroimaging findings in patients with CIN, to raise diagnostic awareness and improve decision making.

METHODS

We performed a systematic review of PubMed and Embase databases from inception (1946/1947) to June 2023 for reports of CIN following administration of iodinated contrast media. Studies with a final diagnosis of CIN, which provided details of neuroimaging were included. All included cases were pooled and descriptive analysis was conducted.

RESULTS

A total of 84 patients were included, with a median age of 64 years. A large proportion of patients had normal imaging (CT 40.8 %, MRI 53.1 %). CT abnormalities included cortical/subarachnoid hyperattenuation (42.1 %), cerebral oedema/sulcal effacement (26.3 %), and loss of grey-white differentiation (7.9 %). Frequently reported MRI abnormalities included brain parenchymal MRI signal change (40.8 %) and cerebral oedema (12.2 %), most commonly observed on FLAIR sequences (26.5 %). Characterisation of imaging findings according to anatomical location and clinical symptoms has been conducted.

CONCLUSIONS

Neuroimaging is an essential part of the diagnostic workup of CIN. Analysis of the anatomical location and laterality of imaging abnormalities may suggest relationship between radiological features and actual clinical symptoms, although this remains to be confirmed with dedicated study. Radiological abnormalities, particularly CT, appear to be transient and reversible in most patients.

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.

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.

Anaphylaxis Following Contrast-Enhanced CT with Iodixanol: A Case Report and Literature Review

Background

Iodixanol-induced anaphylactic reaction is a well-known adverse event of contrast agents, which are generally well-tolerated and reversible. Serious and fatal reactions such as anaphylactic shock after computed tomography (CT) enhancement have been described. However, there is no data on these events in the literature.

Objective

This report describes a case of a serious anaphylactic reaction, possibly related to iodixanol and provides an overview of case reports.

Case Summary

A 47-year-old women who experienced persistent abdominal pain for more than one month, was proposed of hiatal hernia with CT images taken two weeks previously and was admitted to the gastrointestinal surgery department. The patient underwent contrast-enhanced abdominal CT for the evaluation of multiple intraperitoneal hemodynamic features. A few minutes after abdominal enhanced CT scan, the patient was pale, sweating, had muscle tension and trembling, even coma and profound hypotension with 90/43 mm Hg. Immediately she was supported with oxygen inhalation, was treated with adrenaline subcutaneously, dexamethasone intravenously, and rapid intravenous drip of compound sodium chloride. Ten minutes later, the patient was in respiratory and cardiac arrest and the pupils were dilated. CPR and intermittant static push of 1 mg adrenaline were immediately carried. After endotracheal intubation, the patient's spontaneous heart rate and pupils recovered, and her blood pressure recovered to 105/53 mm Hg. It was suggested that the patient was suffering from iodixanol-induced anaphylactic shock and nephropathy, and she was transferred to the intensive care unit. Despite immediate treatment, the patient died.

Conclusion

A 47-year-old female patient with no history of allergies developed severe fatal anaphylactic shock after receiving iodixanol. Although contrast agents induced anaphylactoid/anaphylactic reactions do not often occur, clinicians should be conscious of the potentially serious anaphylactic reaction, which could lead to a life-threatening or fatal event.

Contrast-induced encephalopathy and nonconvulsive status epilepticus after diagnostic cerebral angiography in an end-stage renal disease patient

A 70-year-old man with a history of recurrent ischemic stroke and end-stage renal disease was admitted to the neurology department for a transient ischemic attack. The patient underwent transfemoral cerebral angiography with iopamidol to evaluate the status of carotid stenosis. On the same day, the patient developed drowsy mentality, global aphasia, and fever. Electroencephalography showed continuous regional rhythmic delta activities (0.5 to 1.0 Hz) without definite spatiotemporal evolution, suggestive of focal seizure disorder arising from the left temporal area and ictal-interictal continuum. Computed tomography perfusion images showed hyperperfusion in the left hemisphere. The patient was diagnosed with contrast-induced encephalopathy and associated nonconvulsive status epilepticus. The patient was treated with oral lacosamide, levetiracetam, and daily hemodialysis. The patient’s mental status recovered after 8 days of intensive care unit care.

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 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.

The safety of iodixanol in interventional therapy for patients of different ages with cerebrovascular diseases

OBJECTIVE

We aimed to explore the therapeutic effect and safety of iodixanol in interventional therapy for patients of different ages with cerebrovascular diseases.

METHODS

A total of 132 patients undergoing interventional therapy for cerebrovascular diseases in our hospital were analyzed retrospectively. The patients were divided into the young adult group (≤44 years old, 44 cases), the middle-aged adult group (45-59 years old, 48 cases), and the older adult group (≥60 years old, 40 cases). All patients were treated with iodixsanol as the contrast agent for cerebrovascular interventional therapy. The patients' renal function (serum creatinine (SCr) and blood urea nitrogen (BUN) levels) before and after treatment and the incidence of adverse reactions were compared among the three groups.

RESULTS

At 48 h before operation, 2 h after operation and 48 h after operation, the levels of SCr and BUN in the older adult group were higher than those in the young adult group (all P<0.001), whereas the levels of SCr and BUN were similar between the older adult group and the middle-aged adult group and between the middle-aged adult group and the young adult group (all P>0.05). Within each group, the levels of SCR and BUN at 48 h before operation did not differ from those at 2 h and 48 h after operation (all P>0.05). No intergroup differences were found in the incidences of adverse reactions after using iodixanol for cerebrovascular interventional therapy (all P>0.05).

CONCLUSION

Iodixanol as a contrast medium shows good safety in interventional therapy for patients of different ages with cerebrovascular diseases; additionally, it has no significant impact on the renal function of patients and it leads to a low incidence of adverse reactions.

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.

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.

Contrast-induced encephalopathy: a complication of coronary angiography

Contrast-induced encephalopathy is a rare idiosyncratic reaction to contrast material. A 56-year-old woman with hypertension developed a hemiparesis with confusion and disorientation 3 hours after routine coronary angiography. The procedure had been prolonged, and during it she had received 130 mL of iopromide contrast. A metabolic screen was negative, and cerebral angiography and MR scan of brain were normal. She recovered completely by day 5. Contrast-induced encephalopathy should be considered in patients developing focal neurological deficits following coronary angiography. Patients requiring investigations to exclude acute stroke in this setting should not receive additional intravenous or intra-arterial contrast, although MR with gadolinium appears safe. Better awareness of this complication should avoid potentially harmful interventions such as thrombolysis.

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.

A case of contrast-induced encephalopathy

The differential diagnosis of the patient with encephalopathy is broad and remains a common yet challenging problem for critical care physicians. A case is presented of contrast-induced encephalopathy in an 81-year-old man undergoing a left heart catheterisation after receiving iopamidol, a low-osmolar contrast agent. Immediately after receiving contrast, our patient experienced severe headache, agitation, altered mentation and significant skin hypersensitivity. This rare, acute and reversible neurological disturbance can be associated with administration of intra-arterial, osmotic, iodinated contrast. Although uncommon, it is important to recognise the various presentations, risk factors and treatment of this condition.