Neurotoxic cerebral oedema following coronary angiography

Abstract

A 60-year-old woman was found unconscious in her hospital bed approximately 2 h after routine coronary angiography. Glasgow coma scale was 6, she was intubated immediately and transferred to the intensive care unit. Cerebral computer tomography (CCT) showed unilateral cerebral oedema of the entire right hemisphere without signs of cerebral ischaemia or haemorrhage (figure 1A). No signs of brainstem affection or herniation was seen on initial CCT, but a slight midline shift was present. Neurological examination revealed left-sided hemiplegia and positive Babinski's sign of her left foot. The initial coronary catheterisation was performed as routine diagnostic procedure to assess the extent of suspected coronary artery disease following an observed T wave inversion in the ECG, which turned out to be mild and nonstenotic. During the procedure, no complications were reported except for intermittent elevated blood pressure up to 190/ 95 mm Hg that spontaneously resolved after a few minutes. Follow-up CCT 5 days later showed a completely resolved neurotoxic oedema in parallel with the clinical improvement of the patient who reached full recovery of her neurological symptoms within 10 days from onset (figure 1B). MRI that was performed to exclude underlying cerebral ischaemia or other lesions that might have led to the development of cerebral oedema, but was unremarkable. Past medical history revealed a predominantly right-sided migraine with attacks about once to twice a month. Most attacks were without aura, but she also suffered from infrequent attacks with visual aura. The last migraine attack was approximately 15 years ago. The patient was treated with intravenous dexamethasone 4 mg three times a day over 5 days. She was successfully weaned from the ventilator after suffering from pneumonia, and discharged 2 weeks later in good condition and without neurological deficit. CONCLUSIONIodinated contrast media-related neurotoxicity is a well known but rare complication of cerebral angiography and neurovascular intervention. 1 Clinical symptoms include encephalopathy, epileptic seizures, cortical blindness and other focal neurological deficits. The proposed causative mechanism is disruption of the blood-brain barrier and transit of contrast agent to the cerebral cortex, that leads to a neuronal toxic effect, and intracellular and extracellular oedema. 2 Hypertension is often associated with these transient complications, but its exact role remains subject to discussion. Intermittent elevated blood pressure, as seen in hypertensive encephalopathy (reversible posterior leukoencephalopathy syndrome, reversible cerebral vasoconstriction syndrome) with failure of autoregulation or disruption of the vascular endothelium, may also lead to cerebral oedema. 3 However, this most often affects the posterior brain vasculature, and would probably not lead to unilateral oedema. Most interesting is the past history of migraine attacks that affected mostly her right side. The development of cerebral oedema was previously described in he...

Characteristics of headache during and/or after coronary intervention: A prospective observational study

“…Obermann reported a case of unilateral cerebral oedema after coronary angiography in a patient with a history of ipsilateral migraine, supporting that a previous history of headache is a risk factor after CI (8). A previous history of headache is a common risk factor for CI-related headache as was demonstrated in our study, as well as in previous studies of post-cerebral DSA headache (3,11).…”

“…For example, 6.7.1 Headache attributed to an intracranial endarterial procedure and 6.7.2 Angiography headache have been included in the third edition of the International Classification of Headache Disorders (ICHD-3) (6). As with cerebral angiography, CI can lead to some neurological complications such as contrast-induced encephalopathy (7,8). In clinical practice, we found that many patients who underwent CI complained of headache.…”

Contrast‐induced encephalopathy following cardiac catheterization

“…From the search results, we identified five case series and 38 case reports , for a total of 52 patients. The first published report documenting presumed CIE associated with cardiac catheterization dates from 1970 .…”