Transient Encephalopathy from Angiographic Contrast: A Rare Complication in Neurointerventional Procedures

Abstract

Neurotoxicity from contrast media used in angiography is a rare complication from these procedures. The infrequency with which it is encountered makes it a diagnostic challenge. We present the case of a 51-year-old male who, 30 min after successful angiography for treatment of a right carotid-ophthalmic fusiform aneurysm with a stent, developed psychomotor agitation, disorientation, and progressive left faciobrachial hemiparesis (4/5). An emergency nonenhanced CT showed marked cortical enhancement and edema in the right cerebral hemisphere. Cortical enhancement is thought to be secondary to contrast extravasation due to disruption of the blood-brain barrier. Angiography was performed immediately, without any pathologic findings. After this procedure there was an increase in the left faciobrachial hemiparesis (3/5), right gaze deviation, Gerstmann syndrome, and left anosognosia and left homonymous hemianopsia. Endovenous dexamethasone and mannitol were initiated. Twenty-four hours later an MRI showed no signs of acute infarct, just gyriform signal increase in the right cerebral hemisphere on FLAIR and a decrease in the edema observed before. The patient had progressive improvement of his neurological deficit. A control MRI done 5 days later was normal. The patient recovered completely and was discharged. This rare entity should be kept in mind but diagnosed only when all other causes have been ruled out, because more important and frequent causes, such as acute infarct, must be excluded promptly.

Cerebral Hyperperfusion Syndrome After Angioplasty

“…The higher osmolality of ioxaglate compared with blood may in turn produce fluid extravasation and cerebral edema. The prognosis is usually excellent, as is evidenced by other recently published cases occurring after endovascular procedures (Guimaraens et al, 2010, Fang et al, 2009Paúl et al, 2009). …”

Contrast-induced Encephalopathy after Coil Embolization of an Unruptured Internal Carotid Artery Aneurysm

“…These reports include four cases that developed after coil embolization for ruptured cerebral artery aneurysms (8,12,14). In addition, five cases occurred after cerebral angiography (3,4,15,17), four after carotid artery stenting (5, 10, 13) and one after placement of a flow diversion stent for an arterial aneurysm (11). Factors associated with CIE include inflammation induced by the coil materials (13), vasospasm and subarachnoid hemorrhage and blood pressure changes after surgery of ruptured arterial aneurysms.…”

Confirmation of a Diagnosis by CSF Analysis in a Case of Symptomatic Contrast-induced Encephalopathy with an Onset Immediately after Coil Embolization of an Unruptured Cerebral Aneurysm

“…MRI is often negative for lesions that explain the symptoms, and the high-density area on head CT often disappears rapidly. [1][2][3][4][5][6][7][8][9] Although contrastinduced encephalopathy may be suspected from the symptomatic course and imaging findings, it is difficult to diagnose definitively. In the patient reported here, we strongly suspected contrast-induced encephalopathy from the focal neurological symptoms and imaging findings immediately after the procedure and sampled CSF 10 hours after the procedure.…”

“…Since the condition is suspected to be due to adverse reactions to the contrast agent, it is called contrast-induced encephalopathy. [1][2][3][4][5][6][7][8][9] The disorder is diagnosed primarily according to symptoms and imaging findings but is difficult to diagnose definitively.…”