Eur Radiol (2003) 13:L113–L115 DOI 10.1007/s00330-003-1975-8
Altan Yıldız Esin Yencilek F. Demir Apaydın Meltem Nass Duce Caner Özer Ahmet Atalay
Received: 13 January 2003 Revised: 17 March 2003 Accepted: 2 May 2003 Published online: 6 August 2003 © Springer-Verlag 2003 A. Yıldız (✉) · E. Yencilek F. D. Apaydın · M. N. Duce · C. Özer Department of Radiology, Mersin Üniversitesi Tıp Fakültesi Hastanesi Radyoloji Anabilim Dalı, · Ihsaniye Mahallesi 123, Cadde 4931, 33079 Sokak Mersin, Turkey e-mail:
[email protected] Tel.: +90-324-3374300 Fax: +90-324-3374305 A. Atalay Department of Cardiology, Mersin Üniversitesi Tıp Fakültesi Hastanesi Radyoloji Anabilim Dalı, · Ihsaniye Mahallesi 123, Cadde 4931, 33079 Sokak Mersin, Turkey
CONTRAST MEDIA
Transient partial amnesia complicating cardiac and peripheral arteriography with nonionic contrast medium
Abstract The aim of this study was to present a case of disruption of the blood-brain barrier during the coronary and lower extremity angiographies with radiological and clinical findings. This condition was secondary to intraarterial use of a nonionic, monomeric contrast medium. A total of 450 cc contrast media was used. Computed tomography examination showed contrast enhancement of the right occipital and frontoparietal cortical regions, which returned to normal one day after. The patient also fully recovered from the neurological symptoms within 24 h. We discussed the possible mechanism for blood-brain barrier disruption in this case.
Keywords Blood-brain barrier · Angiography · Computed tomography · Contrast media · Adverse effect
Introduction
Case report
Intraventricular, subarachnoid and brain parenchymal contrast enhancement secondary to disruption of the blood-brain-barrier (BBB) have been described in the literature as uncommon complications of angiography [1, 2, 3, 4, 5, 6]. Cortical blindness, Jacksonian seizures, loss of consciousness, generalized seizures, visual neglect and Wernicke’s aphasia were the reported neurological deficits due to contrast related disruption of BBB. Herein we present a case of cortical contrast enhancement secondary to intraarterial use of a nonionic contrast media (CM) with clinical and radiological findings.
A 63-year-old man underwent coronary and lower extremity angiography via a right brachial approach. The indications of the angiographic studies were ischaemic heart disease and peripheral ischaemia. The sites of the injection of the CM were the right and left coronary arteries, the left ventricle, the ascending aorta and the distal abdominal aorta. The procedure took approximately 2 h, and 14 injections were done. Repeated test injections were also performed, because of some difficulty in the catheterization of coronary arteries. The CM used was iomeprol (Iomeron 400, Bracco, Milan, Italy). Following intraarterial injection of a total amount of 450 cc of CM, the patient experienced transient partial amnesia, headache and right upper extremity numbness. Neurological examination was within normal limits, except the partial amnesia, and there was no disturbance of vision. Immediately, 8 mg of dexametasone was administered intravenously. Arterial blood pressure ranged within normal limits during the procedure. The patient had normal neurological findings before the angiographic examination. Serum creatinine levels were normal during the preprocedural and postprocedural period. Computed tomogra-
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(Fig. 2) and the neurological deficits returned to normal on the same day. The patient did not experience any neurological deficit during the 2 years of observation.
Discussion
Fig. 1 An axial CT scan performed 1 h after angiography shows right occipital cortical enhancement
Fig. 2 Noncontrast axial CT scan performed 1 day after the initial examination shows disappearance of the high density in the right occipital cortical areas phy, performed immediately thereafter, revealed abnormal contrast enhancement at the right frontal, occipital and parietal cortical areas (Fig. 1). Left cerebral hemisphere was normal. Control CT scan, performed the following day, revealed normal findings
The BBB is a complex physiological mechanism that separates the intravascular fluid space and the extracellular fluid space within the brain. The anatomic separation is thought to be the result of specialized tight junctions between endothelial cells (continuous capillaries) and the lack of transendothelial vesicular transport [7]. Contrast media are sterile iodine-containing solutions used in diagnostic imaging procedures. They are categorised into four groups: ionic monomers; ionic dimers; nonionic monomers; and nonionic dimers. Older agents generally fall into the class of ionic monomers, which have a high osmolality and high chemotoxicity [8]. Nonionic agents have been developed to overcome the adverse events associated with older contrast media. Iomeprol is a nonionic, monomeric agent which has a low chemotoxicity, osmolality and viscosity, and high water solubility, and does not contain EDTA [9, 10, 11, 12]. Iomeprol does not bind to plasma proteins, is not metabolized and is rapidly excreted in urine [13, 14]. The physicochemical characteristics of iomeprol allows aqueous solutions of higher iodine concentration (400 mg I/ml) with lower osmolality (0.73 Osm/kg H20 at 370 C, for 400 mg I/ml solution) [15]. There is an extensive body of literature reporting the effects of these agents on the BBB, both intact and disrupted, in animal and clinical studies. Increased transfer of CM across the disrupted BBB may occur in pathological processes (e.g., tumour, stroke) and with overdose of CM [1, 2, 3]. The BBB breakdown after cerebral angiography with ionic CM has been described in several case reports. Transient cortical blindness secondary to BBB disruption is a well documented complication of angiography with ionic CM. Another recognized complication of cerebral angiography with ionic CM is transient global amnesia. Nonionic CMs have a lower toxicity than ionic hyperosmolar CM. But still, transient global amnesia was reported in patients undergoing cerebral angiography with nonionic CM [16]. Even though these complications have been attributed to ischaemic complications of the catheterization technique [17, 18], a direct neurotoxic effect of ionic [19] and nonionic [16] CM has also been proposed as a mechanism. Our patient experienced only transient partial amnesia, especially antegrade type. History of hypertensive attack during the procedure was absent and renal functions were also normal. When we took the radiological findings and the absence of prolonged neurological deficits into account, an ischaemic event due to a plaque did not seem to be possible as the cause of the cortical contrast enhancement. Parenchymal contrast enhancement is usually not seen
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until approximately 6 days in ischaemic events [20, 21]. In our case, cortical contrast enhancement indicated the penetration of the BBB and the neurological symptoms indicated the toxic effect of the contrast agent on the neuronal elements. Although the osmolality of Iomeron 400 is lower than the ionic monomeric CM, its osmolality approaches the threshold of BBB for ruptures, which is approximately 800 mOsm/kg. In our opinion, the higher osmolality and higher viscosity of the Iomeron 400, rather than the other forms of the iomeprol, were the main factors of the BBB breakdown together with the
overuse of the CM. Selective injection to the right carotid system was not performed; thus, the reason for unilateral disruption of the BBB in our case might be excessive CM flow to the right cerebral arterial system secondary to the position of the angiography catheter during the aortic arch study. In conclusion, this case describes a nonionic angiographic CM neurotoxicity. Although nonionic, monomeric CMs are hypo-osmolar and less neurotoxic than ionic monomeric CMs, the use of high-iodine-containing forms and overuse of them must be avoided.
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