Letter to the Editor
Transient cortical blindness after cerebral angiography
Ceguera cortical transitoria secundaria a angiografía cerebral
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The complications described include stroke, such as complete stroke due to thrombosis or vasospasm, or blood extravasation caused by arterial rupture. A less frequent and poorly described complication is transient cortical blindness. Frequency ranges from 0.3 to 1.0%,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> and it is characterized by unilateral or bilateral visual impairment and vision loss, leading to blindness, which appears after the procedure, with no modifications in fundus of eye and without any radiological data to justify. The process improves gradually and is resolved in hours, usually within 72<span class="elsevierStyleHsp" style=""></span>h.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> We report two clinical cases related to this entity.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The first case is a 47 year old male. After undergoing a brain CT, damage was observed incidentally regarding the circle of Willis, indicative of aneurysm. The diagnosis was confirmed after cerebral angiography, showing an aneurysm at the top of the basilar and aneurysmal dilation at the junction of the right middle cerebral artery. Endovascular treatment was performed with embolization of the aneurysm, resulting in a good permeability of the basilar artery and its branches. After the procedure, the patient reported bilateral vision loss with blindness, with no further neurological focus. No modifications were observed in the fundus. An MRI showed signs of edema in T2 sequences in the cortex of the occipital lobe with no signs of acute stroke. He was gradually recovering vision, being asymptomatic within 48<span class="elsevierStyleHsp" style=""></span>h.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The second case is a 69 year old male, admitted with symptoms of holocranial headache with abrupt onset, indicative of subarachnoid hemorrhage, which was confirmed after cranial CT. Diagnostic angiography revealed 2 small blister-like aneurysms, unsuitable for endovascular treatment. After procedure, the patient reported loss of bilateral and global vision. A cranial CT scan ruled out the occurrence of an acute stroke, and transcranial Doppler ultrasound ruled out cerebral vasospasm. The patient regained vision gradually over a period of 24<span class="elsevierStyleHsp" style=""></span>h.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Transient cortical blindness has been described after performing not only cerebral but also aortic angiography or coronary angiography.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2–4</span></a> In these cases a lower frequency is expected, around 0.21–0.45%.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> It has been described with ionic and nonionic contrast agents and is not dose dependent. The onset of symptoms is variable and can occur in minutes or after a few hours after the procedure. It may be unilateral or bilateral, and with a normal eye examination. It can be accompanied by headache, memory loss, mood swings or seizures. Despite the increased use of this method, frequency does not appear to be increased. However, reported cases are few and this is the tip of the iceberg of actual cases. The fact that there is good recovery of the patient in all cases without treatment contributes to the loss of interest in its publication. However, several issues remain unclear. It is still a process of unknown etiology and is thought to be due to an adverse reaction secondary to the passage of contrast medium through the blood–brain barrier by vasodilation, via osmotic agents<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> or by direct reaction on endothelial cells, which undergo a contraction, leading to a dilation of the binding between them (tight-junction). These hypotheses should be confirmed.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Radiological tests such as CT are usually normal and occasionally contrast extravasation is seen in the occipital region, observing they disappear after serial CT scans. In cases where there is evidence of stroke, CTA helps diagnosis.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Cranial MRI does not provide many details. Hyperintense small areas can be observed on T2 sequences in the occipital region, which occasionally can be extended to parietal lobe and usually affect only the cerebral cortex.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> This fact makes us wonder why it appears in this area and not others, since symptomatology is observed with any angiographic study and not only in the posterior cerebral circulation.</p><p id="par0035" class="elsevierStylePara elsevierViewall">From a therapeutic point of view, empirical therapies have been used such as corticosteroids, anticoagulants, or intravenous hydration,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> not showing improvement in a self-limiting process which disappears alone in a period of days. Despite this, the patient is distressed until symptoms disappear. Therefore, a better understanding of this problem would help a better health care.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Rodríguez Arias CA, Martínez-Galdámez M. Ceguera cortical transitoria secundaria a angiografía cerebral. Med Clin (Barc). 2015;145:322–323.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Temporary cortical blindness following angiography" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "N.H. Horwitz" 1 => "L. 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