Letter to the Editor
Transient contrast-induced encephalopathy after internal carotid artery embolisation prior to surgery for nasopharyngeal carcinoma
Encefalopatía transitoria por contraste tras la embolización de la arteria carótida interna previa a la cirugía de carcinoma nasofaríngeo
C. Montejo, A. Rodríguez, M. Pascual-Vicente, A. Renú
Corresponding author
Servicio de Neurología, Hospital Clínic de Barcelona, Barcelona, Spain
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F-H) Resonancia magnética: F) Corte axial de secuencia FLAIR; G-H) Corte axial de secuencias de DWI y ADC, respectivamente. Se observa una alteración de la señal en las secuencias FLAIR y DWI a nivel del córtex parietal y frontal izquierdos, sin restricción en el ADC, compatible con edema vasogénico.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "C. Montejo, A. Rodríguez, M. Pascual-Vicente, A. Renú" "autores" => array:4 [ 0 => array:2 [ "nombre" => "C." "apellidos" => "Montejo" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Rodríguez" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Pascual-Vicente" ] 3 => array:2 [ "nombre" => "A." 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Measurement of left atrial volume with the biplane Simpson method (A) and longitudinal left atrial strain with speckle tracking echocardiography (B).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Á. Lambea Gil, H. Tejada Meza, C.R. López Perales, J. Artal Roy, J. Marta Moreno" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Á." "apellidos" => "Lambea Gil" ] 1 => array:2 [ "nombre" => "H." "apellidos" => "Tejada Meza" ] 2 => array:2 [ "nombre" => "C.R." "apellidos" => "López Perales" ] 3 => array:2 [ "nombre" => "J." "apellidos" => "Artal Roy" ] 4 => array:2 [ "nombre" => "J." 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Montejo, A. Rodríguez, M. Pascual-Vicente, A. Renú" "autores" => array:4 [ 0 => array:2 [ "nombre" => "C." "apellidos" => "Montejo" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Rodríguez" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Pascual-Vicente" ] 3 => array:4 [ "nombre" => "A." "apellidos" => "Renú" "email" => array:1 [ 0 => "arenu@clinic.ub.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Neurología, Hospital Clínic de Barcelona, Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Encefalopatía transitoria por contraste tras la embolización de la arteria carótida interna previa a la cirugía de carcinoma nasofaríngeo" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 930 "Ancho" => 1900 "Tamanyo" => 236568 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Frontal projections of brain angiography with contrast injection into the left common carotid artery, confirming occlusion of the proximal internal carotid artery (beyond carotid bifurcation) (A) and distal internal carotid artery (proximal to the ophthalmic artery) (B). C) Contrast injection into the right common carotid artery, revealing correct compensation of brain circulation through the anterior communicating artery.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Angiography is a technique used in the diagnosis, surgical planning, and treatment of tumours. Presurgical embolisation of the internal carotid artery is a common adjuvant therapy to the surgical resection of head and neck cancers.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> The technique is made possible by the flow compensation provided by the circle of Willis through the intracranial communicating arteries.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Contrast-induced encephalopathy is a rare but reversible complication that appears after the administration of an iodinated contrast agent; it was first described in 1970 in a patient who presented cortical blindness following cardiac catheterisation.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">We present the case of a patient with transient contrast-induced encephalopathy after embolisation of the left internal carotid artery before surgery for nasopharyngeal carcinoma.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Our patient was a 41-year-old man with a history of locally relapsing squamous cell carcinoma of the nasopharynx; he had previously been treated with surgery, chemotherapy, and radiotherapy, and was admitted electively to our centre for surgical reintervention. Three months before surgery, the patient underwent an angiography-based balloon test occlusion of the carotid artery (200<span class="elsevierStyleHsp" style=""></span>mL of non-ionic iodinated contrast agent were administered), which confirmed that there was sufficient flow compensation by the circle of Willis and the absence of neurological symptoms. The day before the procedure he underwent embolisation of the left internal carotid artery in 2 locations: proximally, beyond the carotid bifurcation, and distally, proximal to the ophthalmic artery (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). For the angiography, we used 310<span class="elsevierStyleHsp" style=""></span>mL of non-ionic iodinated contrast. The procedure was uneventful and the patient remained asymptomatic at all times. Renal function was preserved before and after the procedure (glomerular filtration rate >90<span class="elsevierStyleHsp" style=""></span>mL/min) and his arterial blood pressure remained within normal ranges. Six hours after embolisation, the patient presented neurological signs of predominantly motor aphasia, right homonymous hemianopsia, and right facial paralysis. A blood analysis revealed no alterations and the electrocardiography showed sinus rhythm. The baseline sequence of a head CT scan using an iodinated contrast agent (50<span class="elsevierStyleHsp" style=""></span>mL) revealed attenuation of sulci, suggestive of oedema, and cortical contrast uptake in the left hemisphere (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). CT angiography confirmed occlusion of the left internal carotid artery with excellent compensation of intracranial circulation, with perfusion sequences showing no alterations (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B-E). In the acute phase, we started antiepileptic treatment with levetiracetam at 1000<span class="elsevierStyleHsp" style=""></span>mg/12<span class="elsevierStyleHsp" style=""></span>h and dexamethasone at 6<span class="elsevierStyleHsp" style=""></span>mg/4<span class="elsevierStyleHsp" style=""></span>h. An MRI scan performed at 24<span class="elsevierStyleHsp" style=""></span>hours showed signal alterations on the FLAIR and DWI sequences in the left parietal and frontal cortex, with no restriction on the ADC map; these findings are compatible with vasogenic oedema. An electroencephalogram revealed slowing of the background rhythm in the left hemisphere. The patient improved clinically, with symptoms resolving 24<span class="elsevierStyleHsp" style=""></span>hours later.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Contrast-induced encephalopathy is a rare complication that may manifest as cortical blindness, encephalopathy, seizures, and focal neurological signs.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">3–6</span></a> Transient cortical blindness is the most frequent clinical manifestation.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">4,6</span></a> Risk factors include arterial hypertension, kidney failure, diabetes, and adverse reactions to contrast agents.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">3–7</span></a> However, the latter seem to be an idiosyncratic reaction not directly related to the concentration, volume, or type of iodinated contrast used.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> Symptoms manifest soon after the administration of the contrast agent and resolve within 24-72<span class="elsevierStyleHsp" style=""></span>hours.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">3,4,6</span></a> Prognosis is usually favourable, although cases have been reported of permanent deficits or deaths secondary to oedema (15%).<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">4,5</span></a> The most frequent CT findings are cortical or subcortical contrast uptake and sulcal effacement (23%-54%).<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> Dual-energy CT may be useful for differentiating cerebral oedema from pseudoedema.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> Brain MRI frequently reveals increased signal on T2-weighted and FLAIR sequences, with increased intensity on DWI sequences and ADC maps, compatible with vasogenic oedema.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">5–7</span></a> Pathogenic mechanisms include damage to the blood-brain barrier caused by neurotoxicity of the contrast, changes in osmotic concentrations or release of endothelins, and vasospasms caused by vessel wall irritation with subsequent hypoperfusion.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> There is no evidence regarding the treatment of choice.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> Treatment sometimes consists of supportive management with hydration,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> although some authors opt to administer dexamethasone, manitol, antiepileptic drugs, antihypertensive drugs, or even intra-arterial verapamil.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In conclusion, contrast-induced encephalopathy is an important and potentially severe entity to be considered in the differential diagnosis of patients displaying acute focal neurological signs after angiographic procedures with iodinated contrast. It is diagnosed by exclusion, and prognosis is generally excellent; it should therefore be considered before starting thrombolytic treatments.</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: Montejo C, Rodríguez A, Pascual-Vicente M, Renú A. Encefalopatía transitoria por contraste tras la embolización de la arteria carótida interna previa a la cirugía de carcinoma nasofaríngeo. Neurología. 2020;35:287–289.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 930 "Ancho" => 1900 "Tamanyo" => 236568 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Frontal projections of brain angiography with contrast injection into the left common carotid artery, confirming occlusion of the proximal internal carotid artery (beyond carotid bifurcation) (A) and distal internal carotid artery (proximal to the ophthalmic artery) (B). C) Contrast injection into the right common carotid artery, revealing correct compensation of brain circulation through the anterior communicating artery.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 846 "Ancho" => 1900 "Tamanyo" => 325649 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A-E) Computed tomography: A) baseline axial CT slice showing sulcal effacement and cortical contrast uptake in the left hemisphere; B-D) CBV, CBF, and TTP maps, respectively, showing no alterations in brain perfusion, and E) coronal CT angiography slice confirming occlusion of the internal carotid artery after bifurcation, with excellent intracranial compensation. F-H) Magnetic resonance imaging: F) axial FLAIR slice; G-H) axial DWI and ADC sequences, respectively. Signal alteration is observed on the FLAIR and DWI sequences at left parietal and frontal cortex level, with no restriction on the ADC map, which is compatible with vasogenic oedema.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Endovascular embolization of head and neck tumors" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M.A. Lazzaro" 1 => "A. Badruddin" 2 => "O.O. Zaidat" 3 => "Z. Darkhabani" 4 => "D.J. Pandya" 5 => "J.R. 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Fugate" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Neurocrit Care" "fecha" => "2017" "volumen" => "27" "paginaInicial" => "261" "paginaFinal" => "264" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0065" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Contrast-induced encephalopathy following cardiac catheterization" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "R. Spina" 1 => "N. Simon" 2 => "R. Markus" 3 => "D.W. Muller" 4 => "K. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 3 | 0 | 3 |
| 2024 October | 22 | 10 | 32 |
| 2024 September | 31 | 1 | 32 |
| 2024 August | 29 | 4 | 33 |
| 2024 July | 24 | 2 | 26 |
| 2024 June | 21 | 4 | 25 |
| 2024 May | 21 | 13 | 34 |
| 2024 April | 32 | 3 | 35 |
| 2024 March | 34 | 3 | 37 |
| 2024 February | 43 | 5 | 48 |
| 2024 January | 59 | 3 | 62 |
| 2023 December | 66 | 22 | 88 |
| 2023 November | 63 | 20 | 83 |
| 2023 October | 56 | 9 | 65 |
| 2023 September | 34 | 0 | 34 |
| 2023 August | 37 | 4 | 41 |
| 2023 July | 36 | 5 | 41 |
| 2023 June | 44 | 1 | 45 |
| 2023 May | 59 | 8 | 67 |
| 2023 April | 43 | 2 | 45 |
| 2023 March | 54 | 6 | 60 |
| 2023 February | 41 | 0 | 41 |
| 2023 January | 56 | 5 | 61 |
| 2022 December | 40 | 3 | 43 |
| 2022 November | 41 | 9 | 50 |
| 2022 October | 27 | 10 | 37 |
| 2022 September | 47 | 8 | 55 |
| 2022 August | 49 | 14 | 63 |
| 2022 July | 32 | 7 | 39 |
| 2022 June | 22 | 7 | 29 |
| 2022 May | 42 | 8 | 50 |
| 2022 April | 38 | 12 | 50 |
| 2022 March | 61 | 11 | 72 |
| 2022 February | 64 | 8 | 72 |
| 2022 January | 53 | 7 | 60 |
| 2021 December | 33 | 13 | 46 |
| 2021 November | 38 | 10 | 48 |
| 2021 October | 45 | 14 | 59 |
| 2021 September | 27 | 10 | 37 |
| 2021 August | 34 | 9 | 43 |
| 2021 July | 30 | 7 | 37 |
| 2021 June | 26 | 22 | 48 |
| 2021 May | 56 | 9 | 65 |
| 2021 April | 141 | 30 | 171 |
| 2021 March | 60 | 6 | 66 |
| 2021 February | 48 | 11 | 59 |
| 2021 January | 53 | 8 | 61 |
| 2020 December | 60 | 17 | 77 |
| 2020 November | 47 | 8 | 55 |
| 2020 October | 25 | 6 | 31 |
| 2020 September | 26 | 12 | 38 |
| 2020 August | 47 | 8 | 55 |
| 2020 July | 9 | 8 | 17 |
| 2020 June | 13 | 18 | 31 |
| 2020 May | 10 | 3 | 13 |
| 2020 April | 7 | 7 | 14 |
| 2020 March | 7 | 4 | 11 |
| 2020 February | 8 | 6 | 14 |
| 2020 January | 6 | 6 | 12 |
| 2019 December | 13 | 9 | 22 |
| 2019 November | 4 | 11 | 15 |
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