Letter to the Editor
Intra-arterial gadolinium as an alternative to iodinated contrast agents in thrombectomy
Gadolinio intraarterial como alternativa al contraste yodado en la trombectomía
A. de Albóniga-Chindurza, J. Ortega-Quintanilla, J. Alcalde-López, E. Zapata-Arriaza, A. González
Corresponding author
Servicio de Radiología, Neurorradiología Intervencionista, Hospital Universitario Virgen del Rocío, Sevilla, Spain
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"tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "684" "paginaFinal" => "687" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Trastorno psicótico <span class="elsevierStyleItalic">de novo</span> inducido por levetiracetam: ¿existe un perfil de paciente epiléptico neuroestructural y/o biológicamente más vulnerable a desarrollarlo?" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1394 "Ancho" => 1250 "Tamanyo" => 197597 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Neuroimaging studies performed in our 3 patients. A) Brain MRI scan (axial plane, FLAIR sequence) showing multiple patchy areas of corticosubcortical hyperintensity bilaterally, including the hippocampus (particularly the left; purple arrow) and the pons (orange arrows). B) Brain MRI scan (axial plane, non-contrast T1-weighted sequence) showing a hypointense region in the left hippocampus (suggestive of chronic progression; light blue arrow) and signal hyperintensity in the ipsilateral occipital region (suggestive of subacute lesion; green arrow). C) Non-contrast head CT scan (axial plane) revealing a hyperdense area in the right temporal lobe, with no intraventricular extension, and surrounding vasogenic oedema (red arrow). D) CT angiography of the supra-aortic trunks and circle of Willis confirming the presence of an arteriovenous malformation in the right temporal region (dark blue arrow), mainly supplied by the right middle cerebral artery, as well as by the right posterior cerebral artery through the lateral posterior choroidal arteries, and with venous drainage through the right transverse and sigmoid sinuses.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M. León Ruiz, M.L. Rodríguez Sarasa, L. Sanjuán Rodríguez, J. Benito-León, O. Álvarez de Toledo, M.T. Pérez Nieves, S. Arce Arce" "autores" => array:7 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "León Ruiz" ] 1 => array:2 [ "nombre" => "M.L." "apellidos" => "Rodríguez Sarasa" ] 2 => array:2 [ "nombre" => "L." "apellidos" => "Sanjuán Rodríguez" ] 3 => array:2 [ "nombre" => "J." "apellidos" => "Benito-León" ] 4 => array:2 [ "nombre" => "O." "apellidos" => "Álvarez de Toledo" ] 5 => array:2 [ "nombre" => "M.T." 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Ortega-Quintanilla, J. Alcalde-López, E. Zapata-Arriaza, A. González" "autores" => array:5 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "de Albóniga-Chindurza" ] 1 => array:2 [ "nombre" => "J." "apellidos" => "Ortega-Quintanilla" ] 2 => array:2 [ "nombre" => "J." "apellidos" => "Alcalde-López" ] 3 => array:2 [ "nombre" => "E." "apellidos" => "Zapata-Arriaza" ] 4 => array:4 [ "nombre" => "A." "apellidos" => "González" "email" => array:1 [ 0 => "ggjandro@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Radiología, Neurorradiología Intervencionista, Hospital Universitario Virgen del Rocío, Sevilla, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Gadolinio intraarterial como alternativa al contraste yodado en la trombectomía" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1253 "Ancho" => 905 "Tamanyo" => 197362 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Left distal M1 occlusion; angiography study performed from the left internal carotid artery using undiluted gadobutrol.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Thrombectomy has radically changed the management of ischaemic stroke due to large-vessel occlusion.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Angiography requires the use of iodinated contrast agents, although gadolinium may be used in patients with a contraindication to these substances. Gadolinium has been used widely in arterial interventions and peripheral angiography.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> It has also been used in carotid artery angiography,<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> in the treatment of dural arteriovenous fistulas,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> and even in the assessment of patients with ischaemic stroke, when results from non-invasive tests are inconclusive.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Gadolinium-enhanced cerebral angiography for thrombectomy may be an alternative in patients with history of severe adverse reactions to iodinated contrast agents. Although this indication is known, it is rarely mentioned in the literature.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> We recently treated 2 patients with aspiration thrombectomy using gadolinium as the contrast medium.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The first patient was a 69-year-old woman with hypertension and history of papillary carcinoma of the thyroid, which was treated surgically 20 years previously. She came to our hospital due to language impairment and right limb weakness of 6 hours’ progression. The neurological examination revealed severe dysphasia with right faciobrachiocrural hemiparesis, scoring 17 points on the National Institutes of Health Stroke Scale (NIHSS). CT findings scored 8 on the Alberta Stroke Program Early CT Score (ASPECTS), with a hyperdense signal in the left middle cerebral artery; CT angiography was not performed as the patient had presented anaphylaxis to contrast during a follow-up study of the thyroid cancer. Laboratory analysis detected no remarkable alterations, with creatinine clearance of 110 mL/min. Given strong suspicion of large-vessel occlusion, we performed an angiography study with gadobutrol; our patient’s relatives gave informed consent for the compassionate use of this contrast medium. The study revealed left distal M1 segment occlusion (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Manual aspiration with a SOFIA 6 F catheter achieved successful recanalisation (TICI grade 3). The procedure required 26 mL Gadovist® (gadobutrol 604.72 mg/mL) for 3 angiography runs, and was performed with a monoplane angiography system; the patient was not sedated during the procedure. The patient scored 10 points on the NIHSS after the procedure, and 4 at discharge. No complications were recorded during hospitalisation; unknown atrial fibrillation was detected, and kidney function was normal. An MRI study performed a week later revealed subacute punctiform ischaemic lesions in the caudate and lentiform nuclei and the left frontal subcortical region, with no signs of haemorrhage. No complications were observed after a year of follow-up, with the patient scoring 0 on the modified Rankin Scale (mRS).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Our second patient was a 68-year-old man, a smoker, with hypertension and history of oral epidermoid carcinoma, which was treated with surgery and radiation therapy 7 years earlier. He presented sudden-onset weakness of the left limbs, difficulty speaking, and anosognosia, and scored 18 on the NIHSS. CT findings scored 10 on the ASPECTS scale, with images showing hyperdense signal in the right middle cerebral artery; CT angiography was not performed as the patient had presented a severe reaction to contrast medium during an imaging study for cancer. All laboratory parameters were within normal ranges, with creatinine clearance of 90 mL/min. Femoral puncture was performed 2 hours and 15 minutes after symptom onset. The patient’s family gave informed consent for the compassionate use of gadobutrol as a contrast medium. The angiography study revealed internal carotid artery occlusion at the cervical level (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). We performed balloon angioplasty (3 × 20 mm) of the occluded segment and subsequently inserted a SOFIA® 6 F catheter until the internal carotid artery. Manual aspiration thrombectomy achieved complete recanalisation (TICI grade 3) with a single pass. Cervical angiography revealed underlying stenosis; balloon angioplasty (5 × 20 mm) was performed to place a Wallstent® endoprosthesis stent measuring 9 × 40 mm. No signs of aggregation or any other complications were observed after 20 minutes. We used a total of 110 mL undiluted gadobutrol for the angiography runs performed after thrombectomy and during endoprosthesis placement, and gadobutrol at a 50:50 dilution with saline solution for the rest. We performed a total of 15 angiography runs, including the study of the contralateral carotid artery. The patient received 900 mg of intravenous lysine acetylsalicylate and did not require sedation. His neurological symptoms improved, with an NIHSS score of 10 at discharge. No complications were observed during hospitalisation; the permeability of the endoprosthesis was confirmed by Doppler ultrasound; kidney function was preserved. An MRI study conducted 8 days later revealed a subacute infarction in the right temporolateral area, insula, and lentiform nucleus; the latter area displayed haemosiderin deposition. One year later, the patient scored 3 on the mRS and had presented no other remarkable events.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The families of both patients gave informed consent for the compassionate use of gadolinium.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The need for immediate treatment of ischaemic stroke precludes the administration of premedication for iodinated contrast agents in patients with history of severe allergic reactions. Male et al.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> published a similar case: they successfully performed mechanical thrombectomy for right M1 occlusion using intra-arterial gadolinium in a patient with history of anaphylaxis to iodinated contrast agents. Although gadolinium is a known alternative, few cases have been published, which is why we decided to share our experience with this contrast medium.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Gadolinium is widely used in MRI studies to characterise central nervous system lesions, and is particularly useful in patients with inflammatory and tumoural diseases. Significant efforts are currently being made to describe gadolinium deposits in the central nervous system. Although its clinical significance is uncertain, the possibility of gadolinium accumulation in the brain makes molecularly stable types of gadolinium a reasonable option. Non-ionic and macrocyclic gadolinium-based contrast agents (eg, gadobutrol) are preferred; linear contrasts are being discontinued in many countries. Gadolinium deposition in the dentate nucleus and globus pallidus may be associated with repeated exposure to high doses of this contrast agent, and may even play a role in blood-brain barrier permeability.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9</span></a> No other specific complications of intra-arterial administration have been described.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The summary of product characteristics of gadobutrol indicates the possibility of administering doses of up to 0.3 mL/kg. We administered 0.37 mL/kg to the first patient (71 kg) and 0.77 mL/kg to the second (85 kg). This difference is explained by the difficulty of treating tandem occlusions; in these patients, angioplasty requires cervical angiography runs, in addition to a study of the contralateral carotid artery to confirm the position of the circle of Willis. We administered a 50:50 dilution to our second patient with a view to reducing the total dose of gadobutrol. In this patient, image quality was significantly lower than in conventional studies. However, images obtained with undiluted gadobutrol were practically indistinguishable from those obtained with iodinated contrast agents. Undiluted gadobutrol was used in post-thrombectomy studies and during endoprosthesis placement. Biplane imaging is not available at our centre, so we had to perform more angiography runs and therefore required more gadobutrol.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Kidney function was monitored for a week and showed no significant alterations. One year after the procedure, neither patient developed contrast-related complications, such as nephrogenic systemic fibrosis.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> MRI studies performed during hospitalisation showed no unexpected findings.</p><p id="par0050" class="elsevierStylePara elsevierViewall">We report 2 cases of successful thrombectomy with gadobutrol-enhanced imaging and no complications associated with this contrast medium. Compassionate use of gadobutrol may be considered in patients with clear contraindications to iodinated contrast agents.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-01-17" "NotaPie" => array:1 [ 0 => array:1 [ "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: de Albóniga-Chindurza A, Ortega-Quintanilla J, Alcalde-López J, Zapata-Arriaza E, González A. Gadolinio intraarterial como alternativa al contraste yodado en la trombectomía. Neurología. 2020;35:681–683.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1253 "Ancho" => 905 "Tamanyo" => 197362 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Left distal M1 occlusion; angiography study performed from the left internal carotid artery using undiluted gadobutrol.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1533 "Ancho" => 905 "Tamanyo" => 202204 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Occlusion of the cervical segment of the right internal carotid artery; angiography study from the right common carotid artery using a 50:50 dilution of gadobutrol and saline solution.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "2018 Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "W.J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 11 | 2 | 13 |
| 2024 October | 46 | 4 | 50 |
| 2024 September | 46 | 6 | 52 |
| 2024 August | 52 | 5 | 57 |
| 2024 July | 34 | 6 | 40 |
| 2024 June | 29 | 10 | 39 |
| 2024 May | 35 | 8 | 43 |
| 2024 April | 30 | 9 | 39 |
| 2024 March | 44 | 13 | 57 |
| 2024 February | 50 | 8 | 58 |
| 2024 January | 44 | 2 | 46 |
| 2023 December | 42 | 17 | 59 |
| 2023 November | 35 | 5 | 40 |
| 2023 October | 52 | 6 | 58 |
| 2023 September | 28 | 9 | 37 |
| 2023 August | 27 | 12 | 39 |
| 2023 July | 40 | 7 | 47 |
| 2023 June | 57 | 6 | 63 |
| 2023 May | 109 | 8 | 117 |
| 2023 April | 63 | 3 | 66 |
| 2023 March | 14 | 11 | 25 |
| 2023 February | 24 | 8 | 32 |
| 2023 January | 13 | 12 | 25 |
| 2022 December | 17 | 7 | 24 |
| 2022 November | 27 | 12 | 39 |
| 2022 October | 18 | 6 | 24 |
| 2022 September | 19 | 8 | 27 |
| 2022 August | 20 | 14 | 34 |
| 2022 July | 12 | 7 | 19 |
| 2022 June | 11 | 10 | 21 |
| 2022 May | 15 | 16 | 31 |
| 2022 April | 11 | 8 | 19 |
| 2022 March | 11 | 10 | 21 |
| 2022 February | 26 | 4 | 30 |
| 2022 January | 41 | 3 | 44 |
| 2021 December | 19 | 12 | 31 |
| 2021 November | 12 | 9 | 21 |
| 2021 October | 32 | 8 | 40 |
| 2021 September | 31 | 11 | 42 |
| 2021 August | 35 | 10 | 45 |
| 2021 July | 15 | 9 | 24 |
| 2021 June | 15 | 14 | 29 |
| 2021 May | 17 | 9 | 26 |
| 2021 April | 34 | 26 | 60 |
| 2021 March | 15 | 10 | 25 |
| 2021 February | 10 | 6 | 16 |
| 2021 January | 17 | 10 | 27 |
| 2020 December | 7 | 10 | 17 |
| 2020 November | 0 | 4 | 4 |
| 2020 October | 0 | 7 | 7 |
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