Contrast-enhanced encephalopathy and massive cerebral edema after endovascular coiling of cerebral aneurysm. A case report

Contrast-induced encephalopathy (CIEP) is a rare complication after endovascular therapy. The etiology of CIEP is still a matter of debate. We present a rare occurrence of CIEP in a known hypertensive and type 2 diabetic patient after endovascular coiling of cerebral aneurysm with oculomotor nerve palsy. A 68-year old female presented with seven days history of headache and left ptosis or blepharoptosis with mild mydriasis. The headaches were localized mainly at the left side of the nose, orbit, and upper forehead while the left ptosis was associated with blurred vision. Computed tomography angiography revealed an aneurysm in between the C4 segment of the left internal carotid artery (ICA) and the bifurcation of the left posterior communicating artery. Digital subtraction angiography further confirmed the aneurysm. We used the transarterial approach to assess the aneurysm and subsequent coiling. Iohexol (Omnipaque) contrast agent was used during the endovascular procedure. The patient’s condition deteriorated into acute confusion state with cardinal symptomology of CIEP immediately after the operation. Computed tomography scan revealed cortical contrast enhancement in the vascular territory of the ICA as well as edema. Her symptomatology resolved 48 hours after treated with anticonvulsants, intracranial pressure reduction and hydration. Chronic hypertension as well as type 2 diabetics may be critical predisposing factors to CIEP. CIEP should be suspected in patients presenting with acute confusion state after endovascular therapy. Massive edema with ischemic brain changes in white matter of the brain before endovascular procedure should rise suspicion of CIEP. Introduction Contrast-induced encephalopathy (CIEP) is a rare complication after endovascular therapy.1-5 The precise etiological mechanisms via which this occur is still a matter of debate.2,4 Nevertheless, osmotic disruption of the blood-brain barrier (BBB) arising from repeated contrast injections into a single vessel has been speculated as a cause of this complication.3,4,6 Chronic hypertension, transient ischemia attack, compromised cerebral autoregulation, renal failure, enormous contrast volumes, selective vertebralbasilar arteriography (VAG) and male gender have been implicated as predisposing factors of CIEP.5,7-10 The symptomatology of CIEP often commence during the procedure but become apparent few hours after the procedure.5 Most symptoms are typically self-limiting, resolving within 2-4 days of onset.3,11,12 Nevertheless, full recovery may take as long as few weeks in a few patients.3,12 Anomalous cortical contrast enhancement with mild to severe edema, subarachnoid contrast enhancement, as well as striatal contrast enhancement are the typical postprocedural CT findings.2,9,12 Adequate hydration with intravenous crystalloids as well as anticonvulsants are the supportive treatment modalities for this post procedural complication.5,13 The observation of CIEP in a known hypertensive and type 2 diabetic patient after endovascular coiling of aneurysm is very rare and has not been reported in literature. We present a case of CIEP after endovascular coiling of cerebral aneurysm in a hypertensive and type 2 diabetic patient with left oculomotor nerve palsy (OMNP).