Abstract 108: Iatrogenic Intrathecal Gadolinium Contrast Administration During Spinal Pain Procedures Mimicking Subarachnoid Hemorrhage: Two Case Reports

• Published in: Stroke: vascular and interventional neurology Vol. 4; no. S1
• Main Authors: Aggarwal, A, Scarpiello, S, Akinci, Y, Tabibzadeh, N, Zacharatos, H, Jankowitz, B
• Format: Journal Article
• Language: English
• Published: Phoenix Wiley Subscription Services, Inc 01-11-2024
• Subjects: Contrast agents; Convulsions & seizures; Epidural; Hemorrhage; Iatrogenesis; Intubation; Iodine; Neurotoxicity; Tomography
• ISSN: 2694-5746; 2694-5746
• DOI: 10.1161/SVIN.04.suppl_1.108

IntroductionGadolinium‐based contrast agents (GBCAs) are sometimes used off‐label as alternatives to iodine‐based contrast agents for visualization during interventional spinal pain procedures in individuals with known hypersensitivity reactions to iodine. The administration of GBCAs into neuraxial space (i.e. epidural and intrathecal areas) is not FDA approved. When administered intrathecally, blood‐brain barrier does not play a role and contrast passes from the pial surfaces into brain parenchyma by simple diffusion leading to neurotoxicity. The adverse effects range from headaches, encephalopathy, seizures, ataxia, confusion to even death. We report two cases of severe GBCA toxicity after its accidental intrathecal administration during spinal procedures.Case 1An 80‐year‐old female underwent myelography with gadolinium contrast to evaluate for spinal stenosis. After the procedure in the recovery unit, the patient became agitated, confused and experienced a generalized tonic clonic (GTC) seizure necessitating intubation. Computed tomography (CT) scan of the head was highly suggestive of a diffuse subarachnoid hemorrhage (SAH) with intraventricular hemorrhage. (Figure 1 (A‐C)). An External ventricular drain was placed and gadolinium was detected by placing the CSF containing test‐tube in a magnetic resonance imaging scanner. Patient received supportive care in the neurointensive care unit and was started on Levetiracetam. She subsequently recovered and was weaned off Levetiracetam.Case 2A 55‐year‐old male with cervical disk disease and chronic neck pain experienced multiple GTC seizures after receiving outpatient cervical epidural injections with a GBCA. Computed tomography (CT) scan of the head appeared like a diffuse SAH with pneumocephalus in the ventricular system. (Figure 1 (D‐F)). Patient required intubation and was started on anti‐epileptic drugs (AEDs). Patient was additionally treated with Dexamethasone. CT angiogram of head and neck did not demonstrate aneurysm. Patient improved over the course of a few days and was continued on AEDs on discharge.ConclusionIatrogenic gadolinium contrast administration into the intrathecal space can cause severe neurotoxicity leading to encephalopathy and status epilepticus. Physicians should keep this differential in mind and inquire about recent pain or spinal procedures in patients with imaging suggestive of a SAH, particularly in the absence of an underlying vascular malformation. Imaging findings such as presence of pneumocephalus is more suggestive of iatrogenic contrast administration versus an acute SAH. The stability 6 hour and 24‐hour CT scans of the above two cases showed rapid clearing of contrast material and near normalization which would not be expected with a SAH. Treatment is largely supportive along with AEDs and steroids.