Case Report and Literature Review on Low-Osmolar, Non-Ionic Iodine-Based Contrast-Induced Encephalopathy

Figures & data

Figure 1 Contrast-induced encephalopathy in brain computed tomography (CT) scans. (A) Emergency brain CT showed no acute pathological findings. (B) Brain CT 2 hours after surgery indicated multiple high-density regions in the subarachnoid space. (C) Brain CT 10 hours after surgery showed significantly swollen brain tissue, particularly in the right hemisphere, the left frontal lobe, and the left occipital lobe. The high-density shading in the subarachnoid cavity was significantly denser than in previous scans. (D) Brain CT 72 hours after surgery showed the sulci of the right hemisphere became shallow, and low-density shadows could be seen in the frontal parietal lobe. But cerebral edema was significantly improved.

Figure 2 Computed tomography angiography (CTA) showed no evidence of macrovascular embolism in (A) posteroanterior (PA), (B) posterior (P) and (C) left anterior oblique (LAO) view.

Figure 3 Brain magnetic resonance imaging (MRI) 2 hours after surgery showed hyperintense areas in the right cortex in (A) T2-weighted image and (B) fluid-attenuated inversion recovery (FLAIR) images, and no clear signs of subarachnoid hemorrhage were observed on (C) diffusion-weighted imaging (DWI).

Table 1 Cases of CIE Following Cardiac Catheterization with Non-Ionic, Low-Osmolar Contrast Agents from 1970-Present

Reference	Age	Gender	Risk Factor	Procedure	Contrast Agent	Contrast Type	Contrast Volume (mL)	Presentation	Neuroimaging	Treatment Provided	Symptom Duration	Complete Symptom Resolution
Eleftheriou et al (2018)^Citation12	57	F	CKD, HT, DM	Diag+PCI	Iodixanol	Non-ionic, dimer, low osmolar	130	Tonic–clonic seizures	Right-sided relatively widespread edema of the parenchyma (CT)	Supportive care, acyclovir, meropenem, betamethasone.	72 h	Yes
Yen et al (2018)^Citation13	64	M	CKD, HT, DM	Diag+PCI	Iohexol	Non-ionic, monomer, low osmolar	100	Disorientation with raves	Normal (CT, MRI)	Hemodialysis	N/A	Yes
Dattani et al (2018)^Citation3	6	M	HT, DM	Diag	Iohexol	Non-ionic, monomer, low osmolar	120	Confused, aggressive, expressing verbal profanities	Normal (CT)	Supportive care	9 d	Yes
Hamra et al (2017)^Citation14	62	M	HT	Diag+PCI	Iohexol	Non-ionic, monomer, low osmolar	300	Right-sided homonymous hemianopia	Slight enhancement of the venous sinuses (CT)	Supportive care	48 h	Yes
Spina et al (2017)^Citation15	65	M	Previous CIE	Diag	Iopromide	Non-ionic, monomer, low osmolar	120	Global aphasia, bilateral limb weakness	Normal (CT, MRI)	Supportive care	24 h	Yes
Gollol Raju et al (2015)^Citation16	44	F	ESKD, HT, DM	Diag+PCI	Iohexol	Non-ionic, monomer, low osmolar	190	Left-sided weakness, seizure activity	Contrast enhancement of right cerebral hemisphere(CT)	Anticonvulsants, hemodialysis	72 h	Yes
Kocabay et al (2014)^Citation2	68	M	HT	Diag+PCI	Iopromide	Non-ionic, monomer, low osmolar	250	Monoplegia	Normal (CT and MRI)	Supportive care	12 h	Yes
	58	F	HT	Diag+PCI	Iopromide	Non-ionic, monomer, low osmolar	220	Bilateral oculomotor opthalmoplegia	Normal (CT and MRI)	Supportive care	>30 d	No
Kocabay et al (2014)^Citation2	70	M	HT	Diag+PCI	Iopromide	Non-ionic, monomer, low osmolar	130	Cerebellar dysfunction	Normal (CT and MRI)	Supportive care	14 h	Yes
	68	M	HT, DM	Diag+PCI	Iopromide	Non-ionic, monomer, low osmolar	180	Unilateral oculomotor monoplegia	Normal (CT and MRI)	Supportive care	1 h	Yes
Sridhar et al (2014)^Citation17	63	F	HT, DM	Diag (IMA graft)	Iopamidol	Non-ionic, monomer, low osmolar	250	Cortical blindness	Contrast enhancement of occipital lobes (CT), no ischemia or hemorrhage on MRI	Supportive care	72 h	Yes
Ting et al (2013)^Citation18	49	M	–	Diag	Iopromide	Non-ionic, monomer, low osmolar	205	Confusion, decrease in level of consciousness	Normal (CT and MRI/A)	Supportive care	12 h	Yes
Liao et al (2013)^Citation19	76	F	HT, DM	Diag	Ioversol	Non-ionic, monomer, low osmolar	125	Aphasia, cortical blindness, rightsided weakness	Hyperintensity high frontoparietal regions (MRI)	Supportive care	48 h	Yes
Terlecki et al (2013)^Citation20	32	M	–	Diag	Iopromide	Non-ionic, monomer, low osmolar	100	Cortical blindness	Normal (CT)	Supportive care	24 h	Yes
Law et al (2012)^Citation21	69	F	CKD, DM, PCR	Diag+PCI	Iodixanol	Non-ionic, dimer, low osmolar	320	Partial seizure, homonymous hemianopia, hemisensory loss, hemiparesis	Cerebral edema (CT)	Intravenous benzodiazepines, thrombolysis	24 h	Yes
Jiang et al (2012)^Citation22	64	M	HT, DM	Diag+PCI	Iopromide	Non-ionic, monomer, low osmolar	160	Confusion, irritability, limb paralysis, aphasia	Hyperdensity of sagittal sinus (CT). Slowing in a range occipital lobe (EEG)	Supportive care	28 h	Yes
Aykan et al (2012)^Citation23	68	M	HT	Diag+PCI	Iopromide	Non-ionic, monomer, low osmolar	250	Left lower extremity weakness and sensory loss	Contrast enhancement sagittal sinus and occipital lobe (CT)	Supportive care	12 h	Yes
Kocabay et al (2011)^Citation7	47	M	–	Diag+PCI	Iopromide	Non-ionic, monomer, low osmolar	150	Confusion, agitation, nausea, headache	Contrast enhancement of occipital lobes (CT)	Supportive care	8 h	Yes
	70	M	DM	Diag+PCI	Iopromide	Non-ionic, monomer, low osmolar	120	Confusion, agitation, nausea, headache	Contrast enhancement of occipital lobes (CT)	Supportive care	12 h	Yes
Gürer et al (2011)^Citation24	69	M	–	Diag+PCI	Iohexol	Non-ionic, monomer, low osmolar	100	Confusion, headache, vomiting, left hemiplegia,	Focal hyperdense lesions	Supportive care	6 h	Yes
Chisci et al (2011)^Citation25	76	M	CKD, DM	PCI+CAS	Iodixanol	Non-ionic, dimer, low osmolar	200	Stupor, aphasia, hemiparesis	Hyperdensity of cerebral sulci and subarachnoid spaces	Intravenous mannitol, methylprednisone,	48 h	Yes
Akhtar et al (2011)^Citation26	39	F	–	Diag	Iopamidol	Non-ionic, monomer, low osmolar	80	Cortical blindness	Normal (CT, vertebral angiogram)	Antiplatelet therapy, intravenous heparin	1 h	Yes
Borghi et al (2008)^Citation27	74	M	HT	Diag+aorto-gram	Iomeprol	Non-ionic, monomer, low osmolar	320	Cortical blindness	Normal (CT)	Supportive care	24 h	Yes
Sawaya et al (2007)^Citation5	N/A	M	–	Diag+PCI	Iohexol	Non-ionic, monomer, low osmolar	120	Agitation, confusion, convulsions, slurred speech, loss of consciousness	Normal (CT) Diffuse slowing in the theta range over both hemispheres (EEG)	Orotracheal intubation and ventilation, intravenous benzodiazepines, hydration	18 h	Yes
Tatli et al (2007)^Citation28	52	F	–	Diag	Iomeprol	Non-ionic, monomer, low osmolar	150	Cortical blindness	Contrast enhancement of occipital lobes (CT)	Supportive care	5 h	Yes
Yazici et al (2007)^Citation29	70	F	DM, HT	Diag	Iobitridol	Non-ionic, monomer, low osmolar	75	Cortical blindness	Contrast enhancement of occipital lobes (CT)	Supportive care	72 h	Yes
Frye et al (2005)^Citation30	18 mo	M	–	Diag	Ioversol	Non-ionic, monomer, low osmolar	7mL/kg	Myoclonus	Right holohemispheric parenchymal and subarachnoid hyperdensity cerebral edema	Intravenous benzodiazepines	24 h	Yes
Schulte A et al (2004)^Citation31	56	M	–	Diag	Iopromide	Non-ionic, monomer, low osmolar	135	Confusion, dysarthria, cortical blindness	Contrast enhancement right occipital lobe	Supportive care	24 h	Yes
Velden et al (2003)^Citation32	82	F	CKD, HT	Diag+PCI	Iomeprol	Non-ionic, monomer, low osmolar	500	Aphasia, right-sided hemiparesis	Hyperdensities filling the sulci of both cerebral hemispheres	Supportive care	40 h	Yes
Foltys et al (2003)^Citation33	82	M	CKD, DM, HT	Diag (IMA graft)	Iopromide	Non-ionic, monomer, low osmolar	130	Right-sided hemiparesis, aphasia	Cerebral edema and extravascularly localized contrast media left hemisphere	Supportive care	6 h	Yes
Gellen et al (2003)^Citation34	52	N/A	CKD	Diag (IMA graft)	Iopamidol	Non-ionic, monomer, low osmolar	400	Cortical blindness	Contrast enhancement occipital lobes	Supportive care	72 h	Yes
Yildiz et al (2003)^Citation35	63	M	–	Diag+Aortogram	Iomeprol	Non-ionic, monomer, low osmolar	450	Amnesia, numbness, right upper extremity numbness	Contrast enhancement right occipital lobe	Intravenous dexamethasone	12 h	Yes
Lim et al (2002)^Citation36	63	F	DM, HT	Diag (IMA graft)	Iopromide	Non-ionic, monomer, low osmolar	160	Cortical blindness, right homonymous hemianopia	Contrast enhancement of occipital lobes (CT, MRI)	Supportive care, intravenous heparin	48 h	Yes
Zwicker et al (2002)^Citation37	52	F	HT	Diag+PCI	Ioversol	Non-ionic, monomer, low osmolar	280	Cortical blindness	Contrast enhancement of occipital lobes (CT)	Supportive care, antihypertensives	36 h	Yes
Kwok et al (2000)^Citation38	53	M	–	Diag	Ioversol	Non-ionic, monomer, low osmolar	100	Cortical blindness, catatonia	Normal (CT, MRI)	Antiplatelet therapy, low molecular weight heparin	12 h	Yes
Vranckx et al (1999)^Citation39	68	M	–	Diag (IMA graft)+PCI	Iohexol	Non-ionic, monomer, low osmolar	180	Cortical blindness, aphasia, periodic alternating gaze with nystagmus	Contrast enhancement of occipital lobes, temporal lobes, thalami (CT)	CPR, temporary transvenous pacemaker	6 d	No
Sticherling et al (1998)^Citation40	55	M	–	Diag (graft)	Iomeprol	Non-ionic, monomer, low osmolar	280	Cortical blindness	Contrast enhancement of occipital lobes (CT)	Supportive care	5 d	Yes
Kamata et al (1995)^Citation41	62	M	CKD, HT	Diag (IMA graft)+PCI	Iopamidol	Non-ionic, monomer, low osmolar	170	Headache, confusion, cortical blindness	Contrast enhancement cerebellum, thalamus	Thrombolysis, intravenous dexamethasone, glycerine, plasma expander	12 h	Yes
Rama et al (1993)^Citation42	59	M	HT	Diag+PCI	Ioversol	Non-ionic, monomer, low osmolar	220	Cortical blindness	Normal (CT)	Supportive care	12 h	Yes
	45	M	HT	Diag+PCI	Ioversol	Non-ionic, monomer, low osmolar	167	Cortical blindness	Normal (CT)	Supportive care	24 h	Yes
	68	M	HT	Diag+PCI	Ioversol	Non-ionic, monomer, low osmolar	262	Homonymous hemianopia	Normal (CT)	Supportive care	15 min	Yes
Parry et al (1993)^Citation43	62	M	HT	Diag (IMA graft)	Iopamidol	Non-ionic, monomer, low osmolar	270	Cortical blindness, loss of coordination right arm	Contrast enhancement of occipital lobes (CT)	Supportive care	72 h	Yes

Abbreviations: HT, hypertension; DM, diabetes mellitus; CKD, chronic kidney disease; ESKD, end stage kidney disease; CT, computed tomography; MRI, magnetic resonance imaging; Diag, diagnostic; PCI, primary coronary intervention; CAS, carotid artery stenting; EEG, electroencephalogram; IMA, internal mammary artery.

Eleftheriou A, Rashid AS, Lundin F. Late transient contrast-induced encephalopathy after percutaneous coronary intervention. J Stroke Cerebrovasc Dis. 2018;27(6):e104–e106. doi:10.1016/j.jstrokecerebrovasdis.2017.12.05129397312

 PubMed Web of Science ®Google Scholar

Yen CC, Sung SF, Hsu YH. Clinical presentations of contrast-induced encephalopathy in end-stage renal disease. Intern Med J. 2018;48(5):604–605. doi:10.1111/imj.1377629722192

 PubMed Web of Science ®Google Scholar

Dattani A, Au L, Tay KH, Davey P. Contrast-induced encephalopathy following coronary angiography with no radiological features: a case report and literature review. Cardiology. 2018;139(3):197–201. doi:10.1159/00048663629402812

 PubMed Web of Science ®Google Scholar

Hamra M, Bakhit Y, Khan M, Moore R. Case report and literature review on contrast-induced encephalopathy. Future Cardiol. 2017;13(4):331–335. doi:10.2217/fca-2016-007528621151

 PubMed Web of Science ®Google Scholar

Spina R, Simon N, Markus R, Muller DW, Kathir K. Recurrent contrast-induced encephalopathy following coronary angiography. Intern Med J. 2017;47(2):221–224. doi:10.1111/imj.1332128201864

 PubMed Web of Science ®Google Scholar

Raju NSG, Joshi D, Daggubati R, Movahed A. Contrast induced neurotoxicity following coronary angiogram with Iohexol in an end stage renal disease patient. World J Clin Cases. 2015;3:942–945. doi:10.12998/wjcc.v3.i11.94226601097

 PubMed Web of Science ®Google Scholar

Kocabay G, Karabay C, Kalayci A, et al. Contrast-induced neurotoxicity after coronary angiography. Herz. 2014;39(4):522–527. doi:10.1007/s00059-013-3871-623846826

 PubMed Web of Science ®Google Scholar

Sridhar GS, Sadiq MA, Wan Ahmad WA, et al. Transient cortical blindness: a benign but devastating complication after coronary angiography and graft study. J Pak Med Assoc. 2014;64:1195–1197.25823165

 PubMed Web of Science ®Google Scholar

Ting F, Bhat A, Markus R, Ortega M, Ting S. Contrast-induced encephalopathy post-angiography. Internet J Neurol. 2013;16:1–3.

 Google Scholar

Liao MT, Lin TT, Lin YL, Hwang JJ, Tseng CD. Contrast-induced encephalopathy after percutaneous coronary intervention. Acta Cardiol Sin. 2013;29:277–280.27122717

 PubMed Web of Science ®Google Scholar

Terlecki M, Wojciechowska W, Rajzer M, et al. Transient cortical blindness after coronary artery angiography. Adv Interv Cardiol. 2013;9:105–108.

 Google Scholar

Law S, Panichpisal K, Melaku D, et al. Contrast-induced neurotoxicity following cardiac catheterization. Case Rep Med. 2012;2012:267860. doi:10.1155/2012/26786023251169

 PubMedGoogle Scholar

Jiang X, Li JL, Chen X. Contrast-induced encephalopathy following coronary angioplasty with iopromide. Neurosciences. 2012;17:378–379.23022906

 PubMed Web of Science ®Google Scholar

Aykan A, Zehir R, Karabay CY, Kocabay G. Contrast-induced monoplegia following coronary angioplasty with iopromide. Kardiol Pol. 2012;70:499–500.22623245

 PubMed Web of Science ®Google Scholar

Kocabay G, Karabay CY. Iopromide-induced encephalopathy following coronary angioplasty. Perfusion. 2011;26(1):67–70. doi:10.1177/026765911038551120921088

 PubMed Web of Science ®Google Scholar

Gürer B, Yilmaz ER, Kahveci R, Sekerci Z. Non-ionic contrast media neurotoxicity mimicking intracerebral hematoma. Acta Neurochir. 2011;153:419–420. doi:10.1007/s00701-010-0780-920740369

 PubMed Web of Science ®Google Scholar

Chisci E, Setacci F, Donato G, De, Setacci C. A case of contrast-induced encephalopathy using iodixanol. J Endovasc Ther. 2011;18:540–544. doi:10.1583/11-3476.121861745

 PubMed Web of Science ®Google Scholar

Akhtar N, Khatri IA, Naseer A, Ikram J, Ahmed W. Transient cortical blindness after coronary angiography: a case report and literature review. J Pak Med Assoc. 2011;61:295–297.21465952

 PubMed Web of Science ®Google Scholar

Borghi C, Saia F, Marzocchi A, Branzi A. The conundrum of transient cortical blindness following coronary angiography. J Cardiovasc Med. 2008;9:1063–1065. doi:10.2459/JCM.0b013e3282fe1718

 Google Scholar

Sawaya RA, Hammoud R, Arnaout S, Alam S. Contrast-induced encephalopathy following coronary angioplasty with iohexol. South Med J. 2007;100(10):1054–1055. doi:10.1097/SMJ.0b013e318154008617943057

 PubMed Web of Science ®Google Scholar

Tatli E, Buyuklu M, Altun A. An unusual but dramatic complication of coronary angiography: transient cortical blindness. Int J Cardiol. 2007;121:e4–e6. doi:10.1016/j.ijcard.2007.04.12917692963

 PubMed Web of Science ®Google Scholar

Yazici M, Ozhan H, Kinay O, et al. Transient cortical blindness after cardiac catheterization with Iobitridol. Tex Heart Inst J. 2007;34:373–375.17948092

 PubMed Web of Science ®Google Scholar

Frye RE, Newburger JW, Nugent A, Sahin M. Focal seizure and cerebral contrast retention after cardiac catheterization. Pediatr Neurol. 2005;32:213–216. doi:10.1016/j.pediatrneurol.2004.07.01215730907

 PubMed Web of Science ®Google Scholar

Schulte-Altedorneburg G, Rub K, Scheglmann K. Simultaneous ischemic and neurotoxic brain damage after coronary angiography. Neurol Res. 2004;26:79–82. doi:10.1179/01616410477302657014977062

 PubMed Web of Science ®Google Scholar

Velden J, Milz P, Winkler F, Seelos K, Hamann GF. Nonionic contrast neurotoxicity after coronary angiography mimicking subarachnoid hemorrhage. Eur Neurol. 2003;49:249–251. doi:10.1159/00007019812736546

 PubMed Web of Science ®Google Scholar

Foltys H, Krings T, Block F. Cerebral contrast medium extravasation after coronary angioplasty. Nervenarzt. 2003;74:892–895. doi:10.1007/s00115-003-1574-614551695

 PubMed Web of Science ®Google Scholar

Gellen B, Remp T, Mayer T, Milz P, Franz WM. Cortical blindness: a rare but dramatic complication following coronary angiography. Cardiology. 2003;99:57–59. doi:10.1159/00006844312589125

 PubMed Web of Science ®Google Scholar

Yildiz A, Yencilek E, Apaydin FD, Duce MN, Ozer C, Atalay A. Transient partial amnesia complicating cardiac and peripheral arteriography with nonionic contrast medium. Eur Radiol. 2003;13:L113–L115. doi:10.1007/s00330-003-1975-815018175

 PubMed Web of Science ®Google Scholar

Lim KK, Radford DJ. Transient cortical blindness related to coronary angiography and graft study. Med J Aust. 2002;177:43–44. doi:10.5694/j.1326-5377.2002.tb04636.x12088480

 PubMed Web of Science ®Google Scholar

Zwicker JC, Sila CA. MRI findings in a case of transient cortical blindness after cardiac catheterization. Catheter Cardiovasc Interv. 2002;57:47–49. doi:10.1002/ccd.1024612203927

 PubMed Web of Science ®Google Scholar

Kwok BW, Lim TT. Cortical blindness following coronary angiography. Singapore Med J. 2000;41:604–605.11296788

 PubMedGoogle Scholar

Vranckx P, Ysewijn T, Wilms G, Heidb€uchel H, Herregods MC, Desmet W. Acute posterior cerebral circulation syndrome accompanied by serious cardiac rhythm disturbances: a rare but reversible complication following bypass graft angiography. Catheter Cardiovasc Interv. 1999;48:397–401. doi:10.1002/(SICI)1522-726X(199912)48:4<397::AID-CCD16>3.0.CO;2-C10559823

 PubMed Web of Science ®Google Scholar

Sticherling C, Berkefeld J, Auch-Schwelk W, Lanfermann H. Transient bilateral cortical blindness after coronary angiography. Lancet. 1998;351:570. doi:10.1016/S0140-6736(05)78557-39492782

 PubMed Web of Science ®Google Scholar

Kamata J, Fukami K, Yoshida H, et al. Transient cortical blindness following bypass graft angiography: a case report. Angiology. 1995;46:937–946. doi:10.1177/0003319795046010097486215

 PubMed Web of Science ®Google Scholar

Rama BN, Pagano TV, DelCore M, Knobel KR, Lee J. Cortical blindness after cardiac catheterization: effect of re-challenge with dye. Cathet Cardiovasc Diagn. 1993;28:149–151. doi:10.1002/ccd.18102802118448799

 PubMedGoogle Scholar

Parry R, Russell Rees J, Wilde P. Transient cortical blindness after coronary angiography. Br Heart J. 1993;70:563–564. doi:10.1136/hrt.70.6.5638280526

 PubMedGoogle Scholar