Contrast Injection from an Intermediate Catheter Placed in an Intradural Artery is Associated with Contrast-Induced Encephalopathy following Neurointervention

Abstract

Background and purpose: Contrast-induced encephalopathy can result from neurotoxicity of contrast medium in the affected area. The development of intermediate catheters has allowed guidance of catheters to more distal arteries. This study focused on the association between contrast-induced encephalopathy and contrast injection from an intermediate catheter guided into a distal intradural artery during neurointervention for cerebral aneurysms.

Materials and methods: We retrospectively reviewed 420 consecutive aneurysms in 396 patients who underwent neurointervention for extracranial aneurysms and unruptured intracranial aneurysms at our institution from February 2012 to January 2023. Patients were divided into a group with contrast-induced encephalopathy and a group without. To identify risk factors for contrast-induced encephalopathy, we compared clinical, anatomic, and procedural factors between groups by multivariate logistic regression analysis and stepwise selection.

Results: Among the 396 patients who underwent neurointervention for cerebral aneurysms, 14 (3.5%) developed contrast-induced encephalopathy. Compared with the group without contrast-induced encephalopathy, the group with contrast-induced encephalopathy showed significantly higher rates of patients on hemodialysis, previously treated aneurysms, intradural placement of a catheter for angiography, nonionic contrast medium, and flow-diversion procedures in univariate analyses. Stepwise multivariate logistic regression analysis revealed intradural placement of a catheter for angiography (OR = 40.4; 95% CI, 8.63-189) and previously treated aneurysms (OR = 8.20; 95% CI, 2.26-29.6) as independent predictors of contrast-induced encephalopathy.

Conclusions: Contrast injection from an intradural artery and retreatment of recurrent aneurysms were major risk factors for contrast-induced encephalopathy. Attention should be paid to the location of the intermediate catheter for angiography to avoid developing contrast-induced encephalopathy.

FIGURE.

A 70-year-old man undergoing hemodialysis due to end-stage renal failure underwent coil embolization for a right MCA aneurysm with a maximum diameter of 9 mm. Right middle cerebral arteriography (A) and fluoroscopic view (B) show contrast of the right MCA aneurysm from the 6F Sofia catheter, an intermediate catheter guided to the right MCA horizontal segment. Right middle cerebral arteriography (C) shows complete embolization of aneurysm achieved by a stent-assisted technique. Half an hour after completion of the treatment, the patient's condition with stupor, disorientation, and severe left upper and lower extremity paralysis progressively deteriorated. No obvious ischemic and hemorrhagic lesions were seen on MR imaging (D, DWI; E, FLAIR sequence). MRA did not detect arterial occlusion, dissection, or vasospasm. Noncontrast CT (F) shows enhancement due to leakage of contrast medium into the right cerebral cortex and subcortex. After hemodialysis, disturbance of consciousness and left hemiparesis gradually improved. Noncontrast CT (G) 5 days after treatment demonstrates that the contrast-induced enhancement in the right cerebral cortex and subcortex had disappeared. The arrowhead indicates the tip of Sofia catheter.