Severe Encephalopathy Following Cerebral Arteriogram in a Patient with End‐Stage Renal Disease

Disruption of blood brain barrier (BBB) with subsequent subarachnoid contrast extravasation and cerebral edema is a rare complication of intra‐arterial contrast administration. We report a patient with end‐stage renal disease (ESRD) who developed such a complication. A 63‐year‐old man with a history of left orbital apex syndrome on hemodialysis (HD) was admitted with massive epistaxis. A pseudo‐aneurysm of the left internal carotid artery (ICA) required a cerebral arteriogram with coil embolization; a total of 910 ml of isosmolar intra‐arterial contrast was used. Shortly thereafter, the patient developed severe alteration in his mental status. A CT study without contrast of the head showed bilateral subarachnoid hyper‐attenuation with diffuse cerebral edema consistent with contrast‐induced encephalopathy syndrome. The patient was urgently and repetitively dialyzed to remove the contrast leading to a remarkable improvement in his mental status and resolution of both subarachnoid hyper‐attenuation and brain edema. The large volume of intra‐arterial contrast that may be required in neurologic interventional procedures is occasionally associated with breakdown of BBB leading to subarachnoid accumulation and cerebral edema resulting in a severe encephalopathy syndrome. Hemodialysis seems particularly well suited for the patient who has renal failure in whom this syndrome develops.