Acute Encephalopathy and Cardiac Arrest Induced by Intrathecal Gadolinium Administration
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Acute Encephalopathy and Cardiac Arrest Induced by Intrathecal Gadolinium Administration Bianca Besteher1,2
· Ha-Yeun Chung1 · Thomas E. Mayer3 · Otto W. Witte1 · Klaus Kirchhof3 · Matthias Schwab1
Received: 2 August 2019 / Accepted: 4 October 2019 © Springer-Verlag GmbH Germany, part of Springer Nature 2019
Introduction Intravenously applied gadolinium-based contrast agents (GBCA) are widely used for magnetic resonance imaging (MRI) diagnostics in all clinical disciplines. They are considered safe with overall rates of less than 2.4% of acute allergic and non-allergic reactions [1]. Severe adverse effects, such as cardiac arrest [2] occur in 0.0–0.03% when administered in commonly used dosages. Intrathecal use of GBCA has been used off-label for several indications, especially for diagnosis of cerebrospinal fluid (CSF) leaks and is mostly well-tolerated [3]. This article reports an unusual case with acute onset encephalopathy and cardiac arrest following diagnostic intrathecal administration of gadobutrol.
Case Presentation A 69-year-old Caucasian female was admitted to the neurological unit with repetitive severe (visual analogue scale, VAS 7/10), bitemporal headaches lasting minutes after coughing, pressing or lifting heavy objects. Symptom onset had been 12 months earlier following a common cold. An initial cerebral MRI showed diffuse dural thickening and enhancement but no other pathologies. These typical MRI signs and the low CSF pressure of 4 cmH2O led to a suspicion of CSF leakage. Metamizole 1.5 g/day, indomethacin 75 mg/day, theophylline 400–750 mg/day and caffeine 600 mg/day did not reduce the headache suffi Bianca Besteher
[email protected] 1
Department of Neurology, Jena University Hospital, Jena, Germany
2
Department of Psychiatry and Psychotherapy, Jena University Hospital, Philosophenweg 3, 07743 Jena, Germany
3
Department of Neuroradiology, Jena University Hospital, Jena, Germany
ciently or induced intolerable adverse effects. Because of the level of suffering, an extensive diagnostic work-up was performed to identify the site of CSF leakage. Targeted treatment with epidural blood patches is superior to undirected lumbar epidural blood patches [4]; however, neither native MR myelography nor 111Indium-DTPA (diethylenetriamine penta-acetic acid) spectroscopy showed a leak. As the 111Indium-DTPA radioisotope never fully rose above the cerebral convexity, spinal leakage seemed likely. Informed consent was obtained to perform contrast-enhanced MR myelography using intrathecal gadolinium to identify the site of leakage. The patient developed progressive massive sacral pain, uncontrolled defecation, nausea, vomiting, agitation, vertigo and myoclonic jerks followed by disorientation and physical aggressiveness 15 min after injection of 20 ml NaCl 0.9% and 2 ml gadobutrol (Gadovist, Bayer Vital, Leverkusen, Germany). The patient received lorazepame 1 mg and dimenhydrinate 62 mg intravenously as well as antiallergic treatment with prednisolone 100 mg, dimentindene 4
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