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Case Reports Medical Education Research Forum 2019

5-2019

Inadvertent Intrathecal Injection of Ionic Contrast– Seeing is Believing!Gaurav ChauhanHenry Ford Health System

Aman UpadhyayHenry Ford Health System

Mun ChoeHenry Ford Health System

Joseph Salama HannaHenry Ford Health System

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Recommended CitationChauhan, Gaurav; Upadhyay, Aman; Choe, Mun; and Salama Hanna, Joseph, "Inadvertent Intrathecal Injection of Ionic Contrast –Seeing is Believing!" (2019). Case Reports. 9.https://scholarlycommons.henryford.com/merf2019caserpt/9

Abstract CLINICAL VIGNETTE

INTRODUCTION

DISCUSSION

REFERENCES

Inadvertent intrathecal injection of ionic contrast – seeing is believing !

Gaurav Chauhan, MD, Aman Upadhyay, MD, Mun Choe, MD, Joseph M Salama-Hanna, MD

Department of Anesthesiology, Pain Management and Perioperative Medicine

Henry Ford Health System, Detroit, Michigan

The intravenous administration of gadopentetate dimeglumine (GD) is relatively safe and rarely causes

systemic toxicity in the course of routine imaging studies. However, the general safety of intrathecal GD has

not been established. We report a very rare case of an overdose intrathecal GD injection presenting with

neurotoxic manifestations, including a decreased level of consciousness, global aphasia, rigidity, and visual

disturbance. In our case due to his shellfish allergy the physician elected to use a gadolinium based contrast

rather than the standard iodinated contrast dye. The patient’s epidural resulted in an inadvertent intrathecal

injection of GD. In this case report the authors will discuss the pathophysiology and neurological sequlae of

intrathecal GD injection along with the current guidelines for management.

• Gadolinium is a rare paramagnetic metal and GD3 + ion is he most

effective paramagnetic ion. Gadolinium based contrast agents (GBCAs)

are widely used in medicine since 1988.

• GD3 + is a toxic ion which is chelated with organic ligands to create

GBCAs with either a linear or macrocyclic structure. Following

intravenous injection, all GBCAs distribute in the blood and

extravascular–extracellular space. GBCAs are biologically inert and

rapidly eliminated by the kidneys.

• GBCA are administered in about 25% of all MRI examinations. They

are also widely used to facilitate chronic pain procedures under

fluoroscopy. The intravenous application of GD is relatively safe and

rarely causes systemic toxicity in the course of routine imaging studies

• But the impact of GBCA on human health and its mechanism of toxicity

remains unknown. Efforts are underway to understand the mechanisms

of gadolinium toxicity and to therapeutic and preventive solutions for

patients presenting signs and symptoms of gadolinium toxicity. We

present a case report of acute Gadobutrol neurotoxicity and its sequlae.

Molecular structure of Gadobutrol

0.1 ml/ kg

C18H31GdN4O9

81 year old/ M, BMI 34 • Severe spinal stenosis + neurogenic claudication

• Lumbar epidural steroid injection

• Medical h/o Surgical h/o :

• Allergy to shellfish L4 – L5 laminectomy

• Hypertension

• COPD on 2L/ min of O2

Gadobutrol contrast outlining the cauda equina nerve rootsconsistent with intrathecal injection.

Gadobutrol within the thecal sac

18 G Spinal needle at the L5-S1 level

Recovery 5 mins: Severe headache 25 mcg of Fentanyl administered

Nausea / Vomiting, agitation + unbearable HEADACHE

ER Agitated – 1 mg Ativan – Agitation persisted – 1 mg Ativan

2 hours: Confused, Global Aphasia, Vomiting, Seizures – GTCS

2 mg Midazolam + 200 mg Propofol + 140 mg Succinylcholine

Emergency Intubation, NIBP – 180/110, HR 120 bpm, Temp - 40 C

ABG : Metabolic Acidosis, PO2 99, PaCO2 30, HCO3- 14

NICU Extensive workup performed – non-Contrast CT, Viral serologies, LP

12 hours : Severe rigidity, Jerking of left extremities & neck stiffness

Labs WNL, NCCT reported

24 hours: No seizure on Keppra, DSA for Sub-Arachnoid hemorrhage –ve

48 hours: Alert, oriented – extubated, No neurological abnormality detected

NCCT Head – no abnormality detected

Discharged at 72 hours

CONCLUSION

Intrathecal GBCA :• Max dose : 3.3 microM / g of brain or 15 microliters. (Di Chiro et al animal studies)

• GADAVIST – 2 ml 2000 microliters injected intrathecally

• Current Literature – HIGH dose intrathecal GADAVIST

• behavioral changes

• neurological : focal seizure activity, ataxia, hemiparesis and delayed tremor

• histopathological : oligodendroglia loss, astrocyte hypertrophy, etc.

Current literature : Few cases of Gadolinium encephalopathy. High-dose

administration of GD produced a fluctuating level of consciousness and neurological

deficits. In our case 100x dose was administered leading to prolonged effect

Li et al. hypothesized that there is no CSF-brain barrier with regard to GBCA, as diffusion

of the GD into the cerebral gray matter was evident on the T1-weighted and FLAIR

images. GBCA can also penetrate into the cerebral deep white matter through the

perivascular spaces. This provides evidence in vivo to support the idea that the

perivascular space is a channel for CSF-brain exchanges.

The patient was managed symptomatically as the diagnosis was made in retrospect as

NICU was not aware of the inadvertent intrathecal GBCA injection.

Current Management guidelines:• prompt continuous CSF draining through a lumbar drain could be a life-saving

procedure.

• Steroids: in case of closed-head injuries or brain tumors to prevent and help reverse

brain edema.

• Serum and CSF Gadolinium level to diagnose rule out other differentials.

• Symptomatic management

• GBCA injected intrathecally may lead to severe neurological

sequlae and caution should be exercised during procedures

employing GBCA.

• Physicians should be aware of “Gadolinium encephalopathy” as a

clinical entity. A treatment algorithm should be in the facility for

inadvertent intrathecal injection of GBCA.

• Communication is key especially during clinical scenarios when

multiple providers are involved. The expensive neurological

workup would have been avoided if NICU was made aware of

events that transpired during the procedure done in pain clinic.

• Iodinated contrast can be used in shellfish allergy.

1. Goldstein HA et al Safety assessment of gadopentetate dimeglumine in U.S. clinical trials. Radiology. 1990;174:17–23.

2. Di Chiro G et al. MR cisternography and myelography with Gd-DTPA in monkeys. Radiology. 1985;157:373–377.3. Ray DE et al. Neurotoxic potential of gadodiamide after injection into the lateral cerebral ventricle of rats. AJNR Am J Neuroradiol. 1998;19:1455–1462.4. Zeng Q et al Intrathecal gadolinium-enhanced MR myelography and cisternography: a pilot study in human patients. AJR Am J Roentgenol. 1999;173:1109–1115.5. Arlt S et al. Gadolinium encephalopathy due to accidental intrathecal administration of gadopentetate dimeglumine. J Neurol. 2007;254:810–812.

6. Li L et al. Overdosage of intrathecal gadolinium and neurological response. Clin Radiol. 2008;3:1063–1068.