Case Presentation: Patient is a 76-year-old female with past medical history of left cerebellar hemorrhage needing EVD placement and subsequent removal 3 months prior to admission, incidentally found right MCA aneurysm (7 mm), hypertension, hyperlipidemia and tobacco abuse, presented for an elective cerebral angiogram to identify the etiology of her recent intracranial hemorrhage. On prior admission, patient had presented with symptoms of left gaze preference, ataxia and confusion, which had gradually resolved with external ventricular drain placement and close monitoring. To further clarify the source of the bleeding and to characterize the aneurysm further, patient opted for an elective angiogram 2 months after discharge. Her surgical history was significant for prior EVD placement and removal and right knee replacement in the past. She did not have any significant family history of neurological disorders, including stroke. She reported tobacco abuse of 1 pack per day for 30 years, but otherwise denied any alcohol or recreational drug use. On admission, her vitals were all unremarkable. Physical exam including a thorough neurological evaluation did not reveal any abnormalities. After injection of Isovue 300 contrast into the Right internal carotid artery, patient started moving around during the procedure and the procedure had to terminated. Post-procedure patient was found to have right sided gaze preference and mild left hemiparesis. As a result, patient was placed under general anesthesia and taken for emergent angiogram. A stat CT Head without contrast done prior to the angiogram did not show any hemorrhage. The repeat angiogram showed 6.5mm right MCA aneurysm, but otherwise did not show any evidence of stroke or major vessel occlusion to account for the change in mental status of the patient. An EEG obtained did not show any signs of seizure activity. The patient was monitored in the ICU closely and the patient mentation gradually resolved over the course of six days. Upon discharge, patient’s mentation was back to baseline, and she did not have any neurological deficits
Discussion: Contrast induced encephalopathy (CIE) is rare complication that occurs during or after the use of contrast and can present with confusion, motor or sensory deficits or seizures. CIE is typically a diagnosis of exclusion; however, some contrast enhancement may be seen on CT Head in some cases. Our patient had altered mental status immediately post contrast injection and was found to have neurological changes shortly thereafter. Our patient’s angiogram was negative for any occlusion and her EEG did not show any signs of seizure. In our patient, the CT head was done without the use of contrast.It is suspected that the underlying pathophysiology is related to temporary disruption of the blood-brain-barrier integrity that can lead to the neurotoxic effects associated with CIE. However, corticosteroids and hydration has been used in some cases with improvement in symptoms. Premedication with corticosteroids before procedures involving contrast dye has shown to be beneficial in patients with previous episodes of CIE.
Conclusions: In conclusion, we present a rare case of a patient who developed self-limiting CIE. Patients with underlying hypertension, chronic kidney disease, concurrent NSAID use and previous contrast allergies are at increased risk of CIE and physicians should have a high index of suspicion for CIE in patients with afore mentioned conditions.