Contrast Media Extravasation in CT and MRI – A Literature Review and Strategies for Therapy

Abstract

Background Contrast extravasation events in daily radiological routine may lead to serious complications, especially during CT examinations. The resulting symptoms may vary from local pain up to skin ulcers, necrosis or even acute compartment syndrome.There are no uniformly accepted radiological guidelines or recommendations regarding detection and treatment of extravasation events and immanent complications in a timely manner. Method Systematic literature research considering the last 35 years via PubMed using search terms “contrast medium extravasation/paravasation”. Results In the literature, there are conservative management approaches of contrast media extravasation without major evidence base, such as unguent dressings, cooling or splinting. This therapy is mostly symptomatic. Additionally, various invasive techniques are described. We discuss these techniques in the context of contemporary literature, such as the hyaluronidase Injection into the site of extravasation, suction/aspiration technique including flushing of the affected tissue areas and the squeezing technique. However, most citations lack scientific evidence: many articles include anecdotal enumerations, case studies or cite publications from the era, when ionic high osmolar contrast media was state-of-the-art. Besides, many authors derive their extravasation management from studies, where agents other than contrast media were investigated. Conclusion After detailed literature review, we suggest early (plastic) surgical consultation when non-ionic, low-osmolar contrast medium extravasation is about 150 cc or more. In case of extravasation less than 150 cc but in presence of additional symptoms such as impaired perfusion or altered sensibility, the (plastic) surgeon should also be consulted instantly. We do not recommend any invasive first line therapy when contrast media extravasation is less than 150 cc and the patient presents no additional symptoms, besides swelling and local pain. Nevertheless continuous monitoring and accurate conservative management such as active cooling and elevation, splinting of the affected extremity are mandatory as early detection of critical symptoms helps to initiate prompt surgical intervention and avoid sequelae. Key Points Citation Format

Guidewire perforation and compartment syndrome after lower extremity angioplasty

“…Non-traumatic causes include Group A streptococcus infection, prolonged immobilisation such as poor patient positioning during surgery, revascularisation procedures, contrast media extravasation, use of anticoagulants and bleeding disorders. In particular, revascularisation procedures can cause post-ischaemic compartment syndrome due to reperfusion injury [10][11][12][13][14][15].…”

Intravenous contrast medium extravasation: systematic review and updated ESUR Contrast Media Safety Committee Guidelines

“…Proper documentation of CMEX is crucial [12]; at the patient level, this allows early recognition of deterioration and aids interpretation across a broad range of healthcare staff. More broadly, documentation at an institutional level allows auditing which can improve local working practices.…”

“…Previous guidelines around CMEX from the Contrast Media Safety Committee (CMSC) of the European Society of Urogenital Radiology (ESUR) published in 2002 related to older contrast injection protocols [1]. Since then, several prospective studies investigating CMEX risk factors and management as well as systematic reviews have been published [2,3,[11][12][13]. In this paper, we aim to inform update of the CMSC guidelines by performing a systematic review and provide recommendations.…”

Praktische Anwendung von Kontrastmitteln in der Radiologie

“…Es muss also abgewogen werden, welcher Flow wirklich notwendig ist und ob hier nicht reduziert werden kann. Die Häufigkeit für ein Paravasat bei CT-Untersuchungen liegt bei 0,1-0,9 % und bei MRT-Untersuchungen bei 0,06 % [5]. Man sieht, dass das Risiko für Paravasate in der CT also höher ausfällt, was wahrscheinlich an den oftmals schnelleren Injektionen liegt.…”