Delayed cerebral enhancement on post-mortem computed tomography due to residual contrast medium administered shortly before death

Abstract

Postmortem computed tomography (CT) is currently a well-known procedure and helps in postmortem investigations. In this case report, we report a unique postmortem CT finding: delayed cerebral enhancement associated with the antemortem infusion of contrast medium. A 72-year-old female lost consciousness at a restaurant and was taken to a hospital in an ambulance. Despite resuscitation efforts, she died of hypoxic–ischemic encephalopathy caused by cardiac arrest. About 6 h before her death, she underwent enhanced antemortem CT of the head. No abnormal enhancement was observed in the cerebral parenchyma. Then, 11 h after her death, she underwent unenhanced postmortem CT, which showed bilateral hyperdense caudate nucleus and putamina, due to residual iodinated contrast medium, in addition to other characteristic findings of hypoxic–ischemic encephalopathy. The mechanism underlying this phenomenon could be the destruction of the blood–brain barrier, and/or selective vulnerability, due to hypoxic–ischemic changes in the gray matter. Enhancement of basal ganglia on postmortem CT due to antemortem infusion of iodinated contrast medium might suggest hypoxic–ischemic encephalopathy, which should be noted in postmortem CT interpretations.

Both decreased and increased grey-to-white matter attenuation ratio in the putamen and caudate on early head computed tomography differentiate patients with favorable and unfavorable outcomes after prolonged cardiac arrest—secondary analysis of the Prague OHCA study

“…Because deep grey matter structures are more susceptible to hypoxic-ischemic injury, they also suffer early disruption of the blood-brain barrier. This is supported by our observation that attenuation in the thalamus and putamen correlated with attenuation in the dural sinuses probably as a result of leakage and retention of contrast material during the initial angiography, making the use of attenuation values or GWR for prognostication difficult ( 10 ).…”

“…Loss of grey-white matter differentiation on early brain CT is a reliable predictor of poor neurological outcome, in addition to predictors based on pre-hospital circumstances and in-hospital parameters ( 8 , 9 ). Brain CT imaging may be affected by previous contrast agent administration in patients managed with invasive assessment and therapy (i.e., coronary angiography/percutaneous coronary intervention) influencing grey matter attenuation in hypoxic-ischemic injury ( 10 ). All these predictors have already been evaluated in OHCA patients with sustained return of spontaneous circulation ( 7 - 10 ).…”

“…Brain CT imaging may be affected by previous contrast agent administration in patients managed with invasive assessment and therapy (i.e., coronary angiography/percutaneous coronary intervention) influencing grey matter attenuation in hypoxic-ischemic injury ( 10 ). All these predictors have already been evaluated in OHCA patients with sustained return of spontaneous circulation ( 7 - 10 ). Whether the same criteria may also be applied to refractory OHCA patients treated with ECPR has not been extensively studied yet ( 11 - 13 ).…”