Hypersensitivity to an intracerebral stent and symptomatic cerebral lesions: A possible link?

Abstract

Dear Editor, Contact hypersensitivity to metals is frequent in the general population but allergic patients often tolerate medical implants containing those metals. 1 Here, we report the case of a patient with severe nickel hypersensitivity presenting with neurological symptoms and cerebral lesions, which developed after the implantation of a nickel-containing stent.A 45-year-old woman presented with recurrent paresthesia on the left side of the body 3 weeks after stenting of a right internal carotidal aneurysm with a nickel-containing stent (Pipeline â flex embolization device [diverter flow]; ev3, Paris, France). Magnetic resonance imaging (MRI) showed gadolinium-enhancing lesions located downstream of the stent and surrounding edema. An infectious or ischemic cause was excluded. Steroid treatment was administrated for 8 months. Symptoms and lesions cleared progressively. Three weeks after the withdrawal of steroid treatment, the patient presented with a relapse. MRI showed a moderate worsening of the known cerebral lesions and steroid treatment was reintroduced and is currently ongoing. Based on previous reports of allergic reactions to cerebral aneurysm clips, 1,2 a delayed hypersensitivity to the stent was suspected in our patient.Epicutaneous patch tests were performed with the European baseline series (Hermal, Reinbek, Germany) and a personal series, which included the stent, with IQ Ultra â patch test chambers (Chemotechnique Diagnostics, Vellinge, Sweden). Readings were performed on the 4th day. Patch testing with the stent was positive (+) and the skin biopsy of the reaction showed epidermal intercellular edema (spongiosis) with a dermal lymphocytic infiltrate containing a few eosinophils (Fig. 1), consistent with a delayed hypersensitivity reaction. The stent was composed of 75% cobalt chromium, 25% platinum tungsten and less than 2% nickel. Patch testing of cobalt and chrome, the two other components of the stent according to manufacturer, were negative. Patch testing with nickel had to be removed after 24 h on patient request because of an extreme reaction (+++). Patch tests were Figure 1. Clinical picture (upper left). Picture of the stent used in patch testing (upper right). Histopathological image (bottom) (hematoxylin-eosin, original magnification 920).

Nickel-related hypersensitivity reactions following endovascular interventions: A review of current evidence

“…This represented 38.9% of the total patient population. 19 , 21 , 30 , 31 , 33 – 35 , 38 – 41 Six of which underwent treatment for an unruptured intracranial aneurysm by clips, coiling or stents. 19 , 30 , 31 , 39 – 41 Neurological symptoms had emerged at variable onset amongst the patient population.…”

“… 19 , 21 , 30 , 31 , 33 – 35 , 38 – 41 Six of which underwent treatment for an unruptured intracranial aneurysm by clips, coiling or stents. 19 , 30 , 31 , 39 – 41 Neurological symptoms had emerged at variable onset amongst the patient population. Clinical presentation indicative of neurological manifestations included abnormal neurological reflexes, ranging from unilateral hand weakness to sensory disturbances.…”

“…Cardiovascular manifestations ranged from mild heart palpitations to pericardial tamponade. 19 , 20 , 30 , 39 , 41 , 45 …”

“…Device-specific reactions were observed in 5 patients, demarcating 13.9% of the patient population. 26 , 30 , 40 , 41 , 48 Predominantly, device-specific manifestations range from in-stent restenosis (ISR) to total occlusion of the implanted stent. Eosinophilic infiltration and perivascular lymphocytic cuffing were noted upon histopathological assessment of invidious stents.…”

“…Cardiovascular manifestations ranged from mild heart palpitations to pericardial tamponade. 19,20,30,39,41,45 In extracted studies, cardiovascular manifestations were accompanied by ECG changes. Variability in ECG changes had accompanied spatial location of the implanted device.…”