Incidence and Risk Factors for Acute Transient Contrast‐Induced Neurologic Deficit: A Systematic Review With Meta‐Analysis

Abstract

BACKGROUND After MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) demonstrated that endovascular therapy improved outcomes in patients with stroke, the number of endovascular procedures has risen sharply. We describe acute transient contrast‐induced neurological deficit (ATCIND), a group of neurological syndromes associated with arterial contrast administration during angiography. Our goal is to elucidate the incidence, risk factors, outcomes, pathogenesis, and diagnostic characteristics of ATCIND. Our primary objective is to elucidate the incidence of ATCIND in the setting of coronary or cerebral angiography. Secondary outcomes include potential risk factors, demographics, treatment modalities, and patient recovery. METHODS The data that support the findings of this study are available from the corresponding author on reasonable request. The databases of the Cochrane Library, MEDLINE, Web of Science, and Embase were queried, yielding studies from 1974 to 2021. Inclusion criteria for articles were the following: (1) contrast‐induced encephalopathy, contrast‐induced neurotoxicity, or cortical blindness after contrast administration during angiography were the focus of the article; (2) incidence was reported; (3) studies included ≥3 cases; and (4) follow‐up tests were described to rule out other causes. Exclusion criteria included the following: (1) incidence was not reported; (2) unavailable in the English language; (3) abstracts and unpublished studies; and (4) did not exclude other possible causes, or findings suggested other possible causes, such as worsening ischemic injury. Of 627 articles, 7 were retained. This systematic review with meta‐analysis was performed in accordance with guidelines provided by the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) and the Meta‐Analysis of Observational Studies in Epidemiology (MOOSE) checklists. Independent extraction by multiple reviewers was performed. Data were pooled using a random‐effects model. RESULTS The primary study outcome was incidence of ATCIND, which was formulated before data collection began. We hypothesized that the pooled incidence of ATCIND would be similar to that of individual studies. A total of 70 of 21007 patients had the diagnosis of contrast‐induced encephalopathy, contrast‐induced neurotoxicity or angiography‐associated cortical blindness, and ATCIND. The incidence rate of ATCIND is estimated to be 0.51% (CI, 0.3%–1.0%; P <0.001 [ I 2 =29.3]), or 51 per 10 000 patients. Pooled data for risk factors for contrast‐induced encephalopathy were higher contrast dose (odds ratio [OR], 1.072; 95% CI, 0.952–1.192 [ P <0.001]; I 2 =0), and prior stroke (OR, 5.153; CI 1.726–8.581 [ P =0.003]; I 2 =0). Contrast dose >150 mL was a positive, significant predictor of visual disturbance (OR, 7.083; CI, 1.1742–42.793 [ P =0.033]). Full recovery is estimated at 89.5% (95% CI, 76.9%–95.6%; P <0.001 [ I 2 =0]). CONCLUSIONS This study confirms the rare incidence of ATCIND, although it shows moderate heterogeneity, likely reflecting the type of angiography performed. Risk factors include larger contrast dose and prior stroke. Full recovery occurs in the majority of patients. It should remain in the differential diagnosis in patients with certain risk factors for blood–brain barrier compromise.

Fully Reversible Contrast-Induced Encephalopathy Mimicking Stroke after Flow Diverter Treatment of Carotid Cave Aneurysm

“…It has been suggested that higher doses and lower temperatures of contrast media, kidney disorders, arterial hypertension, and acute cerebral infarction are risk factors for CIE [ 9 ]. Higher contrast dose and prior stroke were corroborated as risk factors in a recent meta-analysis [ 10 ]. However, lower doses of contrast agent have also been associated with CIE [ 11 ].…”

“…It has been suggested that higher doses and lower temperatures of contrast media, kidney disorders, arterial hypertension, and acute cerebral infarction are risk factors for CIE. 9 Higher contrast dose and prior stroke were corroborated as risk factors in a recent meta-analysis. 10 However, lower doses of contrast agent have also been associated with CIE. 11 The doses reported in the literature varied widely depending on procedure type with volumes as low as 24 mL in a cerebral angiography case 6 and as high as 360 mL in a spinal angiography case. 12 Our patient received a total volume of contrast of 125 mL.…”

Acute Transient Contrast-Induced Neurologic Deficit as a Complication of Percutaneous Coronary Intervention

“…It was first described in 1970 as contrast-induced neurologic injury secondary to coronary angiography. 1 More recently, these clinical syndromes have been associated with the administration of localized contrast medium injections through coronary, carotid, and cerebral angiography. 1 - 7 In a recent systematic review, the incidence of this rare entity after PCI was estimated to be 0.15%, even less common than the incidences reported in prior contrast studies.…”

“… 1 More recently, these clinical syndromes have been associated with the administration of localized contrast medium injections through coronary, carotid, and cerebral angiography. 1 - 7 In a recent systematic review, the incidence of this rare entity after PCI was estimated to be 0.15%, even less common than the incidences reported in prior contrast studies. 1 Risk factors for the development of ATCIND include kidney dysfunction, large contrast dose, and contrast agents that have higher osmolality and lower hydrophilicity, 1 which are characteristics of the contrast agents used in PCI.…”

Contrast-Induced Encephalopathy Presenting With Fever After Coronary Angiography: A Case Report

“…Regarding the risk factors that have been associated with CIE, one meta-analysis showed that higher contrast doses (OR, 1.072; CI, 0.952-1.192), and having a history of stroke (OR, 5.153; CI, 1.726-8.581), were significant risk factors for developing CIE. Other significant risk factors were renal dysfunction, anticoagulant use, heart failure, Ioversol (as compared with iopromide), and isolated posterior circulation cerebral angiography. They have also found that visual manifestations were more common in patients that were given a contrast dose of more than 150 mL (OR, 7.083; CI, 1.172-42.793) [ 14 ]. However, one case showed manifestations after the administration of only 25 ml of iopromide with symptoms developing immediately within the procedure [ 15 ].…”