Contrast-induced encephalopathy following coronary angioplasty with iopromide.

T administration of contrast agents is usually associated with a few side effects, such as anaphylactoid reaction, heart failure, arrhythmia, renal failure, and encephalopathy. Although non-ionic agents are far less neurotoxic, they have pharmacological side effects, such as seizure, transient cortical blindness, aphasia, and sensory deficit, confusion, short-term memory loss, mental aberrations, hemiparesis and ophthalmoplegia. In the present study, we report a case of a patient who suffered acute encephalopathy after coronary angioplasty was applied with iopromide contrast (Ultravist®, Schering Pharmaceutical Co., Ltd, Guangzhou, China). Similarly to the cases reported by Kocabay et al,1 the patient also became irritable and suffered mental aberrations, aphasia, short-term memory loss, and paralysis of limbs, and totally recovered except for short-term memory loss 28 hours later without specific medication. A 64-year-old male patient, 52 kg, who had no history of systemic or neurologic illnesses, was admitted to our hospital, complaining of typical chest pain for 2 years. He had a history of hypertension, diabetes, and coronary artery disease. After the coronary angiography (CAG) (iopromide contrast usage was 50 ml), his heart rate dropped to 57 bpm from 80 bpm, and his blood pressure dropped to 85/60 mm Hg from 110/70 mm Hg. He became irritable, then developed confusion and paralysis of limbs. Atropine 0.5 mg, and diazepam 5 mg was used immediately, and the heart rate and blood pressure rose to normal range 3 minutes later. A 3.0 x 23 mm drug eluting stent was inserted to the left anterior descending branch (LAD). Iopromide, 160ml was used for the entire operation. The patient remained confused and developed paralysis of limbs, mental aberrations, and subsequently aphasia. His eye movements were not limited, pupils were constricted, reactive, and there was no gaze preference. Positive bilateral Babinski and Chaddock signs were observed. No neck stiffness was observed, and both corneal and oculocephalic reflexes were preserved. Muscle powers were as follow: left limbs grade 2, right upper limbs grade 3, right lower limbs grade 2. Both MRI and magnetic resonance angiography (MRA) of the brain were normal. Routine blood tests, including hemoglobin, red blood cells, leukocyte, lymphocyte, and so forth were normal. A CT of the brain showed highlights in the sagittal sinus and middle line immediately after the operation (Figure 1), and only fundamental supportive medications were used. His signs and symptoms began attenuating gradually 8 hours later, and were fully receded 28 hours after the operation. His neurologic examination returned to normal, and he suffered from a short-term memory loss. The EEG results revealed diffuse slowing in the a range in the occipital region 20 hours after the operation. At 1.5 years after discharge, and after attending monthly clinic follow ups no abnormalities of the nervous system was found by cardiologists and neurologists. Recently, Kocabay et al1 reported 2 cases who suffered from encephalopathy after injecting iopromide (Ultravist®). In our case, the contrast used was Ultravist 370. Other contrast agents that could cause encephalopathy included iohexol,2 ioxilan,3 iopamidol, and metrizamide. The complications of intravascular administration of contrast agents include idiosyncratic (anaphylactoid) reactions, and non-idiosyncratic reactions such as shock, congestive heart failure, cardiac arrhythmias, acute renal failure, and neurotoxic effects. We speculated that iopromide most likely induced this patient’s encephalopathy, as his symptoms started within 1/2 hour after CAG and resolved spontaneously within 28 hours. No other etiologies or contributing causes were suspected. In the absence of other metabolic abnormalities and suspected drugs, spontaneous recovery of the patients’ clinical status by only supportive medications also indicates that the encephalopathy is most likely a toxic reaction to the contrast agent, which resolved spontaneously.