Contrast Induced Encephalopathy after carotid percutaneous transluminal angioplasty in a patient with end stage renal disease undergoing peritoneal Dialysis

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Maria Mattiotti

Maria Mattiotti1,2,3, Sabrina Milan Manani1,2, Maddalena Gnappi1,2,4, Grazia Maria Virzì1,2, Matteo Marcello1,2, Davide Marturano1,2, Ilaria Tantillo1,2, Anna Giuliani1,2, Gaetano La Manna3, Claudio Ronco1,2,4 and Monica Zanella1,2

1 Department of Nephrology, Dialysis and Transplant, St Bortolo Hospital, Vicenza, Italy
2 IRRIV – International Renal Research Institute, Vicenza, Italy
3 Nephrology, Dialysis and Transplant Unit, IRCCS Policlinico Sant'Orsola, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.
4 DIMED, University of Padova, Padova, Italy

Corresponding author:
Dr Maria Mattiotti
Department of Nephrology, Dialysis and Transplantation. San Bortolo Hospital;
International Renal Research Institute Vicenza
Via Rodolfi, 37 – 36100 Vicenza. Italy
Phone:00390444753650
Fax: 00390444931215
E-mail: maria.mattiotti@aulss8.veneto.it

 

Abstract

Introduction. Contrast Induced Encephalopathy (CIE) belongs to Major Adverse Renal and Cardiovascular Events (MARCE) after iodinated contrast medium (IOCM), especially for high-risk patients with several comorbidities such as hypertension, diabetes, heart failure, and Chronic Kidney Disease (CKD). We report a case of CIE in a Peritoneal Dialysis (PD)-patient.
Case report. A 78-year-old, affected by diabetes, hypertension, chronic heart failure, and End Stage Renal Disease (ESRD) treated with PD, underwent a carotid Percutaneous Angioplasty (PTA). Immediately after the exam, he developed mental confusion and aphasia. Encephalic CT scan and MRI excluded acute ischemia or hemorrhage but showed cerebral oedema.  Mannitol and steroids were administered and additional PD exchange was performed with depurative aim. Within 2 days the patient completely recovered.
Discussion. CIE mimics severe neurological diseases. It should be considered as a differential diagnosis if symptoms occur immediately after administration of IOCM, especially in high-risk patients and in case of intra-arterial injection. Clinical presentation includes transient cortical blindness, aphasia, focal neurological defects, and confusion. CIE is often a diagnosis of exclusion, and imaging plays a significant role. Symptoms generally resolve spontaneously within 24-48h, rarely in few days. Symptomatic therapy, including mannitol and steroids could be considered. In literature, CIE is reported only in a few patients affected by ESRD treated with chronic HD, and our is the first available case of a patient treated with chronic PD who developed this rare complication.

Keywords: Peritoneal Dialysis, Contrast-induced encephalopathy, contrast medium

Sorry, this entry is only available in Italian.

Introduzione

I mezzi di contrasto organo-iodati (Iodinated Contrast Medium, IOCM) sono largamente utilizzati per procedure diagnostiche e interventistiche. È risaputo che il loro uso si associa ad un aumentato rischio di eventi avversi maggiori cardiovascolari e renali (Major Adverse Renal and Cardiovascular Events, MARCE), soprattutto nelle persone ad alto rischio per la presenza di più comorbidità, come ipertensione arteriosa, diabete mellito, scompenso cardiaco e insufficienza renale cronica (Chronic Kidney Disease, CKD).
I MARCE comprendono sia eventi maggiori renali (Major Adverse Kidney Events, MAKE) – che includono il peggioramento della funzione renale, la necessità di avvio del trattamento dialitico – sia eventi cardiovascolari maggiori (MACE, Major Adverse Cardiac Event) tra cui l’infarto miocardico, l’ictus, lo scompenso cardiaco, fino al decesso [1].
Il rischio di eventi avversi si è dimostrato significativamente più basso con volumi minori di mezzo di contrasto, utilizzando mezzi di contrasto iso-osmolari, rispetto a mezzi di contrasto di tipo ipo- o iper-osmolare, e in caso di somministrazione endovenosa piuttosto che intra arteriosa: tale rischio è aumentato per i pazienti con funzione renale già compromessa e/o diabete [2–4].
Tra gli eventi avversi maggiori legati all’utilizzo di IOCM più rari, ma potenzialmente gravi, vi è l’encefalopatia indotta da mezzo di contrasto (Contrast-Induced Encefalopathy, CIE) [5, 6]. 

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