Neurocritical care, Cerebrovascular Center, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
Neurocritical care, Cerebrovascular Center, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
J Stroke Cerebrovasc Dis. 2020 Dec;29(12):105350. doi: 10.1016/j.jstrokecerebrovasdis.2020.105350. Epub 2020 Oct 22.
Carbon dioxide (CO) as a contrast agent has been in use as early as the 1920s for visualization of retroperitoneal structures. Digital subtraction angiography (DSA) using CO as a contrast agent for vascular imaging was developed in the 1980s. Currently, CO angiography is an alternative agent in patients with chronic kidney disease (CKD) and those who are at risk of developing contrast-induced nephropathy. However, CO causes neurotoxicity if the gas inadvertently enters the cerebrovascular circulation leading to fatal brain injury.
A 71-year-old female with h/o sickle cell trait, hypertension, obesity, metastatic renal cell cancer status post nephrectomy, bone metastasis, chronic kidney disease was admitted for elective embolization of the humerus bone metastasis. Given the high probability of contrast-induced nephropathy, CO angiography was chosen for embolization of the metastasis. During the procedure, the patient became unresponsive. Emergent medical management with hyperventilation, 100% fraction oxygen inhalation was performed. Her neuroimaging showed global cerebral edema. An intracranial pressure monitor was placed which confirmed intracranial hypertension. Hyperosmolar therapy was administered with no improvement in clinical examination. She progressed to brain stem herniation. Given poor prognosis, the family opted for comfort measures and the patient expired.
Inadvertent carbon dioxide entry into cerebrovascular circulation during angiography can cause fatal brain injury. Caution must be exercised while performing CO angiography in blood vessels above the diaphragm.
早在 20 世纪 20 年代，二氧化碳（CO）就已作为造影剂用于腹膜后结构的可视化。20 世纪 80 年代，开发了使用 CO 作为造影剂进行血管成像的数字减影血管造影（DSA）。目前，CO 血管造影是慢性肾脏病（CKD）患者和有发生造影剂肾病风险患者的替代造影剂。然而，如果气体无意中进入脑血管循环，CO 会引起神经毒性，导致致命的脑损伤。
一名 71 岁女性，有镰状细胞特征病史、高血压、肥胖、肾细胞癌切除术病史、骨转移、慢性肾脏病，因肱骨转移灶择期栓塞入院。由于发生造影剂肾病的可能性较高，选择 CO 血管造影进行转移灶栓塞。在手术过程中，患者失去反应。立即进行过度通气、100%吸氧的紧急医疗处理。她的神经影像学显示全脑水肿。放置颅内压监测器证实存在颅内压升高。给予高渗治疗，但临床检查未见改善。她进展为脑干疝。由于预后不良，家属选择了舒适护理，患者死亡。
血管造影过程中 CO 意外进入脑血管循环可导致致命的脑损伤。在膈上血管行 CO 血管造影时必须小心谨慎。
