Abstract Details

Title Neurotoxicity from Intrathecal Gadolinium Administration (IT-Gad)

Topic General Neurology

Presentation(s) P3 - Poster Session 3 (5:30 PM-6:30 PM)

Poster/Presentation
Number 4-043

Objective NA

Background _{While low-dose (~0.5 mL) IT-Gad has been used off-label for cisternography and myelography, case reports of inadvertent high-dose IT-Gad have highlighted risk of severe neurotoxicity. Herein we describe the clinical course of a patient administered high-dose IT-Gad (~4.3 μmol/g brain).}

Design/Methods

_NA

Results _{This 55-year-old man was mistakenly administered 12 mL of Gadobutrol for purposes of cervical myelography. Convulsive seizures arose within minutes. His initial examination (following lorazepam and fosphenytoin) showed hemodynamic instability and coma with normal pupillary/corneal reflexes but absent cold caloric, gag/cough and deep tendon reflexes. Generalized seizures remitted only with anesthetic doses of pentobarbital, and attempts to wean from a burst suppression pattern on EEG were unsuccessful because of reemergent status epilepticus, despite a 3 antiepileptic drug regimen and methylprednisolone. Discontinuation of pentobarbital without recurrent seizures was possible on day 9. While brainstem reflexes normalized within 12 hours of exposure, he did not regain consciousness until day 11 and examination at that time showed diffuse weakness and areflexia which improved gradually over the course of 3 weeks. His initial head CT showed diffuse contrast enhancement of the subarachnoid, cisternal and intraventricular compartments. MR imaging on day 8 also showed restricted diffusion of the hippocampi, likely from prolonged status epilepticus. Repeat MR imaging (day 23) showed resolution of hippocampal cytotoxic edema, but diffuse cortical enhancement from parenchymal deposition of gadolinium. When last examined, 7-weeks after exposure, seizures had not recurred, but his examination showed severe anterograde memory deficits.}

Conclusions _{Gadolinium encephalopathy is a potentially catastrophic complication of high-dose IT-Gad. Few patients have been reported with a range of neurotoxic effects including coma, seizures, ataxia and other deficits related to focal cerebral dysfunction. While best management practices are unknown, cerebrospinal fluid lavage has been advocated as therapeutic option and may be reasonable given the potential for severe morbidity.}

Authors/Disclosures
Nicholas Calvo, MD (Carilion Clinic) PRESENTER	No disclosure on file
Marium Jamil, MBBS (cape fear valley medical center)	No disclosure on file
	No disclosure on file
Aashit K. Shah, MD, FAAN (Carilion Clinic)	Dr. Shah has stock in Abbot, Abbivie, Gilead, Johnson and Johnson, Pfizer. The institution of Dr. Shah has received research support from Xenon Pharma.
Feryal Nauman, MBBS (Carilion Clinic Neurology - Franklin)	Dr. Nauman has nothing to disclose.
Joseph M. Ferrara, MD, FAAN (ECU Health)	No disclosure on file

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