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Show ]. Clin. Neuro-ophthalmol. 2: 49-54, 1982. Retinal Embolism Following Percutaneous Femoral Cerebral Angiography WALTER C. HARTEL, M.D. THOMAS C. SPOOR, M.D. MARK E. HAMMER, M.D. Abstract A 35-year-old female without evidence of atherosclerotic vascular disease underwent percutaneous femoral cerebral angiography. Peri foveal retinal infarction by exogenous arteriolar emboli produced a permanent absolute pericentral scotoma. Strict adherence to meticulous angiographic technique may prevent such an angiographic complication. Introduction Retinal and cerebral emboli occur as complications of cerebral angiography.l-ti Endogenous emboli from atherosclerotic plaques or blood clots may be causatively traced to angiographic technique as well as the extent of atheromatous disease. 7 . M Exogenous emboli consisting of air, cotton fibrils, or particulate contaminants of contrast media have been less well documented, but may represent a real and preventable angiographic complication.'';' 6. 9-12 Nehen and associates report two cases of exogenous retinal arteriolar embolism following percutaneous carotid angiography.] The case described here documents exogenous retinal arteriolar embolism following percutaneous femoral angiography. To the best of our knowledge, this has not been previously reported. Case Report A 3S-year-old female without prior history of ocular disease underwent percutaneous femoral cerebral angiography to rule out aneurysm as the etiology of persistent headache and nuchal rigidity. Injection of contrast material (Hypaque, Squibb) was accomplished utilizing a closed system catheter From the Division of Ophthalmology, Department of Surgery (WCH, TCS, MEH), University of South Carolina Sch,'o! of Medicine. March 1982 technique. There was no evidence of atherosclerotic disease, aneurysm, or other abnormalities. At the conclusion of the procedure, she experienced right orbital pain and described central scotomata as stationary gray spots in the right field of vision. The following day, a neuro-ophthalmologic consultation was requested. Visual acuity was 20/30 in the right eye and 20/ 20 in the left eye. A 1+ afferent pupillary defect was present in the right eye. Color vision was intact. Amsler grid testing demonstrated two small inferior central and pericentral scotomata in the right visual field. The left eye was normal. Slitlamp examination of the anterior segment and vitreous was normal. Intraocular pressure by tonometry was 14 mm of mercury bilaterally. Abnormal fundiscopic findings were limited to the right perifoveal area, and consisted of retinal edema superior to the right fovea corresponding to regions supplied by the end arterioles which were occluded by multiple intraretinal emboli (Figs. 1.1 and 1b). The left fundus and both discs were totally normal. Formal Goldmann perimetry confirmed the presence of two small inferior relative central and pericentral scotomata (Fig. 2). The left visual field was normal. She was treated with 80 mg of prednisone per day which was r.1pidly tapered over 1 week and then discontinued. Three weeks later, the suprafoveal retinal edema had partially resolved. Emboli were still visible in the arterioles but appeared smaller (Fig. 3). Amsler grid and Goldmann visual field testing showed that the two small scotomata had coalesced into.1 larger inferior relative pericentral scotoma. Two months after the embolic episode, the fundus appeared normal (Fig. 4). Fluorescein angiography (Fig. 5.1) showed very minimal changes consisting of slight irregularity in the calibre of the venules superior to the fovea, and a small defect in the capillary net at 27 seconds. Faint intraretinal staining of the embolized retina was seen in the lO-minute frames (Fig. Sb). An absolute inferior pericentral scotoma persisted (Fig. 6). No other localizing neuro-ophthalmologic signs were present. Visual acuity returned to 20/20 mi- 49 Rctin,11 Embolism (0) Figure lao Fundus photograph I day after angiography showing multiple retinal emboli and perifoveal edema. Figure I b. M~gnifi('d view of right macul~. Journal of Clinical Neuro-ophthalmology HMtel, Spoor, Hammer LEFT RIGHT Figur~ 2. Goldmdnn visudl fi"'ds I ddy dfter dngiogrdphy revedling two smdll inferior reldlive pericentrdl scolomatd. Figur~ 3. Fundus dppeMdnce 3 weeks followin~ dn~io~rdphy. Re'idudl emboli Me smdller dnd the perifovedl edemd subtotdlly resolved. March 1982 51 R('lin.11 Emblliism Figure 4. Normdl fundus dppeMdnce 2 months dfter embolizdlion. (a) Figure 5,.. Fluor"s(,,;n .ln~iogr.lm 2 n1llnths post"mbolism showing only slight Irregul,lnty in the ("libN of th" v"nul"s sup"r;or to the f'lVed dnd capilldry d",poul. Journal of Clinical Neuro-ophthalmology I-IMlel, Spour, Hammer Figure sb. Fluorescein angiogram 2 months postembollsm showing faint Intraretinal stJlnlng l)f embohzed retina (10 minutes). LEFT RIGHT nus in the right eye, but she remained symptomatic from her absolute scotoma. Discussion A low-reported incidence of foreign body emboli after cerebral angiography probably results from infrequently reported or recognized visual symptoms, or from failure to recognize small i1r- March 1982 teriolar emboli ophthalml)scopically.I:I Olivecrona reported .1 0.4 "!c) incidence of di.lgnosed catheter embolism in 5,531 consecutive angiographies utilizing percutaneous femoral, carotid, brachial, and vertebral approaches. 11 More specifically, Francois and associates cited a 0.1 % incidence of retinal arteriolar embolism in 17,556 unspecified angiographies. 'f' 53 Retin,ll Embolism Retin,ll emboli as .mgiographic complications are usually associated with atherosclerotic disease. Earlier reports I". I, as well as the recent case reports by Nehen and associates" draw attention to embolism following percutaneous carotid angiography in young patients without evidence of atherosclerotic dise,lse. Exogenously introduced contamin, 1I1ts were cited dS probable sources of such emboli, but histologic confirmation was lacking. Previously, Silberm,1I1, Cravioto, and Feigin gave histologic evidence of cotton fiber cerebral embolism dfter carotid angiography." Kay and Wilkins reported histologically confirmed cotton fiber emboli to the mesenteric arteries following percutaneous femoral angiography.6 Depending on the technique, potential angiographic contaminants include cotton fibers from gauze pads, glass or plastic fragments from syringes, bioabsorbable powder, environmental particulate matter settling on any of the equipment, and contaminants in the contrast media itself. Our case demonstrates exogenous retinal emboli following percutaneous femoral angiography using a closed-system catheter technique. Multiple small, white, nonrefractile emboli in a patient without evidence of heart disease point to an exogenous embolic source. Ophthalmoscopically, these emboli resembled talc. Keane recently reported a case of talc embolism following carotid self-injection with crushed codeine tablets that further confirms this fundiscopic appearance. IA The rapid dissolution of the emboli and resolution of retinal edema, as well as the subtle angiographic findings seen 2 months after the acute episode, suggest that such embolic events are more common than the previous literature implies. Our patient is unfortunate in that her emboli infarcted the superior parafoveal region, producing a symptomatic scotoma. It would have been difficult to explain her subjective complaints and absolute scotoma given only the late ophthalmoscopic and angiographic findings (Figs. 4 and 5). We wonder if "silent" cerebral and retinal exogenous emboli might be relatively common. These "silent" emboli may account for-the vague neurologic and ocular symptoms following cerebral angiography. To minimize risk of exogenous embolism, angiographic techniques should include meticulous saline flushings of all instruments used, a closed-system method of filling syringes with contrast media, careful rinsing of powder from glove surfaces, and possibly millipore filtration of contrast media. References I. Nehen, A.M., Damgaard-Jensen, L., and Hansen, P.E.: Foreign body embolism of retinal arteries as a complication of carotid angiography. Neuroradiology 15: 85-88, 1978. 2. Pribram, H.F. W., and Couves, CM.: Retinal embolism as a complication of angiography. Neurology 15: 188-190, 1965. 3. Haney, W.P., and Preston, R.E.: Ocular complications of carotid arteriography in carotid occlusive disease. Arch. Ophthalmol. 67: 33-43, 1962. 4. Zatz, L.M., and Iannone, A.M.: Cerebral emboli complicating cerebral angiography. Acta. Radial. (Diagn.) 5: 621-630,1966. 5. Silberman, J., Cravioto, H., and Feigin, I.: Foreign body emboli following cerebral angiography. Arch. Neural. 3: 711-717, 1960. 6. Kay, J.M., and Wilkins, R.A.: Cotton fiber embolism during angiography. Clin. Radiol. 20: 410-413,1969. 7. Cronqvist, H.O.E., and Palacios, E.: Embolic complications in cerebral angiography with the catheter technique. Acta. Radio/. (Diagn.) 10: 97-107,1970. 8. Takahashi, M., and Kawanami, H.: Complications of catheter cerebral angiography. Acta. Radio/. (Diagn.) 13: 248-258, 1972. 9. Brekkan, A., Lexow, P.E., and Woxholt, G.: Glass fragments and other particles contaminating contrast media. Acta. Radio/. (Diagn.) 16: 600-608, 1975. 10. Bellego, A.: Les accidens oculaires de I'arteriographie cerebrale. Rennes, Thesis, 1962. 11. Duquesne!. 1.. Pouillaude, J.M., Froment, J.C, and Papillon, D.: De la presence de fragments de verre dans les opacifiants vasculaires. ]. Radiol. 54: 297-300. 1973. 12. Genee. E.. and Honegger, H.: Netzhaut arterienverschuss bei angiographie der arteria carotis interna. Med. Welt. 18: 1066-1068, 1969. 13. Muci-Mendoza. R., Arruga, J.. Edward, W.O., and Hoyt. W.F.: Retinal fluorescein angiographic evidence for atheromatous microembolism. Stroke 11: 154-158, 1980. 14. Olivecrona, H.: Complications of cerebral angiography. Neuroradio/ogy 14: 175-181, 1977. 15. Francois. J.. Goes, F., and Stockmans, L.: Embolie de I'artere centrale de la retine apres engiographie carotidienne. Ann. Oculist 105: 933-1004, 1972. 10. Levine. R.A.. and Henry, M.D.: Ischemic infarction of the retina following carotid angiography. Am. ]. Ophtha/mo/. 55: 305-367, 1963. 17. Guerry, D.. and Wiesinger, H.: Ocular complications in carotid angiography. Am. ]. Ophthalmol. 55: 243-245, 1903. 18. Keane, J.R.: Embolic retinopathy from carotid artery self injection.]. Clin. Neuro-ophthalmol. 1: 119-121, 1981. Write for reprints to: Thomas C Spoor, M.D., 3321 Medical Park Road, Suite 300, Columbia, South Carolina 29203. Journal of Clinical Neuro-ophthalmology |
