Complex imaging features of accidental cerebral intraventricular gadolinium administration

Report of 2 cases

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Gadolinium diethylenetriamine pentaacetic acid (Gd-DTPA) is a contrast agent commonly used for enhancing MRI. In this paper, the authors report on 2 cases of postoperative inadvertent administration of Gd-DTPA directly into a ventriculostomy tubing side port that was mistaken for intravenous tubing. Both cases demonstrated a low signal on MRI throughout the ventricular system and dependent portions of the subarachnoid spaces, which was originally believed to be CSF with areas of T1 shortening in the nondependent portions of the subarachnoid spaces, and misinterpreted as basal leptomeningeal enhancement and meningitis. The authors propose that the appearance of profound T1 hypointensity within the ventricles and diffuse susceptibility artifact along the ependyma is pathognomonic of intraventricular Gd-DTPA and should be recognized.

Abbreviation used in this paper:Gd-DTPA = gadolinium diethylenetriamine pentaacetic acid.

Article Information

Address correspondence to: Nita Nayak, M.D., University of California, Los Angeles, 757 Westwood Boulevard, Suite 1638, Los Angeles, California 90095. email: nnayak@mednet.ucla.edu.

Please include this information when citing this paper: published online March 15, 2013; DOI: 10.3171/2013.2.JNS121712.

© AANS, except where prohibited by US copyright law.

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Figures

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    Case 1. Preoperative, contrast-enhanced, axial T1-weighted MR image demonstrates right tentorial leaflet meningioma (A). After resection, the postcontrast T1-weighted images demonstrate very dark ventricles with ependymal “enhancement” (B), as well as contrast within the surgical cavity and throughout the basal cisterns (C and D), with diluted hyperintense Gd appearing to “float” on top of the concentrated hypointense Gd within the fourth ventricle and foramina of Luschka (D). A coronal view (E) also reveals basilar leptomeningeal “enhancement.” Note the lack of nasal mucosal enhancement normally observed on postcontrast images (D).

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    Case 1. After intraventricular administration of concentrated Gd-DTPA, the patient developed diffuse cerebral edema, as demonstrated by the sulcal effacement (A and B), loss of gray-white matter differentiation (C), and low-lying cerebellar tonsils (D) on subsequent head CT scans. Note the intraventricular shunt traversing the left lateral ventricle.

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    Case 2. Preoperative, contrast-enhanced, T1-weighted MR images reveal a cystic, cerebellar lesion shown to be a lung cancer metastasis (A). After resection, postcontrast T1-weighted MR images similarly demonstrate very dark ventricles with ependymal “enhancement” (B), as well as frank basilar leptomeningeal “enhancement” (C and D). Again, as in Case 1, note the lack of expected nasal mucosal enhancement (E).

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    Case 2. This patient similarly developed diffuse cerebral edema, as demonstrated by the sulcal effacement on subsequent head CT scans. Additionally, there was hyperdense layering fluid within the occipital horns of the lateral ventricles (left and right), which was initially interpreted as acute ventricular hemorrhage but likely reflects concentrated Gd.

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