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Hotel Dieu De France Hospital Beirut, Lebanon
Contrast-induced renal failure is defined by an increase in the serum creatinine level of 44 µmol/L or more within 48 hr. We report the first selective digital angiography of a cerebral aneurysm using gadolinium in the setting of renal failure.
A 55-year-old woman with polycystic kidney disease and a serum creatinine level of 181 µmol/L, was referred for presurgical angiographic evaluation of the right middle cerebral artery for an aneurysm that was suspected on previous MR angiography (Fig. 6A). After local anesthesia had been administered, a 5-French catheter was advanced by femoral route into the right internal carotid artery. A total volume of 30 mL (0.21 mmol/kg) of gadodiamide (Omniscan; Nycomed, Norway) diluted to 85% was power-injected at a rate of 3 mL/sec for 2 sec; the contrast agent was used in different projections to best depict the aneurysm configuration (Fig. 6B). The patient did not experience any clinical side effects, and the serum creatinine level remained unchanged at 48 hr.
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The risk of contrast-induced acute renal failure increases in patients with renal insufficiency and may increase with the volume of iodine administered [1]. Carbon dioxide is an alternative contrast agent in peripheral vessels, but neurologic complications have been reported after accidental exposure of cerebral arteries [1]. Since the first use of gadolinium in 1993 during an emergency embolization, a limited number of series of diagnostic and interventional procedures with this agent have been published [2, 3].
Gadolinium has an atomic number of 64 kV and a k-absorption edge of 52 kV. The optimal peak kilovoltage for imaging appears to be between 77 and 96 kV. The density of gadolinium observed in our patient was excellent at 96 W even through the dense bone of the skull. Gadodiamide is nearly completely excreted by glomerular filtration even in patients with impaired renal function [3]. Although no direct nephrotoxicity has been observed, most authors have limited the total volume to 0.4 mmol/kg because of the lack of data regarding the safety of using higher dosages [1]. Finally, among well-known causes of progressive renal failure, polycystic kidney disease is a connective disorder inherited as an autosomal dominant trait [4]. Using MR angiography or, less often, catheter angiography, the detection rate of associated intracranial aneurysms is between 5% and 10%; this rate rises to 25% at autopsy [4]. Thus, gadolinium-enhanced digital angiography may represent a valuable gold standard in patients with impaired renal function who have undergone MR angiography or who are being considered for treatment.
In summary, gadodiamide-enhanced cerebral angiography seems a safe alternative in renal failure, especially in patients who will undergo angiography repeatedly during their lifetime.
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  D. J. Spinosa, J. A. Kaufmann, and G. D. Hartwell Gadolinium Chelates in Angiography and Interventional Radiology: A Useful Alternative to Iodinated Contrast Media for Angiography Radiology, May 1, 2002; 223(2): 319 - 325. [Abstract] [Full Text] [PDF]
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