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Life-threatening allergic vasculitis after clipping an unruptured aneurysm: Case report, weighing the risk of nickel allergy.

Grande A, Grewal S, Tackla R, Ringer AJ - Surg Neurol Int (2014)

Bottom Line: Arriving in our emergency department 11 days later, she progressively declined during the next weeks, facing deteriorating clinical status (i.e. seizures) and additional infarctions in the left frontal lobe, midline shift, and new infarctions in the bilateral frontal lobe, right sylvian, right insular regions, and posterior cerebral artery distribution.During decompressive surgery, biopsy findings raised the possibility of lymphocytic vasculitis; consultations with rheumatology, allergy, and immunology specialists identified that our patient had a nickel allergy.Nickel-related allergies are more common than appreciated, affecting up to 10% of patients.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, University of Cincinnati College of Medicine, Comprehensive Stroke Center at the UC Neuroscience Institute, and Mayfield Clinic, Cincinnati, OH, USA.

ABSTRACT

Background: This case report represents one of the estimated 17,000 aneurysms clipped annually in the United States, often with nickel-containing clips. The authors highlight the development of life-threatening allergic vasculitis in a 33-year-old woman after aneurysm clipping.

Case description: After suffering subarachnoid hemorrhage, the patient had coil embolization at another facility for rupture of a right internal carotid artery (ICA) aneurysm. An incidental finding, an unruptured left posterior communicating artery aneurysm unamenable to coiling, was then successfully clipped via a left pterional craniotomy. Arriving in our emergency department 11 days later, she progressively declined during the next weeks, facing deteriorating clinical status (i.e. seizures) and additional infarctions in the left frontal lobe, midline shift, and new infarctions in the bilateral frontal lobe, right sylvian, right insular regions, and posterior cerebral artery distribution. During decompressive surgery, biopsy findings raised the possibility of lymphocytic vasculitis; consultations with rheumatology, allergy, and immunology specialists identified that our patient had a nickel allergy. After reoperation to replace the nickel-containing clip with one of a titanium alloy, the patient had an uncomplicated postoperative course and was discharged 6 days later to a rehabilitation facility.

Conclusions: Nickel-related allergies are more common than appreciated, affecting up to 10% of patients. Fortunately, severe reactions are rare; nevertheless, vascular neurosurgeons should be aware of this potential complication when using cobalt alloy aneurysms clips. The use of titanium alloy clips eliminates this risk.

No MeSH data available.


Related in: MedlinePlus

Tracing the month long course of life-threatening vasculitis after aneurysm clipping in a 33-year-old woman. Initial clipping. (a) After coil embolization for rupture of a right internal carotid artery (ICA) aneurysm, an unruptured left posterior communicating artery (PComA) aneurysm was incidentally detected and then treated by clipping; this intraoperative angiogram demonstrated flow in PComA and fetal posterior cerebral artery (PCA) after clipping and no residual aneurysm filling. (b) Postoperative CT confirms clipping was successful. Readmission and reclipping. Eleven days later (day 1), patient returns to the emergency department where head CT (c) and MRI (d) showed acute infarction in the orbitofrontal and left frontal opercular cortical regions. CTs during hospital days 11–22. Day 11 (e), progressive mass effect and infarction; day 12 (f), after surgical decompression, evolution of new bifrontal infarctions and day 16 (g) demonstrating new left PCA infarct with worsening of bilateral frontal infarctions. Day 17 (h), repeat angiogram shows high-grade stenosis and near-complete occlusion of the left PCA at the P1-2 junction; mild short segment stenosis involves several cortical branch vessels of left MCA. Day 22 (i), intraoperative angiogram after nickel-containing clip removal was replaced with titanium clip
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Figure 1: Tracing the month long course of life-threatening vasculitis after aneurysm clipping in a 33-year-old woman. Initial clipping. (a) After coil embolization for rupture of a right internal carotid artery (ICA) aneurysm, an unruptured left posterior communicating artery (PComA) aneurysm was incidentally detected and then treated by clipping; this intraoperative angiogram demonstrated flow in PComA and fetal posterior cerebral artery (PCA) after clipping and no residual aneurysm filling. (b) Postoperative CT confirms clipping was successful. Readmission and reclipping. Eleven days later (day 1), patient returns to the emergency department where head CT (c) and MRI (d) showed acute infarction in the orbitofrontal and left frontal opercular cortical regions. CTs during hospital days 11–22. Day 11 (e), progressive mass effect and infarction; day 12 (f), after surgical decompression, evolution of new bifrontal infarctions and day 16 (g) demonstrating new left PCA infarct with worsening of bilateral frontal infarctions. Day 17 (h), repeat angiogram shows high-grade stenosis and near-complete occlusion of the left PCA at the P1-2 junction; mild short segment stenosis involves several cortical branch vessels of left MCA. Day 22 (i), intraoperative angiogram after nickel-containing clip removal was replaced with titanium clip

Mentions: After suffering a subarachnoid hemorrhage (SAH), a 33-year-old woman underwent a coil embolization at an outside hospital for rupture of a right internal carotid artery (ICA) aneurysm [Figure 1]. At that time, cerebral angiography incidentally revealed an unruptured left PComA aneurysm that was deemed high risk for coiling. Following an excellent recovery from SAH, treatment of the unruptured aneurysm was recommended. Referred to our institution's cerebrovascular and stroke center for elective surgical repair, the patient underwent a left pterional craniotomy with anterior clinoidectomy and clipping of the unruptured aneurysm. With an uncomplicated initial postoperative course, she was discharged home the next day.


Life-threatening allergic vasculitis after clipping an unruptured aneurysm: Case report, weighing the risk of nickel allergy.

Grande A, Grewal S, Tackla R, Ringer AJ - Surg Neurol Int (2014)

Tracing the month long course of life-threatening vasculitis after aneurysm clipping in a 33-year-old woman. Initial clipping. (a) After coil embolization for rupture of a right internal carotid artery (ICA) aneurysm, an unruptured left posterior communicating artery (PComA) aneurysm was incidentally detected and then treated by clipping; this intraoperative angiogram demonstrated flow in PComA and fetal posterior cerebral artery (PCA) after clipping and no residual aneurysm filling. (b) Postoperative CT confirms clipping was successful. Readmission and reclipping. Eleven days later (day 1), patient returns to the emergency department where head CT (c) and MRI (d) showed acute infarction in the orbitofrontal and left frontal opercular cortical regions. CTs during hospital days 11–22. Day 11 (e), progressive mass effect and infarction; day 12 (f), after surgical decompression, evolution of new bifrontal infarctions and day 16 (g) demonstrating new left PCA infarct with worsening of bilateral frontal infarctions. Day 17 (h), repeat angiogram shows high-grade stenosis and near-complete occlusion of the left PCA at the P1-2 junction; mild short segment stenosis involves several cortical branch vessels of left MCA. Day 22 (i), intraoperative angiogram after nickel-containing clip removal was replaced with titanium clip
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4109169&req=5

Figure 1: Tracing the month long course of life-threatening vasculitis after aneurysm clipping in a 33-year-old woman. Initial clipping. (a) After coil embolization for rupture of a right internal carotid artery (ICA) aneurysm, an unruptured left posterior communicating artery (PComA) aneurysm was incidentally detected and then treated by clipping; this intraoperative angiogram demonstrated flow in PComA and fetal posterior cerebral artery (PCA) after clipping and no residual aneurysm filling. (b) Postoperative CT confirms clipping was successful. Readmission and reclipping. Eleven days later (day 1), patient returns to the emergency department where head CT (c) and MRI (d) showed acute infarction in the orbitofrontal and left frontal opercular cortical regions. CTs during hospital days 11–22. Day 11 (e), progressive mass effect and infarction; day 12 (f), after surgical decompression, evolution of new bifrontal infarctions and day 16 (g) demonstrating new left PCA infarct with worsening of bilateral frontal infarctions. Day 17 (h), repeat angiogram shows high-grade stenosis and near-complete occlusion of the left PCA at the P1-2 junction; mild short segment stenosis involves several cortical branch vessels of left MCA. Day 22 (i), intraoperative angiogram after nickel-containing clip removal was replaced with titanium clip
Mentions: After suffering a subarachnoid hemorrhage (SAH), a 33-year-old woman underwent a coil embolization at an outside hospital for rupture of a right internal carotid artery (ICA) aneurysm [Figure 1]. At that time, cerebral angiography incidentally revealed an unruptured left PComA aneurysm that was deemed high risk for coiling. Following an excellent recovery from SAH, treatment of the unruptured aneurysm was recommended. Referred to our institution's cerebrovascular and stroke center for elective surgical repair, the patient underwent a left pterional craniotomy with anterior clinoidectomy and clipping of the unruptured aneurysm. With an uncomplicated initial postoperative course, she was discharged home the next day.

Bottom Line: Arriving in our emergency department 11 days later, she progressively declined during the next weeks, facing deteriorating clinical status (i.e. seizures) and additional infarctions in the left frontal lobe, midline shift, and new infarctions in the bilateral frontal lobe, right sylvian, right insular regions, and posterior cerebral artery distribution.During decompressive surgery, biopsy findings raised the possibility of lymphocytic vasculitis; consultations with rheumatology, allergy, and immunology specialists identified that our patient had a nickel allergy.Nickel-related allergies are more common than appreciated, affecting up to 10% of patients.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, University of Cincinnati College of Medicine, Comprehensive Stroke Center at the UC Neuroscience Institute, and Mayfield Clinic, Cincinnati, OH, USA.

ABSTRACT

Background: This case report represents one of the estimated 17,000 aneurysms clipped annually in the United States, often with nickel-containing clips. The authors highlight the development of life-threatening allergic vasculitis in a 33-year-old woman after aneurysm clipping.

Case description: After suffering subarachnoid hemorrhage, the patient had coil embolization at another facility for rupture of a right internal carotid artery (ICA) aneurysm. An incidental finding, an unruptured left posterior communicating artery aneurysm unamenable to coiling, was then successfully clipped via a left pterional craniotomy. Arriving in our emergency department 11 days later, she progressively declined during the next weeks, facing deteriorating clinical status (i.e. seizures) and additional infarctions in the left frontal lobe, midline shift, and new infarctions in the bilateral frontal lobe, right sylvian, right insular regions, and posterior cerebral artery distribution. During decompressive surgery, biopsy findings raised the possibility of lymphocytic vasculitis; consultations with rheumatology, allergy, and immunology specialists identified that our patient had a nickel allergy. After reoperation to replace the nickel-containing clip with one of a titanium alloy, the patient had an uncomplicated postoperative course and was discharged 6 days later to a rehabilitation facility.

Conclusions: Nickel-related allergies are more common than appreciated, affecting up to 10% of patients. Fortunately, severe reactions are rare; nevertheless, vascular neurosurgeons should be aware of this potential complication when using cobalt alloy aneurysms clips. The use of titanium alloy clips eliminates this risk.

No MeSH data available.


Related in: MedlinePlus