Contrast-induced encephalopathy following bronchial artery embolization: A case report and literature review in a patient with pulmonary tuberculosis and aspergillosis

Abstract

The current study analyzed a case of contrast-induced encephalopathy (CIE) following bronchial artery embolization (BAE) in a patient with hemoptysis due to pulmonary tuberculosis complicated by pulmonary aspergillosis. A 56-year-old male patient developed CIE after BAE was retrospectively analyzed. An ectopic bronchial artery originates from the proximal segment of the right vertebral artery. The patient developed CIE postoperatively, which resolved after treatment with corticosteroids and intracranial pressure reduction. A follow-up cranial MRI after 6 months showed complete resolution of previous edema. A literature review identified three cases of CIE after BAE, all presenting with hemoptysis, and symptom resolution within 3 days.

Introduction

Hemoptysis is the expectoration of blood originating from the lower respiratory tract distal to the larynx, which differs from bleeding at other sites. Even minor hemoptysis can lead to life-threatening airway obstruction, while massive hemoptysis carries a mortality rate as high as 75 %[1]. In China, pulmonary tuberculosis (TB) is the most common etiology, accounting for approximately 65 % of cases [2]^. As a critical respiratory condition, hemoptysis often responds poorly to medical therapy, with high recurrence rates, and surgical intervention is associated with significant trauma and risks. Consequently, bronchial artery embolization (BAE) has emerged as the first-line treatment due to its minimally invasive nature, safety, repeatability, and high success rate [3].

The use of bronchial angioembolization for managing hemoptysis due to pulmonary TB, while BAE is effective, it carries potential risks that must be considered in the treatment decision-making process [4]. A case report by Chu et al. [5] presented an unusual case of contrast-induced encephalopathy mimicking stroke after a second cerebral DSA (Digital Subtraction Angiography) [5]. Early diagnosis of CIE is critical, as it may require discontinuation of contrast media administration, supportive care, and in some cases, treatment with other medications to manage symptoms [5].

Case presentation

The study was ethically approved by the ethical review board of Guangzhou Chest Hospital (2022) No. 47. A 56-year-old male was admitted with a 2-year history of intermittent cough and hemoptysis, exacerbated over the past 9 days. Prior chest CT revealed bilateral pulmonary patchy, nodular. The patient was diagnosed with pulmonary TB at a local hospital and received anti-TB treatment with the regimen "INH + RFP + PZA + EMB". Six months after starting the medication, the patient developed drug-induced hepatitis. After discontinuing the drugs for six months, a re-examination showed positive TB DNA in sputum. Anti-TB treatment was restarted with the regimen "INH + RFT + EMB + LFX". Despite 2 years of anti-TB therapy, the patient experienced recurrent hemoptysis (∼15 mL/day).Physical examination showed normal consciousness, muscle strength, and vision, with clear lung fields and no adventitious sounds. Medical history included poorly controlled type 2 diabetes (fasting glucose: 8–9 mmol/L). Repeated chest CT on admission demonstrated persistent cavitary lesions with vascular proliferation surrounding the right upper and lower lung fields (Fig. 1). Due to refractory hemoptysis, BAE was performed on day 3.

Fig. 1.

Plain and enhanced chest CT scan of the patient (Figs. A and C: Secondary tuberculosis lesions are observed in the anterior segment of the right upper lobe and the dorsal segment of the right lower lobe, with cavitation formation within the lesions. Nodular tissue-density shadows are noted within the cavity of the right lower lobe dorsal segment. Figs. B and D (arterial phase of contrast-enhanced scans): Dilated and tortuous vessels surrounding the lesions are visualized. (E, F, G): Bronchoarteriography. Ectopic bronchial artery originating from the proximal right vertebral artery.

Angiography revealed a hypertrophied, tortuous right bronchial artery with systemic-pulmonary shunting (Fig. 1E). Embolization was performed using polyvinyl alcohol (PVA) and gelatin sponge particles. Subsequent angiography identified an ectopic bronchial artery originating from the proximal right vertebral artery (Figure S1F), with mild parenchymal staining in the right upper lung (Figure S1G).

During selective cannulation, the patient developed a severe headache, prompting procedure termination. 150 mL iodixanol (isosmolar, third-generation nonionic dimer) was administered. Postoperatively, the patient reported persistent headaches, blurred vision, vomiting, and generalized weakness. Emergent MRI at 3 h revealed left cortical edema without infarction (Figure S1). The ophthalmologic evaluation confirmed complete bilateral blindness with diabetic retinopathy. Neurologic examination was otherwise normal. CIE with cortical blindness was diagnosed, and treatment included mannitol (125 mL), methylprednisolone (40 mg), hydration, and neuroprotective therapy. Vision partially recovered (20 cm object perception) by 24 h and fully normalized by 48 h. Bronchoscopy demonstrated necrotic material in the right lower lobe cavity; Bronchoalveolar lavage fluid (BALF) GeneXpert MTB/RIF confirmed rifampin-sensitive TB and BALF smear and culture for acid-fast bacilli were negative on staining; however, TB RNA in BALF was positive. The histopathology revealed granulomatous inflammation with fungal hyphae (Figure S1A, B, C), consistent with TB and aspergillosis.

The patient was discharged on "INH + PZA + EMB + LFX" and antifungal treatment with voriconazole at a dose of 0.2 g every 12 h (0.2 q12h). A six-month follow-up MRI showed complete resolution of cortical edema.

Literature review

A literature from January 1970 to April 2025, using the terms "bronchial arteriography " and, contrast-induced encephalopathy was performed. Two relevant studies were retrieved, and only 1 case was of contrast-induced encephalopathy complicating bronchial artery angiography.

In the China National Knowledge Infrastructure (CNKI) and Wanfang Databases, using "Bronchial artery angiography, contrast-induced encephalopathy" and "Bronchial artery, cortical blindness" as the keywords, no relevant literature was found.

Clinical features

Among the three selected patients (Males: 2, Female: 1), two were from the literature and one was in the current study, with an average age of 49.7 years. The underlying diseases included one case of type 2 diabetes, one case of esophageal cancer after resection, and the past medical history of one case was unknown. Imaging data showed that the thickened and tortuous bronchial arteries originated from the right subclavian artery in 2 cases and from the left bronchial artery in 1 case. The super-selective sites were the right bronchial artery in 2 cases, and the super-selective site in 1 case was unknown. In the MRI of the 3 patients, the lesions showed high signals in DWI and FLAIR. The symptoms of all three patients occurred after the interventional procedure, disappeared within 3 days, and the MRI reexamined was normal. The specific clinical data are shown in Table S1.

Discussion

The etiology of hemoptysis is complex and diverse. In China, common etiologies include pulmonary TB, bronchiectasis, lung tumors, and pulmonary aspergillosis. In the current case, the patient was initially found in the inflammatory infiltration stage after TB infection. The inflammation caused dilation and increased permeability of capillaries around the lesion, leading to blood-tinged sputum or minor hemoptysis. In the later stage, irreversible lesions such as caseous necrosis, cavities, pulmonary fibrosis, and bronchiectasis formed, which further eroded the bronchial arteries and created conditions for subsequent aspergillus colonization. The hyphae of chronic pulmonary aspergillosis (CPA) further eroded the blood vessels around the TB lesions, exacerbating the patient's hemoptysis.

Clinically, it is easy to fall into the mindset of single diagnosis. TB and CPA are quite similar in terms of chronic cough and hemoptysis symptoms, pathological manifestations of granulomatous inflammation, and imaging findings such as pulmonary cavities and inflammatory infiltration. The neglect of concurrent infection thus leads to misdiagnosis. The patient had poor response to long-term medical hemostatic therapy. After admission, selective angiography of the responsible blood vessels and embolization were arranged immediately. Postoperatively, the patient presented with cortical blindness and was diagnosed with CIE after BAE following relevant examinations.

The CIE is a rare neurological complication after intravascular use of contrast agents. Relevant reports mainly occur after coronary angiography and cerebral arteriography [6], with an incidence rate of approximately 0.13 % - 2.92 % [7]. It can present as cortical blindness, headache, vomiting, fatigue, epileptic seizures, disturbance of consciousness, or focal neurological deficits. A retrospective study conducted in China pointed out that among 4528 patients who underwent ioversol cerebral angiography, 11 cases (0.24 %) developed cortical blindness after the operation [8]. However, cases of CIE complicating BAE are extremely rare.

Currently, only Zhang F [9] and Wang Yeqing's team [10] have reported individual cases. The pathogenesis of CIE has not been fully elucidated and may be related to the following mechanisms. (A) Blood-brain barrier disruption: Uchiyama Y [11] found that the iodine concentration in the cerebrospinal fluid of patients undergoing intracranial angiography increased, suggesting that contrast agents may damage the blood-brain barrier by down-regulating the expression of tight-junction proteins. The supine position during the operation easily leads to the accumulation of contrast agents in the visual cortex area of the occipital lobe, causing local toxic damage [6]. (B) Direct cytotoxicity: The blood-brain barrier in the occipital lobe is the weakest [12] and may be more vulnerable. (C) Cerebral vasospasm: Contrast agents can induce vascular endothelial cells to release endothelin and inhibit nitric oxide synthase activity, resulting in cerebral vasospasm and reduced local perfusion [13].

Conclusion

To the best of our knowledge, this is the first reported case in China of CIE complicating BAE, mainly manifested as cortical blindness. This case's diagnosis and treatment process indicate clinicians still have insufficient awareness of CIE complicating BAE. Due to the non-specific clinical manifestations of CIE (such as cortical blindness, headache, disturbance of consciousness, etc.).

Ethical Approval No

Ethical Approval of Guangzhou Chest Hospital (2022) No. 47

CRediT authorship contribution statement

Xiao Haihao: Writing – review & editing, Supervision, Conceptualization. Zhang Lin: Resources, Methodology. Li Tianyi: Project administration, Investigation. Khan Muhammad: Writing – review & editing, Methodology, Conceptualization. Wu Jingqiang: Writing – original draft, Conceptualization. Liu Deqing: Writing – original draft, Conceptualization.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A. Supplementary material

Supplementary material

MRI results of the patient's head: MR Examination 3 h after BAE: showed mild edema in the left occipital cortex, slightly low signal in the T1 sequence ①), slightly decreased signal in the T2 sequence (②), increased signal in the FLAIR (Fluid-Attenuated Inversion Recovery) and DWI (Diffusion-Weighted Imaging). Sequences (③ and ④), and slightly decreased Apparent Diffusion Coefficient (ADC) signal (⑤); MR Reexamination 6 months after BAE showed that the original left occipital cortex was basically normal at T1, T2, and FLAIR (⑥, ⑦, ⑧). (A, B, C): Pathological results of bronchoscopy and bronchial mucosal biopsy. A: Bronchoscopy reveals a cavitary opening in the subsegmental branch B6c of the right lower lobe dorsal segment, with an accumulation of yellowish necrotic debris. Figure B: Pathological biopsy of the necrotic material demonstrates granulomatous inflammatory changes. Figure C: Special staining of the necrotic debris shows positive fungal fluorescent staining