Fatal gadolinium-induced encephalopathy following accidental intrathecal administration: a case report and a comprehensive evidence-based review

  title={Fatal gadolinium-induced encephalopathy following accidental intrathecal administration: a case report and a comprehensive evidence-based review},
  author={David Anthony Provenzano and Zachary Pellis and Leonard DeRiggi},
  journal={Regional Anesthesia \& Pain Medicine},
  pages={721 - 729}
Gadolinium-based contrast agents (GBCAs) have been suggested as off-label alternatives to iodine-based contrast agents for fluoroscopic imaging during interventional pain procedures. We report a case of accidental intrathecal administration of a GBCA during a neuraxial interventional pain procedure leading to acute gadolinium neurotoxicity, which resulted in encephalopathy and ultimately death. To our knowledge, it is the first published case of fatal intrathecal gadolinium-induced… 

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Intrathecal gadolinium: a fatal flaw

  • T. Maus
  • Medicine
    Regional Anesthesia & Pain Medicine
  • 2019
The timely case report and review of the literature by Provenzano et al illuminates the risks associated with the use of a gadolinium-based contrast agent (GBCA) in neuraxial interventional pain procedures.

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Man with altered mental status

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