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Case Reports
Misconnections in the Critically Ill: Injection of High-Dose Gadolinium into an External Ventricular Drain.
- Sumit Singh, Sepehr Rejai, Zarah Antongiorgi, Nestor Gonzalez, and Matthias Stelzner.
- From the *Department of Anesthesiology and Perioperative Medicine, †Neurosurgery, and ‡VA Greater Los Angeles Health Care System, UCLA Medical Center, Los Angeles, California.
- A A Case Rep. 2016 Mar 1; 6 (5): 121-3.
AbstractWe report an unfortunate case of accidental administration of intrathecal gadolinium through an external ventricular drain in a postcraniotomy patient during magnetic resonance imaging of the brain. The incident occurred after the venous contrast line was connected mistakenly to the ventricular drainage catheter. The patient subsequently developed confusion, aphasia, and right facial droop with new computed tomography evidence of diffuse cerebral edema and stroke. Review of the magnetic resonance image revealed the inappropriate presence of subarachnoid gadolinium. Despite all interventions, the patient developed irreversible neurologic disability. We address the clinical sequelae, management strategies, and factors contributing to the catheter misconnection that led to this event.
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