773

Case Reports

Two Cases of Occipital Infarction FollowingCardiac Catheterization

Armando Oliva, CPT, MC, USAR, and Barbara Scherokman, MD

Transient visual disturbance following cardiac catheterization has been regarded as a benign andtransient complication. We describe two cases of computed-tomography-documented occipitalinfarction after cardiac catheterization that emphasize a complication more serious than previouslythought. (Stroke 1988;19:773-775)

Transient cortical blindness is a rare but well-described complication of cardiac catheter-ization.1"5 Reports indicate that it is a benign

condition, and complete recovery of vision should beexpected. We report two cases of computed-tomog-raphy-documented occipital lobe infarction followingcardiac catheterization suggesting a complication moreserious than previously regarded.

Case ReportsCase 1

A 71-year-old man was admitted for preoperativeevaluation of a 5-cm abdominal aortic aneurysm.Medical history included diffuse peripheral vasculardisease, one-block claudication, amaurosis fugax,bilateral carotid endarterectomies, and Type IVhyperlipidemia. Cardiac catheterization via the fem-oral approach revealed significant two-vessel coro-nary artery disease. Immediately after the procedure,he was noted to be somnolent but easily arousable andhe could attend for brief periods. Pupils were 3 mm,symmetric, and briskly reactive to light. Fundo-scopic examination was unremarkable. The patientdenied any subjective visual disturbance yet couldnot count fingers or distinguish light from dark. Heconfabulated answers requiring intact vision. Theremainder of his neurologic examination was unre-markable. An emergency CT of the head withoutcontrast revealed an area of decreased density in theright occipital lobe (Figure 1).

Over the next 2 days, both mental status and visionreturned to normal. A head CT with contrast performed

From the Neurology Service, Walter Reed Army Medical Center,Washington, DC, and the Department of Neurology, UniformedServices University of the Health Sciences, Bethesda, Maryland.

The opinions or assertions contained herein are the private onesof the authors and are not to be construed as official or as necessarilyreflecting the views of the Department of Defense, the Departmentof the Army, or the Uniformed Services University of the HealthSciences.

Address for reprints: Barbara Scherokman, MD, NeurologyDepartment, Uniformed Services University of the Health Sciences,4301 Jones Bridge Road, Bethesda, MD 20814-4799.

Received September 10, 1987; accepted December 10, 1987.

2 weeks after the acute event revealed an enhancingright occipital lobe infarction (Figure 2).

Case 2A 69-year-old man with a history of a myocardial

infarction was admitted for evaluation of worseningdyspnea on exertion. Cardiac catheterization via thefemoral approach revealed a 50% right coronary arterylesion and no evidence of valvular heart disease.Immediately after catheterization, the patient com-plained of decreased vision bilaterally. Neurologicexamination revealed an intact mental status. Visualacuity was limited to light perception only. Pupils were4 mm and briskly reactive. Fundoscopic examinationwas unremarkable. The remainder of the neurologicexamination was otherwise normal. An emergencynoncontrast CT of the head was negative.

The next day, the patient's vision improved tocounting fingers at 2 feet, but a left homonymoushemianopsia was also present. CT of the head withcontrast 2 weeks later demonstrated bilateral occipitalinfarctions, right greater than left (Figure 3). Onemonth later, the patient's best corrected visual acuitywas 20/50 oculus dexter (OD) and 20/40 oculus sinister(OS) with a persistent left homonymous hemianopsia.

DiscussionNumerous reports describe the varied complications

of cardiac catheterization1"6; however, only 33 cases oftransient visual disturbance have been described.7"11

The most comprehensive analysis, a prospective seriesof 2,006 cases undergoing cardiac catheterization,reported a total of 20 patients (1%) who experiencedtransient visual disturbances.7 The incidence washigher in women (2%, 11 of 548) than in men (0.6%,9 of 1,458). The visual disturbance was recognizedwithin the first hour following catheterization, and allpatients had a complete recovery within 24 hours.Fifteen patients had only a partial loss of vision, andfive had complete cortical blindness. An alteration ofmental status was seen in seven cases, and six casesdenied their blindness (Anton's syndrome), as in Case1. One patient had a transient visual agnosia. The

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774 Stroke Vol 19, No 6, June 1988

FIGURE 1. Case1: Noncontrast computed tomogram showingdecreased density within right occipital lobe. Abo note oldlacunar disease.

neurologic examination was otherwise unremarkable inmost patients (95%). One patient had a mild righthemiparesis that resolved over 4 days. Eight of 13electroencephalograms (EEGs) were abnormal, dem-onstrating bilateral temporal or temporo-occipitalslowing that resolved on subsequent tracings. CT scanswere not obtained.

Braunwald and Swan" reported a 31-year-old manwho developed the inability to detect light immediatelyafter catheterization. Complete recovery of vision wasnoted the following day. In another report, a 52-year-old woman developed cortical blindness, head-ache, and nausea after cardiac catheterization.8 Hersymptoms were associated with transient hypotension(140/100 to 84/60 mm Hg), and the deficit resolvedspontaneously over 18 hours. An EEG performedduring the acute episode demonstrated intermittentbifrontal 2-Hz delta activity and a depressed alpharhythm over the left occipital leads. In addition,absence of an evoked response following photicstimulation was noted. Three other cases of "transientblurred vision" were also reported in a series of 5,250cardiac catheterizations performed via the femoralroute; however, details of their clinical course arelacking.' In a brief report, eight of > 30,000 patientsundergoing cardiac catheterization experienced neuro-ophthalmologic complications; of these, four hadradiographic evidence of bilateral occipital infarctions,all of whom had permanent visual deficits.10

Transient visual disturbances and cortical blindnessare better-known complications following vertebralangiography, with an estimated incidence of l-4%12"14

and accounted for 12% of all cases of cortical blindness

FIGURE 2. Case 1: Contrast computed tomogram showingenhancing lesion within right occipital lobe. Also present is oldlacunar disease and small enhancing left thalamic infarction.

following cerebral angiography in one series.15 Severalmechanisms have been proposed to explain the clini-cal findings, and similar mechanisms may explainthe transient visual disturbances after cardiaccatheterization.7 Blindness results presumably fromoccipital lobe ischemia. Somnolence, commonly seenin "top of the basilar" syndrome,16 frequently accom-panies postcatheterization visual disturbances and sug-gests ischemia to the rostral brainstem. Presumably,both upper brainstem and bilateral occipital ischemiadevelop due to a lesion at the distal basilar artery.Occipital lobe ischemia may result from 1) dislodg-ment of atheromatous material, 2) embolization ofthrombus from the catheter tip, 3) in situ thrombosis orspasm of cerebral vessels, 4) a hypotensive episode, 5)preexisting hypertensive disease or migraine head-aches, or 6) selective vulnerability of occipital lobes tocontrast media toxicity.7 Of 20 patients studied pro-spectivery, the incidence of transient visual disturbanceappeared to be significantly higher in patients withnormal coronary arteries (3.7% vs. 0.8%).7 If presenceof atheromatous coronary artery disease is taken as amarker of atherosclerosis elsewhere, dislodgment ofatheromatous material causing blindness would appearto be a less likely mechanism. Although hypotensionmay be a contributing factor, only one patient devel-oped a visual disturbance during transient hypoten-sion.8 Another patient had transient hypotension thatwas treated and then developed visual loss with

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Oliva and Scherokman Infarction From Cardiac Catheterization 775

FIGURE 3. Case 2: Contrast computed tomogram showingbilateral occipital enhancing lesions.

documented normal blood pressure.7 The other mech-anisms suggested may indeed play significant roles;however, none of these has ever been demonstratedradiologicalry or pathologically.

The largest series studying transient visual distur-bance following cardiac catheterization regards it as abenign complication.7 The clinical course of onepatient described here suggests that permanent neuro-logic deficit can be present. Furthermore, CT findingsin both of our patients imply that, at least in some cases,structural occipital lobe damage can result, even inpatients who appear to recover clinically. Since mostpatients in previous reports were not studied with CT,it is impossible to say how often these patients will haveresidual occipital infarctions. Our two cases suggest

that transient visual disturbance following cardiaccatheterization is a much more serious complicationthan has been suggested previously.

References1. Adams DF, Fraser DB, Abrams HL: The complications of

coronary arteriography. Circulation 1973;48:609-6182. Davis K, Kennedy JW, Kemp HG, Judkins MP, Gosselin AJ,

Killip T: Complications of coronary arteriography from theCollaborative Study of Coronary Artery Surgery (CASS).Circulation 1979;59:1105-1112

3. Gwost J, Stoebe T, Chesler E, Weir EK: Analysis of thecomplications of cardiac catheterization over nine years.Cathet Cardiovasc Diagn 1982;8:13-21

4. Weissman BM, Levinsohn MW, Aram DM, Ben-Shachar G:The neurological sequelae of cardiac catheterization (abstract).Ann Neural 1984;16:398

5. Dawson DM, Fisher EG: Neurologic complications of cardiaccatheterization. Neurology 1977;27:496-497

6. Lockwood K, Capraro J, Hanson M, Conomy J: Neurologiccomplications of cardiac catheterization (abstract). Neurology1983;33(suppl 2):143

7. Vik-Mo H, Todnem K, Foiling M, Rosland GA: Transientvisual disturbance during cardiac catheterization with angiog-raphy. Cathet Cardiovasc Diagn 1986;12:l-4

8. Fischer-Williams M, Gottschalk PG, Browell JN: Transientcortical blindness: An unusual complication of coronaryangiography. Neurology 1970;20:353-355

9. Bourassa MG, Noble J: Complication rate of coronary arte-riography: A review of 5250 cases studied by a percutaneousfemoral technique. Circulation 1976^3:106-114

10. Hanson MR, Tomsak RR, Komorsky GS: Neuro-ophthalmo-logic complications of cardiac catheterization (abstract). Neu-rology 1986;36(suppl 1):193

11. Braunwald E, Swan HJC: Cooperative studies on cardiaccatheterization. Circulation 1968;37(suppl III):III-1—III-113

12. Horwitz NH, Wencr L: Temporary cortical blindness followingangiography. J Neurosurg 1974;4O:583-586

13. Silverman SM, Bergman PS, Bender MB: The dynamics oftransient cerebral blindness. Report of nine episodes followingvertebral angiography. Arch Neurol 1961;4:111—126

14. Prendes JL: Transient cortical blindness following vertebralangiography. Headache 1978;18:222-224

15. Aldrich MS, Alessi AG, Beck RW, Gilman S: Corticalblindness: Etiology, diagnosis and prognosis. Ann Neurol1987;21:149-158

16. Caplan L: "Top of the basilar" syndrome. Neurology 198O;3O:72-79

KEY WORDS • blindness • cerebral infarction • heartcatheterization • tomography, x-ray computed

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A Oliva and B ScherokmanTwo cases of occipital infarction following cardiac catheterization.

Print ISSN: 0039-2499. Online ISSN: 1524-4628 Copyright © 1988 American Heart Association, Inc. All rights reserved.

is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231Stroke doi: 10.1161/01.STR.19.6.773

1988;19:773-775Stroke. 

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