Contrast Media Extravasation in CT and MRI – A Literature Review and Strategies for Therapy

Abstract

Background Contrast extravasation events in daily radiological routine may lead to serious complications, especially during CT examinations. The resulting symptoms may vary from local pain up to skin ulcers, necrosis or even acute compartment syndrome.

There are no uniformly accepted radiological guidelines or recommendations regarding detection and treatment of extravasation events and immanent complications in a timely manner.

Method Systematic literature research considering the last 35 years via PubMed using search terms “contrast medium extravasation/paravasation”.

Results In the literature, there are conservative management approaches of contrast media extravasation without major evidence base, such as unguent dressings, cooling or splinting. This therapy is mostly symptomatic. Additionally, various invasive techniques are described. We discuss these techniques in the context of contemporary literature, such as the hyaluronidase Injection into the site of extravasation, suction/aspiration technique including flushing of the affected tissue areas and the squeezing technique. However, most citations lack scientific evidence: many articles include anecdotal enumerations, case studies or cite publications from the era, when ionic high osmolar contrast media was state-of-the-art. Besides, many authors derive their extravasation management from studies, where agents other than contrast media were investigated.

Conclusion After detailed literature review, we suggest early (plastic) surgical consultation when non-ionic, low-osmolar contrast medium extravasation is about 150 cc or more. In case of extravasation less than 150 cc but in presence of additional symptoms such as impaired perfusion or altered sensibility, the (plastic) surgeon should also be consulted instantly. We do not recommend any invasive first line therapy when contrast media extravasation is less than 150 cc and the patient presents no additional symptoms, besides swelling and local pain. Nevertheless continuous monitoring and accurate conservative management such as active cooling and elevation, splinting of the affected extremity are mandatory as early detection of critical symptoms helps to initiate prompt surgical intervention and avoid sequelae.

Key Points 

• Morbidity after contrast media extravasation is extremely rare.

• Predicting sequelae after contrast extravasation is difficult at first sight.

• Treatments such as hyaluronidase injection, suction/aspiration, squeeze technique have been described.

• Surgical consultation is recommended for extravasation > 150 cc or when additional symptoms occur.

Citation Format

• Mandlik V, Prantl L, Schreyer AG. Contrast Media Extravasation in CT and MRI – A Literature Review and Strategies for Therapy. Fortschr Röntgenstr 2019; 191: 25 – 32

Key words

CT - contrast agents - extravasation

• References

• 1 Bae KT. Intravenous contrast medium administration and scan timing at CT: considerations and approaches. Radiology 2010; 256: 32-61
• 2 Sum W, Ridley LJ. Recognition and management of contrast media extravasation. Australas Radiol 2006; 50: 549-552
• 3 Lewis GB, Hecker JF. Radiological examination of failure of intravenous infusions. Br J Surg 1991; 78: 500-501
• 4 Bellin MF, Jakobsen JA, Tomassin I. et al. Contrast medium extravasation injury: guidelines for prevention and management. Eur Radiol 2002; 12: 2807-2812
• 5 Kim SM, Cook KH, Lee IJ. et al. Computed tomography contrast media extravasation: treatment algorithm and immediate treatment by squeezing with multiple slit incisions. Int Wound J 2017; 14: 430-434
• 6 Pacheco Compana FJ, Gago Vidal B, Mendez Diaz C. Extravasation of contrast media at the puncture site: Strategies for managment. Radiologia 2014; 56: 295-302
• 7 Nicola R, Shaqdan KW, Aran S. et al. Contrast Media Extravasation of Computed Tomography and Magnetic Resonance Imaging: Management Guidelines for the Radiologist. Curr Probl Diagn Radiol 2016; 45: 161-164
• 8 Chew FS. Extravasation of iodinated contrast medium during CT: self-assessment module. Am J Roentgenol 2010; 195: S80-S85
• 9 Radiology ESoG. ESUR contrast media guidelines.
• 10 radiology Aco. ACR manual on contrast media. 2013
• 11 Cohan RH, Ellis JH, Garner WL. Extravasation of radiographic contrast material: recognition, prevention, and treatment. Radiology 1996; 200: 593-604
• 12 Federle MP, Chang PJ, Confer S. et al. Frequency and effects of extravasation of ionic and nonionic CT contrast media during rapid bolus injection. Radiology 1998; 206: 637-640
• 13 Cohan RH, Bullard MA, Ellis JH. et al. Local reactions after injection of iodinated contrast material: detection, management, and outcome. Acad Radiol 1997; 4: 711-718
• 14 Niv G, Costa M, Kicak P. et al. Vascular extravasation of contrast medium in radiological examinations: University of California San Diego Health System Experience. J Patient Saf 2014; 10: 105-110
• 15 Jacobs JE, Birnbaum BA, Langlotz CP. Contrast media reactions and extravasation: relationship to intravenous injection rates. Radiology 1998; 209: 411-416
• 16 Shaqdan K, Aran S, Thrall J. et al. Incidence of contrast medium extravasation for CT and MRI in a large academic medical centre: a report on 502391 injections. Clin Radiol 2014; 69: 1264-1272
• 17 Langstein HN, Duman H, Seelig D. et al. Retrospective study of the management of chemotherapeutic extravasation injury. Ann Plast Surg 2002; 49: 369-374
• 18 Hawi N, Citak M, Liodakis E. et al. Development of compartment syndrome after intravenous administration of an X-ray contrast medium. Recommendations on acute therapy regimens. Unfallchirurg 2014; 117: 374-379
• 19 Gault DT. Extravasation injuries. Br J Plast Surg 1993; 46: 91-96
• 20 Hao D, Ai T, Goerner F. et al. MRI contrast agents: basic chemistry and safety. J Magn Reson Imaging 2012; 36: 1060-1071
• 21 Cohan RH, Leder RA, Bolick D. et al. Extravascular extravasation of radiographic contrast media. Effects of conventional and low-osmolar agents in the rat thigh. Invest Radiol 1990; 25: 504-510
• 22 Cochran ST, Bomyea K, Sayre JW. Trends in adverse events after IV administration of contrast media. Am J Roentgenol 2001; 176: 1385-1388
• 23 Khan MS, Holmes JD. Reducing the morbidity from extravasation injuries. Ann Plast Surg 2002; 48: 628-632 ; discussion 32
• 24 Hastings-Tolsma MT, Yucha CB, Tompkins J. et al. Effect of warm and cold applications on the resolution of i.v. infiltrations. Res Nurs Health 1993; 16: 171-178
• 25 Sznitowska M, Janicki S. Percutaneous absorption of heparin: a critical review of experimental results. Pol Merkur Lekarski 2000; 7: 58-63
• 26 Massey T, Derry S, Moore RA. et al. Topical NSAIDs for acute pain in adults. Cochrane Database Syst Rev 2010; CD007402
• 27 Ng L, Monagle K, Monagle P. et al. Topical use of antithrombotics: review of literature. Thromb Res 2015; 135: 575-581
• 28 Laurie SW, Wilson KL, Kernahan DA. et al. Intravenous extravasation injuries: the effectiveness of hyaluronidase in their treatment. Ann Plast Surg 1984; 13: 191-194
• 29 McAlister WH, Kissane JM. Comparison of soft tissue effects of conventional ionic, low osmolar ionic and nonionic iodine containing contrast material in experimental animals. Pediatr Radiol 1990; 20: 170-174
• 30 Vandeweyer E, Heymans O, Deraemaecker R. Extravasation injuries and emergency suction as treatment. Plast Reconstr Surg 2000; 105: 109-110
• 31 Loth TS, Jones DE. Extravasations of radiographic contrast material in the upper extremity. J Hand Surg Am 1988; 13: 395-398
• 32 Tsai YS, Cheng SM, Ng SP. et al. Squeeze maneuver: an easy way to manage radiological contrast-medium extravasation. Acta Radiol 2007; 48: 605-607
• 33 Chan PS, Steinberg DR, Pepe MD. et al. The significance of the three volar spaces in forearm compartment syndrome: a clinical and cadaveric correlation. J Hand Surg Am 1998; 23: 1077-1081
• 34 Lanz U, Felderhoff J. Ischemic contractures of the forearm and hand. Handchir Mikrochir Plast Chir 2000; 32: 6-25
• 35 Benson LS, Sathy MJ, Port RB. Forearm compartment syndrome due to automated injection of computed tomography contrast material. J Orthop Trauma 1996; 10: 433-436
• 36 Memolo M, Dyer R, Zagoria RJ. Extravasation injury with nonionic contrast material. Am J Roentgenol 1993; 160: 203-204
• 37 Fallscheer P, Kammer E, Roeren T. et al. Injury to the upper extremity caused by extravasation of contrast medium: a true emergency. Scand J Plast Reconstr Surg Hand Surg 2007; 41: 26-32
• 38 Sbitany H, Koltz PF, Mays C. et al. CT contrast extravasation in the upper extremity: strategies for management. Int J Surg 2010; 8: 384-386
• 39 Kim SH, Park JH, Kim YI. et al. Experimental tissue damage after subcutaneous injection of water soluble contrast media. Invest Radiol 1990; 25: 678-685
• 40 Cohan RH, Dunnick NR, Leder RA. et al. Extravasation of nonionic radiologic contrast media: efficacy of conservative treatment. Radiology 1990; 176: 65-67
• 41 Wang CL, Cohan RH, Ellis JH. et al. Frequency, management, and outcome of extravasation of nonionic iodinated contrast medium in 69657 intravenous injections. Radiology 2007; 243: 80-87
• 42 Wienbeck S, Fischbach R, Kloska SP. et al. Prospective study of access site complications of automated contrast injection with peripheral venous access in MDCT. Am J Roentgenol 2010; 195: 825-829