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Fatal gadolinium-induced encephalopathy following accidental intrathecal administration: a case report and a comprehensive evidence-based review
  1. David Anthony Provenzano1,
  2. Zachary Pellis1 and
  3. Leonard DeRiggi2
  1. 1Pain Diagnostics and Interventional Care, Sewickley, Pennsylvania, USA
  2. 2Brighton Radiology Associates, Sewickley, Pennsylvania, USA
  1. Correspondence to Dr David Anthony Provenzano, Pain Diagnostics and Interventional Care, Sewickley, PA 15143, USA; davidprovenzano{at}


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 encephalopathy and the first published case of intrathecal gadoteridol causing serious neurologic complications. In addition, the case presented here is placed in context with an associated comprehensive, evidence-based review of the use of gadolinium in interventional pain procedures, addressing gadolinium chemistry and pharmacologic properties, neurotoxicity and radiology. Physicians must be aware that gadolinium poses a significant risk of acute neurotoxicity even in small doses. Until further safety research is performed, GBCAs should not be considered a safe alternative for use in neuraxial interventional spine procedures when there is a risk of inadvertent intrathecal administration.

  • gadolinium
  • intrathecal
  • neurotoxicity
  • gadoteridol

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  • Presented at This work was presented in part at: American Society of Regional Anesthesia and Pain Medicine 16th Annual Meeting, Lake Buena Vista, Florida, USA, November 2017.

  • Contributors All authors were involved in the analysis, synthesis and writing of this case report and the evidence-based review on gadolinium-based contrast agents.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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