Can contrast agents be given to a patient with intracranial (within the skull) bleeding?

Contrast Administration in Patients with Intracranial Bleeding

Intravenous contrast agents can be safely administered to patients with intracranial bleeding when clinically indicated, as there is no evidence that IV contrast worsens intracranial hemorrhage. The decision should be based on the clinical necessity of obtaining contrast-enhanced imaging to guide management decisions that could impact mortality and morbidity outcomes.

Contrast Administration Safety in Intracranial Hemorrhage

Intravenous Contrast

• Intravenous gadolinium-based contrast agents are indicated for MRI visualization of "lesions with disrupted blood brain barrier and/or abnormal vascularity in the brain (intracranial lesions), spine and associated tissues" 1
• CT angiography with iodinated contrast is routinely used in the evaluation of intracranial hemorrhage to identify underlying vascular abnormalities
• Research has shown that "intravenous iodinated contrast in doses typically required for CT angiography and perfusion imaging was not associated with symptomatic intracranial hemorrhage" 2

Clinical Indications for Contrast Use

When evaluating patients with intracranial hemorrhage, contrast-enhanced imaging is particularly important for:

1. Identifying underlying vascular abnormalities:

   • Arteriovenous malformations
   • Aneurysms
   • Arteriovenous fistulas
   • Tumor vascularity

2. Evaluating venous sinus thrombosis:

   • Dural venous sinus thrombosis (DVST) is an important cause of ICH that requires specific treatment 3
   • Adequate venous opacification is essential to exclude DVST as a potential cause of hemorrhage

Imaging Recommendations in Intracranial Hemorrhage

The American College of Radiology (ACR) Appropriateness Criteria provides guidance for imaging in patients with acute mental status changes associated with intracranial bleeding:

• "A noncontrast head CT is usually the initial test of choice" for acute mental status changes associated with increased risk for intracranial bleeding 4
• For further evaluation or when the initial noncontrast CT is inconclusive, "contrast-enhanced brain MRI may be performed for definitive characterization of a focal lesion identified on initial noncontrast CT examination" 4

Important Contraindications and Precautions

While contrast can be administered to patients with intracranial hemorrhage, certain precautions must be observed:

1. Avoid intrathecal administration:

   • Intrathecal administration of gadolinium-based contrast agents can cause serious adverse reactions including "death, coma, encephalopathy, and seizures" 1
   • Gadolinium is only approved for intravenous use, not intrathecal administration 1

2. Renal function considerations:

   • Screen patients for acute kidney injury and chronic kidney disease
   • Gadolinium-based contrast agents increase the risk for nephrogenic systemic fibrosis in patients with impaired renal function 1

3. Hypersensitivity reactions:

   • Monitor for anaphylactic/anaphylactoid reactions with cardiovascular, respiratory, and cutaneous manifestations 1

Management of Medications in Intracranial Hemorrhage

While administering contrast is generally safe, management of certain medications is critical in patients with intracranial hemorrhage:

• Discontinue anticoagulants and antiplatelets: "We recommend discontinuing antiplatelet agents when intracranial hemorrhage is present or suspected" 4
• Avoid NSAIDs: "Discontinue all NSAIDs immediately when ICH is present or suspected" 5

Conclusion

Intravenous contrast can be safely administered to patients with intracranial hemorrhage when there is clinical indication for contrast-enhanced imaging. The benefits of identifying underlying vascular abnormalities or other pathologies that could guide treatment decisions generally outweigh the theoretical risks of contrast administration in the setting of intracranial hemorrhage.