Hemorrhagic Stroke and Blindness after Hyaluronic Acid/Polylactic Acid Filler Injection

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J Neurosonol Neuroimag. 2023;15(1):68-70

Publication date (electronic) : 2023 June 30

doi : https://doi.org/10.31728/jnn.2023.00139

Yeo Jun Yoon, MD, Doyeon Kook, MD, Hye Sun Choi, MD, Jiyun Lee, MD, Yo Han Jung, MD, PhD

Department of Neurology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea

Correspondence: Yo Han Jung, MD, PhD Department of Neurology, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea Tel: +82-2-2228-3328 Fax: +82-2-3462-5904 E-mail: yhjung@yuhs.ac

Received 2023 May 28; Revised 2023 June 14; Accepted 2023 June 14.

Abstract

CASE

A 61-year-old male presented to the emergency department with sudden ocular pain and visual loss in the left eye 10 minutes after receiving a cosmetic filler injection into the glabella. The filler injection comprised of 25% hyaluronic acid and 75% poly-L-lactic acid. The patient had a history of hypertension, for which he had been taking amlodipine and candesartan. He had no history of cardiovascular disease. His initial vital signs were as follows: blood pressure, 131/70 mmHg, heart rate, 80 beats/min, respiratory rate, 20/min, and body temperature, 36.7°C. Electrocardiography revealed a sinus rhythm. Initial blood tests were within normal limits, including a complete blood cell count and routine chemistry panel. He was consciousness and his neurologic examination was normal. Physical examination at the emergency department showed redness on the left forehead, periorbital, and glabellar area. His vision was 20/20 in the right eye, but the left eye vision was limited to only light perception. Ophthalmologic examination showed sluggish pupillary light reflex and afferent pupillary defect in the left eye. Fundoscopic examination of the patient’s left eye showed segmented irregularities of retinal arterioles, edematous macula, and cherry red spot, which indicated central retinal artery occlusion (Fig. 1A).

Fig. 1.

Fundoscopy, magnetic resonance imaging, and magnetic resonance angiography (MRA) findings. Initial fundoscopic examination of the patient’s left eye showing segmented irregularities of retinal arterioles (arrows), edematous macula (arrowhead), and cherry red spot (A). Initial diffusion-weighted image shows multiple scattered lesions in left frontal and parietal lobes (B). Initial MRA shows no significant stenosis in the intracranial arteries (C).

Diffusion-weighted imaging revealed small, acute multifocal infarctions in the left frontal and parietal lobes (Fig. 1B). Magnetic resonance angiography (MRA) showed no steno-occlusive lesions of the intracranial artery (Fig. 1C). To prevent further infarctions, treatment with an antiplatelet agent (aspirin 100 mg/day) was initiated. However, small subarachnoid hemorrhages were observed in the left frontal and parietal lobes on the susceptibility-weighted-imaging on the second day after admission (Fig. 2A). Consequently, the antiplatelet therapy was discontinued. On the fourth day after admission, another small intracerebral hemorrhage was found in the left frontal lobe on a follow-up brain computed tomography (Fig. 2B).

Fig. 2.

Follow-up magnetic resonance imaging and computed tomography (CT) images. Susceptibility-weighted-imaging sequence shows small subarachnoid hemorrhages in the left frontal and parietal lobes (A). Follow-up CT shows a small intracerebral hemorrhage in the left frontal lobe (B).

No other neurologic deficits were observed during admission. The pain and redness in the left forehead, periorbital, and glabellar area improved after regular wound dressings. However, the left eye vision showed no improvement. He was discharged one week after admission.

DISCUSSION

We report the unique case of combined cerebral infarction, visual loss, and intracranial hemorrhage after a facial filler injection.

Retrograde arterial emboli have been suggested as the mechanism for arterial occlusion after filler injection.2 During facial filler injection, injection material may accidentally enter the arterial system and form emboli. When injection pressure exceeds systolic arterial pressure, filler emboli can be pushed to proximal sites of the arterial system. Emboli passing through the supraorbital or supratrochlear artery can obstruct the ophthalmic artery or the central retinal artery, causing visual loss. If the emboli travel proximally further into the internal carotid artery, they can obstruct cerebral arteries by anterograde embolism.3,4

Several researchers have reported the use of an antiplatelet agent, hyperbaric oxygen, and steroids for the treatment of acute ischemic stroke after facial filler injection. However, there are currently no randomized clinical trials or treatment guidelines available.5,6 A prior animal study has suggested that intravascular hyaluronic acid emboli could induce the formation of red thrombus. In such cases, the use of intravenous urokinase and hyaluronidase can be beneficial.7 Based on this idea, the use of intravenous recombinant tissue plasminogen activator (IV-rtPA) in filler-induced acute ischemic stroke has been reported in a case report.8 The use of intravenous hyaluronidase infusion as a treatment for filler-induced acute ischemic stroke has not yet been reported.

Although there are currently no reports of spontaneous intracranial hemorrhage after filler injection, an underlying mechanism can be postulated based on previous studies. A previous in vitro study has shown that hyaluronic acid binds to human endothelial cells.9 A recent study has reported that hyaluronic acid can play a role in progress of acute ischemic hemorrhagic stroke patients through inflammatory responses.10 Since hyaluronic acid is a ligand for Toll like receptor (TLR), an increase in plasma hyaluronic acid level can trigger TLR associated immune responses. Therefore, intravascular hyaluronic acid might have caused an immune response within intracranial arteries and its endothelial cells, leading to blood-brain barrier disruption and intracranial hemorrhage. In summary, we present the case of cerebral infarction, subarachnoid hemorrhage, and intracerebral hemorrhage after filler injection. Although cerebral infarction and visual loss have been reported as possible complications after filler injection, clinicians should also recognize that intracranial hemorrhage is a potential complication after injection.

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