Correspondence
Delayed-onset Cerebral Infarction after Cosmetic Facial Injection Using Hyaluronic Acid
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Financial disclosure statements have been obtained, and the authors of this article have reported no conflicts of interest.
A 25-year-old female without any known systemic disease reported experiencing a sudden onset of right eye blindness after hyaluronic acid injection into the nose, and
developed delayed course of left upper limb weakness 9 hours later. Initially, she was brought to our emergency department for right eye blindness. The fundus revealed right central retinal artery occlusion (Fig. 1A, 1B). Nine hours later, acute onset of left upper limb weakness with muscle power grade 4 in the left elbow, wrist, hand and grade 5 in the left shoulder and other three extremities was noted. Brain magnetic resonance imaging (MRI) revealed many small acute infarcts, mainly in the right middle cerebral artery territory (Fig. 1C). The young stroke survey was all within the normal limit, except the trans-esophageal echocardiography showed an atrial septal defect (ASD) with a size of 2.7 cm. Finally, the visual loss and left upper limb weakness remained after discharge.
Cosmetic facial injection using hyaluronic acid as fillers is often performed because of its convenience, ease of implementation, and safety profile. However, several possible complications, including local erythema, infection, skin necrosis, blindness,
panophthalmoplegia, pulmonary embolism, and cerebral infarction may occur1. In previous
reports, the retrograde embolic mechanism in the artery route was investigated that an injection performed in the face, orbit, and nasal area can result in fundus artery occlusion or brain infarction through rich vascular anastomosis1, 2. However, explaining the delayed
forced from the ophthalmic artery into the internal carotid artery, the emboli may be pumped into the cerebral circulation immediately3, 4.
From the perspective of the venous return system, delayed course of foreign body embolism could occur. Rare cases of non-thrombotic pulmonary embolism (NTPE) have been reported with a delayed course of symptoms after injection of hyaluronic acid5. In the
present case, if foreign body emboli were injected into the venous system of the face, the emboli may return to the heart and possibly cause NTPE syndrome. However, this patient did not develop the symptoms of pulmonary embolism; instead, cerebral infarction
occurred. We posit that the emboli of the hyaluronic acid might have entered the vessel not only through the artery by the retrograde mechanism, which caused central retinal artery occlusion, but also through the antegrade venous system return to the right atrium, and might have then passed through ASD, which caused paradoxical embolism and ultimately resulted in cerebral infarction.
In the present case, the new onset of weakness developed 9 hours after visual loss and was distributed only in the left elbow, wrist and hand. The special distribution of
monoparesis can be attributed to Penfield and Boldrey’s cortical homunculus, that is, lesion of the primary motor cortex, which could be correlated with the distribution, presented in the brain MRI (Fig. 1D) and confirmed the delayed course of cerebral infarction. In conclusion, we highlight the importance of further evaluation and careful history taking of
1. He MS, Sheu MM, Huang ZL, Tsai CH, Tsai RK. Sudden bilateral vision loss and brain infarction following cosmetic hyaluronic acid injection. JAMA Ophthalmol 2013;131(9):1234-5.
2. Chen Y, Wang W, Li J, Yu Y, Li L, Lu N. Fundus artery occlusion caused by cosmetic facial injections. Chin Med J 2014;127(8):1434-7.
3. Egido JA, Arroyo R, Marcos A, Jimenez-Alfaro I. Middle cerebral artery embolism and unilateral visual loss after autologous fat injection into the glabellar area. Stroke 1993;24(4):615-6.
4. Kim EG, Eom TK, Kang SJ. Severe visual loss and cerebral infarction after injection of hyaluronic acid gel. J Craniofac Surg 2014;25(2):684-6.
5. Jang JG, Hong KS, Choi EY. A case of nonthrombotic pulmonary embolism after facial injection of hyaluronic Acid in an illegal cosmetic procedure. Tuberc Respir
Figures Legend
Figure 1. (A) Fundus examination of the right eye demonstrates a cherry-red spot (red arrow), which indicated central retinal artery occlusion (B) Fundus examination of the left eye revealed normal retina and optic disc appearance (C) Brain MRI revealed many small acute infarcts distributed over primary motor cortex (orange cross line) (D) Primary motor cortex with infarction site (red line)
