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Intraspinal Arachnoiditis and Hydrocephalus After Lumbar Myelography Using Methylglucamine Iocarmate

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Intraspinal Arachnoiditis and Hydrocephalus After Lumbar Myelography Using Methylglucamine Iocarmate J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.41.2.108 on 1 February 1978. Downloaded from Journal ofNeurology, Neurosurgery, and Psychiatry, 1978, 41, 108-112 Intraspinal arachnoiditis and hydrocephalus after lumbar myelography using methylglucamine iocarmate T. STAEHELIN JENSEN AND 0. HEIN From the Department of Neurology, Vejle County Hospital, and the Department of Neurosurgery, Odense University Hospital, Denmark SUMMARY A 35 year old woman developed a severe meningeal reaction after lumbar myelo- graphy using the water-soluble contrast medium methylglucamine iocarmate. Three months after myelography the findings were a transverse spinal cord syndrome corresponding to the middle thoracic segments resulting from well developed leptomeningeal adhesions. This was combined with a noncommunicating hydrocephalus, probably the result of leptomeningeal fibrosis in the posterior fossa. After treatment with a ventriculoatrial shunt the patient is almost free of symptoms. A possible pathogenetic relationship between the contrast medium, the chronic leptomeningeal changes, and the symptoms of our patient is discussed on the basis guest. Protected by copyright. of the literature. Although myelography is one of the most valuable The water-soluble contrast media-for example, diagnostic tests in various spinal cord lesions, methylglucamine iothalamate (Conray) and several of the contrast media used in this diag- methylglucamine iocarmate (meglumine iocar- nostic procedure give rise to a broad spectrum of mate, Dimer-X)-are used mainly for investigation side effects. Among these the most common are of the lumbar part of the spinal canal, giving more acute or chronic leptomeningeal reactions (Autio detailed pictures than oil-based contrast media. et al., 1972; Ahlgren, 1973; Halaburt and Lester, However, like the oily contrast media, these agents 1973; Irstam and Rosencrantz, 1973). are more or less neurotoxic, and various compli- Oil-based contrast media-for example, io- cations may be observed after myelography with phendylate, Pantopaque-which are mainly used water-soluble contrast agents. In recent years de- in the cervicodorsal region, in cases of suspected layed adhesive arachnoidal changes after the use spinal cord or nerve root compression, have an of these substances have been reported more fre- irritating effect on the medulla and the nerve quently (Autio et al., 1972; Ahlgren, 1973, 1975; roots. Their use is frequently accompanied by Halaburt and Lester, 1973; Irstam and Rosen- acute mild leptomeningeal inflammation, with an crantz, 1973). All arachnoidal changes observed increase in cell and protein content of the cere- to date have been located exclusively in the caudal http://jnnp.bmj.com/ brospinal fluid. Although serious cases of chronic region of the spinal canal (Ahlgren, 1973; Hala- arachnoiditis or adhesive arachnoidal changes burt and Lester, 1973; Irstam and Rosencrantz, after the use of iophendylate are uncommon, they 1973; Slatis et al., 1974). This paper describes an have been observed both in the upper intraspinal unusual case of intracranial and midthoracic region and intracranially, and are occasionally arachnoiditis in which the clinical symptoms ap- followed by hydrocephalus with a lethal course peared shortly after lumbar myelography with (Tarlov, 1945; Mason and Raaf, 1962; Mayher the water-soluble contrast medium meglumine et al., 1971; Christy et al., 1974). In all these cases iocarmate. on September 28, 2021 by the leptomeningeal changes were thought to be a result of a direct inflammatory effect of the iodised Case report compound. The patient was a 35 year old woman, with a Address for correspondence and reprint requests: Dr T. Staehelin except for transient biliary Jensen, Department of Neurosurgery, Arhus University Hospital, 8000 history of good health, Arhus C, Denmark. tract symptoms in 1968. Accepted 5 August 1977 In 1973 and 1974 she experienced transient re- 108 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.41.2.108 on 1 February 1978. Downloaded from Intraspinal arachnoiditis and hydrocephalus after lumbar myelography 109 lapsing lumbar pain, but was otherwise healthy nausea, and restlessness in her legs. At this time and fit. In October 1974, without preceding her temperature had fallen to 330C and later rose trauma, she developed acute pains in the right steadily to 39.3°. The next day the patient was lumbar region, radiating to the right leg. Three still in a poor condition; she was febrile with rest- months later she was admitted to the local less movements of all limbs, and a pronounced hospital with unaltered pain. Physical examination neck rigidity was noted. Apart from hypaesthae- showed a slightly weakened right patellar reflex, sia and hypalgesia in the perianal area, no neuro- but the neurological examination was otherwise logical deficit was found. No fluid could be re- normal. A lumbar disc herniation was suspected moved in repeated lumbar punctures. After eight and lumbar myelography using meglumine iocar- days her temperature was normal, but there was mate (Dimer-X) was carried out on 31 January still slight neck stiffness, and the patient com- 1975. Lumbar puncture and injection of the con- plained of headache which persisted unchanged trast medium was performed with the patient in a until she was discharged five weeks later. sitting position; the remaining part of the exam- During the subsequent months, the frequency ination was made with the trunk elevated 150. and intensity of headaches increased. Three The cerebrospinal fluid was clear, colourless, con- months after myelography she had bifrontal head- tained no cells, and the protein content was 0.33 ache daily accompanied by repeated vomiting, g/l. Dimer-X 5 ml diluted with 4 ml cerebrospinal and rapidly developing gait disturbances with fluid was injected. The contrast medium was not limb weakness and an unsteady gait. When the aspirated at the end of the examination. patient was admitted to the neurological depart- During myelography, which showed normal ment of Vejle County Hospital in May 1975, conditions, the contrast medium was seen to move physical examination revealed bilateral papil- guest. Protected by copyright. up to the level of the twelfth thoracic vertebra loedema (1-2 diopters). There was moderate (Fig. 1). spastic paresis of both legs and a bilateral sensory After myelography the patient was kept in a loss distal to the fourth thoracic dermatome. Her sitting position. A few hours after the examina- gait was spastic and ataxic, and a slight inco- tion, while still resting with the trunk and head ordination was also present in the upper extremi- elevated, she complained of intense headache, ties. A provisional clinical diagnosis was made of http://jnnp.bmj.com/ Fig. 1 Initial lumbar myelography with 5 ml Dimer-X, showing well-filled root pockets and normal appearances of fila radicularia. on September 28, 2021 by J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.41.2.108 on 1 February 1978. Downloaded from 110 T. Staehelin Jensen and 0. Hein a space-occupying lesion in the spinal canal and arachnoid membrane piece of tissue in which in the posterior fossa, and the patient was trans- arachnoid and dura mater were fused was obtained. ferred to the neurosurgical department of Odense Focal cell proliferation could be seen at the junc- County Hospital, where suboccipital ethyl mono- tion of the two membranes. There were no malig- iodostearate (Duroliopaque) myelography revealed nant changes nor any sign of acute inflammation, a complete obstruction at the level of the sixth and fungi and bacteria could not be demonstrated. thoracic vertebra (Fig. 2). Cerebrospinal fluid The histological findings were thus typical of a from the suboccipital level was clear and colour- chronic adhesive arachnoiditis. less; it contained 0.1 g/l of protein and there were During steroid treatment (dexamethasone), with no abnormal cells. a total dose of 200 mg during and after the operation, there was a marked but transient im- OPERATION provement in the patient's condition so that she Laminectomy of thoracic vertebrae 5-7 inclusive was able to walk, but three weeks after the opera- was performed on the day of admission. The tion there was a relapse. She had progressive arachnoid membrane was milky, greatly thickened paresis of the lower extremities and headaches, and adherent, with pouch formation partly to the culminating in unconsciousness lasting seconds to spinal cord and partly between the arachnoid and minutes accompanied by explosive vomiting. Intra- the dura mater. Adhesions continued both ventricular pressure was monitored continuously cranially and caudally. A biopsy sample of the and showed that these episodes of unconsciousness coincided with transient increases in pressure from 10-20 mmHg to some 90 mmHg. There was pro- gressive papilloedema (2-3 diopters), and fresh guest. Protected by copyright. retinal haemorrhages were seen. Ventriculography was carried out in June 1975 and showed that the supratentorial ventricular system was moderately dilated, whereas the fourth ventricle was filled and in normal position. No air passed into the cisterna magna or to the subarach- noid space as a whole, indicating a noncom- municating hydrocephalus. A ventriculoatrial shunt (Hakim-Cordis- Medium) was implanted three days after ventri- culography, and her condition gradually improved with intensive physiotherapy. Fifteen months later she is capable of walking with little difficulty,
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