대 한 방 사 선 의 학 회 지 1993 ; 29 (3) : 391 ~393 Journal of Korean Radiological Society, May, 1993 Severe Aseptic Meningitis with Hydrocephalus Following Iotrolan Myelography: A Case Report Jae Hyoung Kim, M.D., Choong Kun Ha, M.D.*, In Oak Ahn, M.D. Dψartmeη t 0/ Diagnostic Radiology, Gyeongsang National University, College 0/ Medicine - Abstract- A case of severe aseptic meningitis with communicating hydrocephalus following iotrolan myelography is presented. The patient’s condition improved veη quickly after corticosteroid therapy. Rapid improvement and absence of pathogenic organisms in the CSF cu\ture strongly favor an aseptic meningitis. This is the first re­ ported case of aseptic meningitis with the secondaη development of hydrocephalus caused by iotrolan myelography Index Words: Contrast media, complications 10.448 Myelography, complications 30.446, 30.1222 Aseptic meningitis as a complication of derwent cervica1 myelography using lumbar myelography has been reported verγ rarely (1 -3) puncture technique because of persistent pares­ since metrizamide was replaced with new non­ thesia in both upper extremities. Before instilla­ ionic contrast media such as iopamid이， iohexol tion of 15ml of iotrolan (Isovist, Schering AG, and iotrolan, Iotrolan is a new contrast medium Berlin; 240mg Ij ml), the patient did not have with a non-ionic dimer of triiodinated benzene any signs or symptoms of meningitis. The cere­ ring. Recently we have experienced a severe brospinal fluid (CSF) obtained during the proce­ aseptic meningitis with hydrocephalus developed dure was c1ear. Mter myelography, the patient after iotrolan myelography. Only one case of rested in a supined position with the head elevat­ 0 mild aseptic meningitis associated with iotrolan ed 15-30 • myelography was reported in 1991 (4). This is Next morning after myelography, the patient the first reported case of aseptic meningitis with complained of headache, high fever (40 0 C) and the secondarγ development of hydrocepha1us neck stiffness. Over the next severa1 hours he de­ caused by these new non-ionic contrast media. veloped loss of bilateral pupillarγ light reflexes, left herniparesis and increased deep tendon re­ CASE REPORT flexes in a11 extremities, 없ld became drowsy Under the impression of iatrogenic bacterial A 49-year old man, who had a previous cervi- meningitis or aseptic meningitis, CT examination cal spina1 operation for C4j C5 dislocation, un- was performed, which showed a moderate degree *경상대학교 의과대 학 신경과학교실 * Department 0/ Neμ rology， Gyeongsaηg National University, College 0/ Medicine 이 논문은 199 2 년 11 월 17 일 접수하여 199 3 년 2 월 22 일에 채택되었음 . Received November 17, 1992, Accepted February 22, 1993 - 391 - Journal of Korean Radiological Society 1993 ; 29 (3) : 391 ~393 Fig. 1. CT scan one day after myelography shows moderate com­ municating hydrocephalus with obliteration of extracerebral sub­ archnoid spaces. Enhanced CT scans (not shown) showed no ab­ normal enhancement around basal Clsterns. Fig. 2. On CT scan seven days after myelography, hydrocephalus is decreased and extracerebral sub­ arachnoid spaces are well visual­ ized. 1 2 of communicating hydrocephalus with oblitera- phalus (Fig. 2) . tion of the extracerebral subarachnoid spaces (Fig. 1). A lumbar puncture was performed, and DISCUSSION the CSF appeared turbid and xanthochrornic. The CSF pressure was 200mm H 20 with non­ Hydrophilicity and osmolality of contrast physiologic Q-test. A WBC count was more than media are important factors in producing the 2000jml with 95% polymorphonuclear leukocyte, side effects associated with myelogarphy. Since with a protein level of 269 mgj dl, and glucose the advent of new non-ionic myelographic con­ level of 8mgj dl. After the cultures of CSF and trast media such as ioparnid이， iohexol and blood were done, we adrninistered both antibiot- iotrolan with high hydrophilicity and low ics and corticosteroid. osmolality, side effects after myelography have Two days later the patient markedly im­ been decreased. Iotrolan is highly hydrophilic proved; the mental status became alert, bilateral and has nearly the same osmolality as CSF and pupillaπ reflexes were normalized, and left blood in a concentration up to 30mg Ij ml, that herniparesis disappeared. Headache, rnild fever is , approximately half that of ioparnidol and and neck stiffness were still persistent. This dra­ iohexol. In regard to aseptic meningitis as a com­ matic clinical improvement led us to strongly plication of myelography, its exact cause is still consider the possibility of aseptic meningitis, and unknown although the toxic effect of contrast antibiotics was discontinued. media itself (6) and contrast media-induced im­ The results of CSF and blood cultures mune mechanism (5 ,7) have been suggested. showed no pathogenic organisms. The patient Sand et al mentioned that previously undergone was completely symptom-free seven days after myelography or spinal operation may be risk fac­ myelography when the CSF was clear and its tors concerning development of aseptic meningi­ pressure was 170mm H 20 with physiologic Q tis (6). However, their cases were too small for test. A WBC count was 42j ml with predorninant their concept to be accepted. Kelly et al de­ mononuclear leukocyte. The protein and glucose scribed that hydroce-phalus accompanying asep­ levels were within normal range. Follow-up CT tic menigitis was probably caused by immunologi­ exarnination performed seven days after myelo­ cally mediated generalized arachnoiditis (5) . graphy showed markedly decreased hydroce- Hydrocephalus is thought to be a result of severe …@ Jae Hyoung Kim , et al : Severe Aseptic Meningitis with Hydrocephalus Following lotrolan Myelography arachnoiditis in aseptic meningitis. fect of intrathecal iohexol on visual evoked Clinical features of aseptic meningitis are sim­ response latency: a comparison including inci­ ilar to those of bacterial meningitis following dence of headache with iopamidol and metri­ zamide in myeloradiculography. Clin Radiol 1987; myelography (8). Although, in general, symptoms 38:7_1-74 of bacterial meningitis often seem to occur later 2. Alexiou J , Deloffre D, Vandresse J-H, Boucquey (i.e. 24-96 hours) and persist longer than those J-p, Sintzoff S. Post-myelographic meningeal irri­ of aseptic meningitis (6), the differentiation be­ tation with iohexol. Neuroradiol 1991; 33:85-86 tween these two types of meningitis is difficult 3. Lee DK, Yi SD, Park YC. A case of aseptic puru­ both clinically and on the CSF profile. Only the lent meningitis complicationg Niopam CT result of CSF and blood cultures can make a dif­ cisternography. The Joumal of the Korean Neu­ ferential diagnosis. Therefore, rapid improve­ rological Association 1988; 6:78-82 ment of the patient’s condition and absence of 4. Nak와‘oshi T , Moriwaka F, Tashiro K, et al. Asep­ pathogenic organisms in the CSF, as in our case, tic meningitis complicating iotrolan myelography. AJNR 1991; 12:173 are in favor of aseptic meningitis. 5. Kelley RE, Daroff RB , Sheremata WA, McCor­ The effect of corticosteroid in treatment of mick JR. Unusual effects of metrizamide lumbar aseptic meningitis is not certain although a few myelography. constellation of aseptic meningitis, reports have described its effectiveness (5 ,7). It is arachnoiditis, communicating hydrocephalus, and usu꾀 ly recommended that all patients with asep­ Guillain-Barre syndrome. Arch Neurol 1980; 37: tic meningitis following myelography should ini­ 588-589 tially be treated with antibiotics until the result 6. Sand T, Anda S, Hellum K, Hesselberg JP, Dale of CSF culture is available (6). L. Chemical meningitis in metrizamide myelo­ Although the causative mechanism of aseptic garphy: report of seven cases. N euroradiol 1986; 28:69-71 meningitis following myelography is not certain, 7. Weissman BM. Delayed onset of dexamethasone­ iotrolan may cause severe aseptic meningitis and dependent cerebral dysfunction following metri­ the possibility of this complication should be kept zamide myelography. Arch Neurol 1984; 4 1: 569 in mind. 570 8. Schlesinger JJ, Salit IE, McCormack G. Strepto­ REFERENCES coccal meningitis after myelography. Arch Neurol 1982; 39:576-577 1. Broadbridge AT, Bayliss SG, Brayshaw CI. The ef- 〈국문 요약〉 lotrolan 척추강조영술 후 수두증을 동반한 중증 무균성 뇌막엽의 발생 : 증례 보고 경 상대학교 의과대학 진단방사선 과학교실 ， 신경과학교실* 김 재 형 • 하 충 건 * . 안 인 옥 경추부 탈골 수술을 받은 49세 남자 환자에샤 Iotrolan 척추강조영술 후 발생한 수두증을 동반하는 중증 무균성 뇌막염 1 례를 보고한다. 환자는 척추강 시행 다음날 부터 갑작스런 고열， 뇌막자극 증후， 의식의 저하， 대광반사 소 실 및 건반사 증가 등의 소견을 나타냈으며 전산화단층촬영에서 뇌실 확장 소견을 보였다 . 뇌척수액은 전형적인 세 균성 뇌막염 소견을 보였으나 균은 동정되지 않았고 ， 스테로이드 투여 후 1 일 만에 급 속한 상태 호전을 보여 무균성 뇌 막염 임 을 시 사하였다. 수두증을 동반한 무균성 뇌 막염 은 Me tri z amid e 를 재 외 하면 Iopamidol, Iohexol , Iotrolan 등이 사용된 이래로는 첫번째 보고이다 . n m ο 빙 국제방사선 종양학회 총회 장 소 : 일본 교또 기 간 : 93 년 6 월 21 일 -6월 25 일 제 8차 International Congress on the Ultrasonic Examination of the Breast 장 소 : Heidelberg( 독일) 기 간 : 93 년 7 월 1 일 -7월 4 일 문 의 : 연세의대 영동세브란스 오기근 교수 TEL: 569-0110( 교 3111, 2532) World Federation for ULS in Med. & Bio 장 소 : 일본 삿뽀로 기 간 : 93 년 7 월 17 일 -7월 22 일 20th Annual Refresher Course International Skeletal Society venue: Westin Harbour Cast!e Hote!, Toronto, CANAND contact : Dawne Rya!s, Rya!s and Associates, lnc. , P.O.Box 1925, Roswell, GA30077 -1925,USA.(Tel : 404 -641 -9773, Fax : 404-552 -9859 )1 993/8/ 18-21 E.C.R. 장 소 : 비엔나 기 간 : 93 년 9 월 12 일 -9월 17 일 International Diagnostic Radiology Conference 장 소 : Sa!zburg( 오스트리아) 기 간 : 93 년 9 월 19 일 -9월 24 일 N euroradiologicum 장 소:구마모또 기 간 : 93 년 9 월 25 일 - 10 월 1 일 ULS in Med. & Rad. 장 소 : lnsbruck( 오 스트리 아) 기 간 : 93 년 10 월 12 일 - 10 월 17 일 RSNA 장 소: 시카고 기 간 : 93 년 11 월 28 일 - 12 월 3 일 394 -.