Fatal complications after myelography with meglumine diatrizoate

Inadvertent intrathecal injections and best practice management

The intrathecal space has become an important anatomic site for medical intervention not only in anesthesia practice, but also in many other medical specialties. Undesired/inadvertent intrathecal injections (UII) are generally rare. There is tremendous variation in reported inadvertent administrations via an intrathecal route in the literature, mainly as individual cases and very small case-series reports. This review aims to identify potential sources of UII, its clinical presentations, and appropriate management. The inadvertent injectants are classified as anesthetic agents and pain medicines, chemotherapeutics, radiological contrast agents, antibiotics and corticosteroids, and miscellaneous chemical agents such as tranexamic acid. The clinical effects of UII are dependent upon inadvertent injectant(s) and dose being administered intrathecally, and can range from no adverse effect to profound neurological consequences and/or death. Prompt cerebrospinal fluid (CSF) lavage and cardiopulmonary support seem to be the mainstay of treatment. If serious consequences are anticipated, CSF lavage could be lifesaving. This review additionally provides some options for comprehensive management and preventing strategies.

Accidental Intrathecal Injection of Ionic Contrast: Case Report and Review of the Literature

BACKGROUND

Ionic contrast, if accidentally injected into the intrathecal space during routine imaging studies or interventional procedures, may significantly interfere with neuronal activity, potentially causing ascending tonic-clonic seizure syndrome and even death. As a result, ionic contrast is strictly contraindicated for intrathecal use. Rapid recognition of the condition followed by prompt management, typically involving aggressive cerebrospinal fluid (CSF) drainage, is critical to improving patient outcome. Lumbar drain has previously been well described as a management strategy.

CASE DESCRIPTION

We present a case of accidental intrathecal injection of an ionic contrast agent, iothalamate meglumine, in a patient undergoing cervical epidural steroid injection. This patient was managed successfully with drainage of CSF using an external ventricular drain alone.

CONCLUSION

Our literature review and analysis of the previously published cases demonstrate that aggressive CSF drainage is essential to improve outcomes, and in some cases an external ventricular drain alone may be effectively used.

Malignant Cerebral Edema following CT Myelogram Using Isovue-M 300 Intrathecal Nonionic Water-Soluble Contrast: A Case Report

Lumbar myelogram utilizing nonionic contrast is a commonly performed procedure to identify spinal pathology. Complication rates are low. Cerebral edema has been shown to occur following intrathecal injection of ionic contrast; however, no current literature has documented this complication relating to the ubiquitously used nonionic contrast medium. We report a case of a patient who developed malignant cerebral edema following a lumbar myelogram with Isovue-M 300 nonionic water-soluble intrathecal contrast. We believe this is the first reported case of cerebral edema resulting from the use of a nonionic contrast.

Inadvertent intrathecal administration of ionic contrast medium to a dog

A hyperosmolar ionic contrast medium, ioxithalamate (Telebrix), was inadvertently injected intrathecally to a dog during myelography. The resultant severe adverse effects were myoclonus, uncontrollable seizures, and hyperthermia. These symptoms have been described by some authors as "ascending tonic-clonic seizure syndrome". The dog completely recovered within 24 h. The literature on 47 humans receiving intrathecal ionic contrast medium after 1966, one dog and one horse was reviewed, including the drugs involved, the circumstances of their use, and the symptoms, treatment and outcome of patients who received the drugs intrathecally. Recommendations to prevent such a misuse are given. The present report and review are a reminder that ionic contrast media are absolutely contraindicated for myelography. Only nonionic contrast media can be used intrathecally. All of the hyperosmolar contrast media are ionic and therefore contraindicated for myelography.

FDA Requirements for Manufacturer Labeling of Oral Iron Products Need Upgrading Intrathecal Injection of Ionic Contrast Media may be Fatal

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs.

Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program, which is presented in cooperation with the Institute for Safe Medication Practices. If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800-233-7767 (800-23-ERROR).

Any reports published by ISMP will be anonymous. Comments are also invited; the writers’ names will be published if desired. ISMP may be contacted at the address shown below.

Fatal ascending tonic-clonic seizure syndrome

A fatal case of ascending tonic-clonic seizure (ATCS) syndrome resulted from the inadvertent, unrecognized use of a hyperosmolar ionic contrast agent during myelography. The patient presented with lower-extremity myoclonic jerking, agitation, hyperthermia, rhabdomyolysis, and disseminated intravascular coagulation. Emergency physicians must be cognizant of this unique toxidrome to initiate early, aggressive care.

Symptomatic spinal intradural arachnoid cyst development after lumbar myelography. Case report and review of the literature

STUDY DESIGN

This case report describes the unique occurrence of acquired intradural spinal arachnoid cyst after lumbar puncture, which was proven radiographically and surgically.

OBJECTIVES

To review and explore complications of lumbar puncture in the context of subsequent cyst development and to review the incidence, presentation, pathogenesis, and management of spinal intradural arachnoid cysts.

SUMMARY OF BACKGROUND DATA

The etiology of the spinal intradural arachnoid cyst remains obscure; some such cysts are ascribed anecdotally to previous trauma or arachnoiditis, whereas the majority are idiopathic and assumed by many authors to be congenital.

METHODS

A 20-Year-old woman with back and leg pain underwent lumbar myelography that yielded normal results with no evidence of arachnoid cyst at that time. Within 5 months, clinical symptoms of cauda equina compression and an S1 radiculopathy developed. Subsequent myelography and magnetic resonance imaging revealed a lumbar spinal arachnoid cyst. There was no history of intervening trauma or arachnoiditis. The lumbar puncture was thought to be the cause of the arachnoid cyst.

RESULTS

A laminectomy was performed with complete excision of the arachnoid cyst. The patient had an unremarkable postoperative course with excellent relief of her symptoms.

CONCLUSIONS

This case provides supporting evidence for the traumatic etiology of spinal intradural arachnoid cyst. The development of an intradural spinal arachnoid cyst should be included as a possible complication of lumbar puncture.

Spinal myoclonus following intrathecal administration of diatrizoate meglumine

Life-threatening myoclonus developed in a patient following inadvertent intrathecal usage of 60% diatrizoate meglumine. Rhabdomyolysis and myoglobinuria occurred. The patient was successfully treated with midazolam and vecuronium and complete recovery occurred.

Intrathecal injection of high-dose meglumine amidotrizoate with complete recovery

Rarely we are faced with accidental spinal injection of potentially toxic substances. We present 2 cases in which amidetrizoate, water-soluble ionic contrast medium, was accidentally injected intrathecally. Our treatment consisted of vigorous hydration and barbiturate coma. This report suggests that for water-soluble ionic contrast media increasing cerebrospinal fluid circulation by vigorous hydration may be as effective as spinal lavage in diminishing toxicity.

Serious or fatal complications after inadvertent administration of ionic water-soluble contrast media in myelography

The consequences of the inadvertent administration, by the intrathecal route, of ionic contrast media instead of iopamidol in seven subjects are reported. The ionic compounds were diatrizoate, iodamide and ioxitalamate. The outcome was fatal in three out of seven subjects, and it depended on the type and the dose of the administered contrast agent. The serious or fatal reactions observed are a tragic confirmation of the predictive power of neurotoxicity data obtained in animal studies with various iodinated water-soluble compounds. The margin of safety, represented by the ratio of LD50 i.ce. in mice to clinical dose in humans, both normalized to bodyweight, appears to reliably reflect the risk of toxic reactions after intrathecal administration of iodinated contrast agents.

Post-myelographic meningeal irritation with iohexol

A 45-year-old woman developed signs of meningeal irritation after myelography with iohexol. Her condition improved very quickly (after antibiotic treatment). Rapid improvement, absence of pathogenic organisms in the pre-treatment CSF culture, the level of CSF pleocytosis and protein were in favor of chemical meningitis.