Does myodil introduced for ventriculography lead to symptomatic lumbar arachnoiditis?

Unusual radiographic images of radiopaque contrast media incidentally observed in intracranial region: two case reports

The oil-based contrast medium has extremely slow clearance rate from cerebrospinal fluid. The medium known as myodil or pantopaque or iopenydylate was firstly introduced in 1944 to be used in myelography, cisternography and ventriculography. It was commonly used until 1980s but was later replaced by water-soluble mediums in 1990s because of its complication and sequelae. Although rare, images of the remnants may still be encountered on radiograms since its remnants may be seen after six decades. In this article, incidental radiopaque images in panoramic radiography and cone-beam computed tomography (CBCT) were presented in two patients whose myelography was taken before herniated discs' operation. Unusual incidental radiopacities in intracranial region were observed on panoramic radiography image of a male and CBCT image of a female, both of whom underwent myelography more than 30 years ago. Dentomaxillofacial radiologists should be aware of this radiographic appearance, should be able to differentiate it from possible pathologies.

Pantopaque contrast mimicking intracanalicular vestibular schwannoma

Pantopaque (iophendylate) is an oily contrast medium historically used during spine imaging. Due to its persistence in the subarachnoid space and the potential to lead to severe arachnoiditis, it is no longer used today. We present a 40-year-old male with new-onset headaches, imbalance, and vertigo. Brain magnetic resonance imaging revealed a 2-mm T1 -hyperintense intracanalicular lesion. Numerous hyperdense foci were scattered throughout the subarachnoid space on computed tomography. Further history revealed the patient received Pantopaque 30 years prior, after sustaining spinal trauma. Remnant Pantopaque contrast is an important differential when evaluating a patient with a suspected intracranial tumor in order to avoid unwarranted surgical intervention. Laryngoscope, 127:1916-1919, 2017.

Asymptomatic thoracic Pantopaque cyst mimicking an intradural extramedullary lipoma on MR images

OBJECTIVE

Oil-based contrast media such as Pantopaque have not used for imaging for several decades, but because these contrast media have an extremely low clearance rate, the remnant contrast media or residual sequelae of these materials may be encountered in the clinical field.

CLINICAL PRESENTATION

A 63-year-old woman presented to our hospital complaining of increasing lower back pain and lower extremity paresthesia with incontinence for 2 years. A plain X-ray film revealed single droplet-like mass at the lower thoracic T9-T10. A magnetic resonance image (MRI) study revealed a dorsally placed extramedullary intradural lesion, compressing the thoracic cord and minimally displacing it anteriorly. Spinal stenosis was also noted at the L4-5 level.

INTERVENTION

The patient was performed for two consecutive surgeries. Total laminectomy was performed at T9-T10 to remove mass. A 0.5 × 0.5 × 4 cm yellowish intradural extramedullary cystic mass was removed without any leakage of cystic contents. Partial hemi-laminectomy and foraminotomy was then done at L4-5 levels for radiculopathy symptom relief. The fluid from the cyst was composed mainly of iodide.

CONCLUSION

Intraspinal masses showing metal-like density in X-ray or computed tomography but in MRI showing only lipoma or cystic lesions, not metallic characteristics, the differential diagnosis should include iophendylate (Pantopaque) cyst. Oil-based contrast medium is believed to have the potential to make a syrinx formation via arachnoiditis, which can lead to severe neurologic deteriorations, so even if the patients do not represent with an acute neurologic deficit, surgical total removal of remnant material without leaking should be considered.

Thoracic spinal iophendylate-induced arachnoiditis mimicking an intramedullary spinal cord neoplasm. Case report

Iophendylate (Pantopaque or Myodil) was commonly used from the 1940s until the late 1980s for myelography, cisternography, and ventriculography. Although such instances are rare, several different long-term sequelae have been described in the literature and associated with intrathecal iophendylate. The authors describe an unusual case of arachnoiditis caused by residual thoracic iophendylate imitating an expansile intramedullary lesion on magnetic resonance images obtained 30 years after the initial myelographic injection.

Syringomyelia caused by intrathecal remnants of oil-based contrast medium

✓ Oily contrast medium had been in use since the early 19th century as a radiographic agent for detecting spinal lesions and spinal cord tumors until the late 20th century. At that point computed tomography scanning and magnetic resonance imaging, or other hydrophilic contrast medium substituted for it. Adverse effects of oil-based dye, both acute and chronic, had been reported since the middle of the 20th century. In this paper the authors report the case of syringomyelia that seemed to be caused mainly by remaining oily contrast medium for 44 years.

Syringomyelia secondary to adhesive arachnoiditis caused by oily contrast medium after a long period of time is well known. In the present case, however, surgery revealed only mild arachnoiditis at the level of syringomyelia as well as both solid and liquid remnants of contrast medium.

Generally, cerebrospinal fluid (CSF) blockage due to an arachnoid adhesion is considered to cause syringomyelia following adhesive arachnoiditis. The authors speculated that in the present case syringomyelia was induced by a mechanism different from that in the previously reported cases; the oily contrast medium itself seems to have induced the functional block of CSF and impaired the buffer system of the intrathecal pressure. No reports on thoracic adhesive arachnoiditis and syringomyelia caused by oil-based dye referred to this mechanism in reviewing the literature.

Arachnoiditis ossificans with progressive syringomyelia and spinal arachnoid cyst

We present a 30-year-old man with progressive spastic paraparesis. Spinal imaging revealed extensive calcification of the thoracic cord and cauda equina arachnoid, an intradural extramedullary cyst and evidence of rapidly progressing syringomyelia. Radiological diagnosis was arachnoiditis ossificans and an attempt at surgical decompression was made because of progressive neurologic deterioration. Due to tenacious adhesion of the calcified plaques to the cord and roots, only cyst drainage was achieved; the patient had no clinical improvement. A literature review revealed only two other cases reported in the literature with co-existence of arachnoiditis ossificans and syringomyelia. In none of the previous cases was there an intradural extramedullary arachnoid cyst, nor did the syrinx progress in such a rapid fashion. An attempt is made to explain possible pathophysiological mechanisms leading to this unusual pathology.

Cord compression secondary to intradural ossification

The authors describe two patients presenting with a previous history of spinal trauma and a several-year history of sensory changes secondary to spinal cord compression. Both patients underwent laminectomy and spinal decompression operations. In both cases intradural bone causing neural compression was removed at operation. Potential mechanisms to explain intradural ossification and the relevant literature are reviewed.

Granulomatous meningitis as a late complication of iodized oil myelography

The present report is an autopsy case of an 83 year old man with severe kyphoscoliosis and granulomatous meningitis as a late complication of iodized oil myelography. He suffered from mild cognitive impairment and died of pneumonia. At autopsy, the brain showed yellow-brown granular material on its surface, mainly in the Sylvian fissure. Microscopically, granulation tissue was seen around areas of ossification encasing the foreign material. Iodized oil apparently changed into two types of foreign bodies: eosinophilic membranous lipodystrophy-like features and homogenous yellow crystals of various sizes. The pathology was identical to foreign-body granulomatous meningitis, caused by iodized oil myelography, and caused cognitive impairment in this patient.

Arachnoiditis ossificans of the cauda equina

✓ The authors describe a case of arachnoiditis ossificans (AO) of the cauda equina. The lesion is a rare pathological entity usually confined to the thoracic and high lumbar regions that can cause progressive spinal cord and cauda equina compression, inducing severe neurological deterioration. The authors analyze the clinical symptoms, radiological features, histological data, and treatment options relating to this case and 13 others described in the literature; additionally, they consider the possible mechanisms responsible for ossification of the leptomeninges. Although clustered arachnoidal cells are usually implicated in its pathogenesis, an environment induced by arachnoiditis and disturbed cerebrospinal fluid flow appears to be a more important factor. A therapeutic strategy is proposed for AO for which no effective treatment currently exists.

Aracnoidite constritiva causada por pantopaque resultando em siringomielia e paraparesia: relato de caso

Relatamos caso de aracnoidite constritiva torácica, verificada 10 anos após o uso de pantopaque, que foi utilizado em mielografia no diagnóstico de cisto aracnóideo.

Arachnoiditis associated with arachnoid cyst formation and cord tethering following myelography: magnetic resonance features

The reported incidence of clinically significant arachnoiditis following oil-based contrast media myelography is approximately 1%. The incidence of arachnoiditis in the dorsal spine is even more rare. Acquired arachnoid cyst formation can occur with arachnoiditis of various aetiologies. A case is presented of a patient with chronic backache, radiculopathy, weakness and muscle wasting, who had undergone myelography with oil-based contrast media about 28 years ago. There was no history of spinal surgery, spinal canal stenosis, disc disease or trauma, all of which are known to increase the risk of arachnoiditis. Magnetic resonance imaging features are presented in this case of arachnoiditis with arachnoid cyst formation, and cord tethering.

Symptomatic lumbar spinal arachnoiditis: fact or fallacy?

It is generally accepted that chronic adhesive lumbar arachnoiditis is a cause of symptoms, notably back pain and/or pain (of almost any type, not necessarily 'anatomical') in the lower limbs, although there is no clearly defined clinical pattern which is clearly associated with this syndrome. There is no doubt that arachnoiditis occurs as a pathological and radiological entity due to a number of causes. In the view of the present authors, the nexus between the pathology and radiology on the one hand, and the patients' symptoms on the other hand, has not been demonstrated with any degree of scientific rigor.

Arachnoiditis ossificans of the cauda equina demonstrated on computed tomography scanogram. A case report

STUDY DESIGN

This case report illustrates a patient with arachnoiditis ossificans of the cauda equina of sufficient severity to be demonstrable on a computed tomography scout view.

OBJECTIVES

The diagnosis of extensive arachnoiditis ossificans by computed tomography does not necessitate surgical intervention. The authors patient had only mild, chronic symptoms when treated expectantly.

SUMMARY OF BACKGROUND DATA

The value of axial computed tomography in visualizing and characterizing the lesions of arachnoiditis ossificans has been well documented. Arachnoiditis ossificans involving the cauda equina is uncommon. To the authors' knowledge, this report represents the first case of arachnoiditis ossificans of the cauda equina in which the arachnoid calcifications were of sufficient density to be obvious on a computed tomography scan.

METHODS

The patient was reviewed by a neurologist for paraesthesia in his right foot, occasional backaches, and urinary frequency. Physical examination revealed only a mild loss of lumber lordosis and an area of hypoesthesia in the right foot. He then was investigated with computed tomography, which showed extensive arachnoiditis ossificans. Because his symptoms were mild, surgery was not contemplated.

RESULTS

The patient's symptoms remained minimal despite being treated conservatively.

CONCLUSIONS

The value of computed tomography in delineating the lesions of arachnoiditis ossificans and the outcome of surgery for resection of its compressive osseous plaques have been well described. Despite extensive arachnoid calcification caused by arachnoiditis ossificans involving the cauda equina that was visible on a computed tomography scan, this patient continued to have only low-grade symptoms when treated conservatively.

Patterns of chronic adhesive arachnoiditis following Myodil myelography: the significance of spinal canal stenosis and previous surgery

109 patients who had undergone Myodil myelography on at least one occasion were identified. The patterns of lumbar nerve root distribution in this group were examined using magnetic resonance imaging. The relationship between these patterns and the presence of spinal stenosis or previous surgery was investigated. Chronic adhesive arachnoiditic nerve root patterns were seen in 68 patients and were classified into three groups according to Delemarter et al. Central clumping of nerve roots (type 1) and complete opacification of the thecal sac (type 3), extending over at least one vertebral level, were significantly related to spinal stenosis at an adjacent level (p < 0.0001). Peripheral adhesion of nerve roots to the theca (type 2) was significantly related to previous surgery at the level of abnormality (p < 0.00005). Only a single case of arachnoiditic nerve root patterns was seen in the absence of stenosis or previous surgery. We conclude that chronic adhesive arachnoiditis is significantly related to previous Myodil myelography in the presence of spinal stenosis or previous surgery but that Myodil alone rarely produces these changes.