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Tools for the Diagnosis and Management of Nervous System Diseases
Published in Philip B. Gorelick, Fernando D. Testai, Graeme J. Hankey, Joanna M. Wardlaw, Hankey's Clinical Neurology, 2020
William McAuliffe, Elizabeth Berry-Kravis, Gian D. Pal, Deborah A. Hall
CT myelography is used in conjunction with myelography after X-ray contrast is instilled into the spinal CSF via LP. Helical CT datasets are acquired with multiplanar reconstructions. Excellent detail is given in relation to the intrathecal nerve roots and the bony anatomy (Figures 2.45–2.48). The outline of the cord is demonstrated, but intrinsic signal abnormality within the cord is not perceptible and is much more easily defined with MRI.
Central nervous system
Published in A Stewart Whitley, Jan Dodgeon, Angela Meadows, Jane Cullingworth, Ken Holmes, Marcus Jackson, Graham Hoadley, Randeep Kumar Kulshrestha, Clark’s Procedures in Diagnostic Imaging: A System-Based Approach, 2020
A Stewart Whitley, Jan Dodgeon, Angela Meadows, Jane Cullingworth, Ken Holmes, Marcus Jackson, Graham Hoadley, Randeep Kumar Kulshrestha
Myelography is the radiographic investigation of the spinal canal. It requires the injection of a water-soluble, non-ionic contrast agent into the subarachnoid space, usually via a lumbar puncture. The contrast agent mixes with the CSF as it flows along the subarachnoid spaces. By tilting the imaging table into the various positions, the full extent of the spinal cord and nerve roots can be examined. It is recommended that cervical and thoracic myelography be carried out at specialised neuroradiology centres with immediate access to CT and only if MRI is unavailable or contra-indicated (e.g. pacemaker in situ).
Sally’s Story: Opioid Usage Over a Number of Years in a Chronic Pain Patient
Published in Michael S. Margoles, Richard Weiner, Chronic PAIN, 2019
He used water-soluble dye for the myelogram. Routine myelography views and CT scan views were taken during the procedure. The myelogram showed an extruded disc fragment (ruptured disc) in the space between the L4 and L5 disc spaces. It was obvious that the fragment had ruptured at the L4–5 level and then began to travel downward. It appeared to be resting against the L5 nerve root. The cause of her enhanced right leg pain had been found.
Migration of lipiodol into lateral ventricles after embolization of cerebral arteriovenous malformation: a case report
Published in British Journal of Neurosurgery, 2023
Mamoru Murakami, Gaku Fujiwara, Daisuke Maruyama, Yujiro Komaru, Nobukuni Murakami
We suspect the patient developed pyrexia from chemical meningitis due to lipiodol in the lateral ventricle. Iophendylate, known as pantopaque in the USA or myodil in the UK, is an oil-based contrast material. It was widely used as a contrast agent for myelography in addition to lipiodol until the 1980s, but it is no longer used because oil-based contrast medium has a low clearance rate from the CSF, which raised concerns about the development of arachnoiditis.4 Indeed, intracranial migration of iophendylate four decades after conventional myelography was reported.5 Fifty-six of 119 patients who had undergone myelography had acute symptoms following injection of the unabsorbed contrast material.4 Headache, nausea, vomiting, and giddiness were common, and pyrexia was observed in 10 of the 56 patients, persisting for an average of three days.4 Our patient exhibited pyrexia above 38.5 degrees for 2 weeks, which was eventually cured by corticosteroid administration for one month. Based on the examination of CSF with an increased white blood cell count, especially eosinophils, pyrexia was likely caused by chemical meningitis due to lipiodol rather than inflammatory reaction to intraventricular hemorrhage.
Cranial Polyneuropathy Secondary to Remote Iophendylate Myelography
Published in Neuro-Ophthalmology, 2022
Iophendylate (Pantopaque® in the USA; Myodil in the UK), was an oil-based contrast medium widely used for myelography and ventriculo-cisternography beginning in the 1940s and continuing until the era of CT scanning, when water-soluble iodinated contrast began to be used. It was popular for many years because it was considered safer than other agents at the time. The major problem with this agent, however, was its poor absorption, clearing at a rate of 0.5 to 3 ml per year.3 In general, great care was taken to aspirate completely the iophendylate after myelography, but this usually was not possible. Acute adverse events could occur as early as an hour or two after myelography and included fever, neck stiffness, cranial nerve palsies, optic neuritis, cortical blindness, dizziness, and myelopathy.1,4–6 Chronic retention usually manifested as an adhesive arachnoiditis that often was asymptomatic; however, in 1–2% of individuals, it caused non-specific lumbosacral back pain, urinary retention, progressive myelopathy, hydrocephalus, brainstem dysfunction, and/or seizures, years after initial exposure.7–10 For example, the patient reported by Pascuzzi et al.8 experienced seizures attributed to iophendylate 10–15 years after myelography, whereas the patient reported by Huang et al.9 developed iophendylate-induced arachnoiditis mimicking an intramedullary spinal cord tumour 30 years after myelography. In all cases, residual iophendylate was present in the subarachnoid space adjacent to the area of dysfunction.
Current perspectives on the recognition and diagnosis of low CSF pressure headache syndromes
Published in Expert Review of Neurotherapeutics, 2022
Nikolaos Giagkou, Ioanna Spanou, Dimos D. Mitsikostas
SIH remains the most emblematic low CSF pressure headache syndrome. Recently, familiarity with SIH has greatly increased, improving the diagnosis, but the condition can still go unnoticed. Cases with less intense headache and without sudden onset are at increased risk. This is also true for cases not exhibiting the characteristic pachymeningeal enhancement. For this reason, patients presenting with headache should always be enquired about any postural changes in their symptoms. Eliciting a history of orthostatic headache, currently or at the beginning of symptoms, is the surest way to a diagnosis as this will lead to the appreciation of subtler, compared to the difficult-to-miss pachymeningeal enhancement, signs on neuroimaging that will confirm the presence of the condition. Even after the possibility of SIH has been considered, diagnostic challenges remain, especially when brain and spinal MRI and CSF opening pressure are all without definite findings. These patients will require specialized spinal imaging that might not be readily accessible and is interventional (CT myelography, Digital subtraction myelography) [95]. Accessibility to specialized imaging also becomes important for patients with confirmed low CSF pressure headache syndromes that do not respond to blind EBP treatment. In these cases, targeted treatment either with blood or sealant, or with surgery is needed, but for targeted treatment to be offered, the specific pathology and site causing the leak must be first identified.