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.

Long-term outcome of embolotherapy and surgery for high-flow extremity arteriovenous malformations.

PURPOSE: To assess the long-term efficacy of embolotherapy in combination with surgery for management of symptomatic high-flow arteriovenous malformations (HFAVMs) of the lower and upper extremities. MATERIALS AND METHODS: Twenty consecutive patients with symptomatic high-flow lower extremity AVMs (LE-AVMs; n = 9) and upper extremity AVMs (UE-AVMs; n = 11) were treated from 1982 to 1999. All nine patients with LE-AVM had pain and seven had ulceration of the skin. All 11 patients with UE-AVM had debilitating pain, seven had weakness of the affected hand, and two had bony erosion. Embolization of the nidus beneath the site of maximum pain or ulceration was performed percutaneously from the femoral artery through coaxially placed microcatheters (n = 18) or surgical cutdown (n = 2). Cyanoacrylate (isobutyl or n-butyl) diluted with iophendylate or ethiodized oil was used in 19 of 20 patients. RESULTS: Follow-up was completed in eight of nine patients with LE-AVM (mean, 8.6 y) and nine of 11 patients with UE-AVM (mean, 7.4 y) after treatment. One patient with localized LE-AVM was functioning well 13 years after embolotherapy and another was functioning well 16 years after undergoing three embolotherapy procedures and two skin grafts. Five of nine patients with LE-AVM required below-the-knee (n = 4) or above-the-knee (n = 1) amputation 1-6 years after technically and clinically successful embolotherapy. All three trifurcation arteries were diffusely involved in HFAVM in patients requiring amputation. Healing of the two amputation sites, involved by AVM at the knee, was excellent after preoperative geniculate artery embolotherapy. All 11 patients with UE-AVM experienced marked symptomatic improvement; seven after embolotherapy alone and the other four after resection of AVM. One complication of digital spasm was reversed by administration of nerve blocks. CONCLUSIONS: LE-AVM with diffuse involvement of all three trifurcation arteries ultimately required amputation because of recurrence of symptoms after technically and clinically successful embolotherapy. Cyanoacrylate embolotherapy alone or in combination with surgical resection of the AVM provided excellent long-term palliation in patients with UE-AVM.

Ethanol sclerosis of a mediastinal cyst.

The authors report a mediastinal cyst treated by aspiration and ethanol sclerosis, which were performed under ultrasonographic guidance. Mediastinoscopy and thoracotomy were thus avoided. One year later there had been no recurrence of the cyst or any symptoms.

Prolongation of epidural anesthesia using a lipid drug carrier with procaine, lidocaine, and tetracaine.

This study evaluated the effect of a lipid drug carrier (iophendylate) on epidural anesthesia. The intensity and duration of motor blockade produced by aqueous and lipid preparations of local anesthetics were assessed in rabbits with long-term indwelling catheters in the epidural space. Motor blockades produced by procaine (1%, 2%, and 4%), lidocaine (1%, 2%, and 4%), and tetracaine (0.5%, 1%, and 2%) in normal saline solution were compared with the effects produced by equimolar amounts of the drug solutions in iophendylate. Procaine (4%) in aqueous solution produced motor blockade lasting 30 +/- 3.54 min (mean +/- SD) versus 84 +/- 4.18 min in lipid solution. Lidocaine (2% and 4%) in aqueous solution produced motor blockade lasting 41 +/- 4.18 and 65 +/- 6.12 min versus 39 +/- 4.18 and 118 +/- 10.1 min, respectively, in lipid solution. Aqueous tetracaine (0.5%, 1%, and 2%) produced motor blockade of 106 +/- 9.62, 189 +/- 6.52, and 273 +/- 26.8 min versus 284 +/- 14.7, 335 +/- 15.8, and 365 +/- 26.9 min, respectively, in their lipid counterparts. A control group of animals that received normal saline solution or iophendylate alone did not exhibit motor blockade. These results may be attributed to sustained release of local anesthetics from the lipid vehicle. Hence, lipid drug carriers may be effective in prolonging epidural anesthesia.

[Transcatheter hepatic artery infusion chemotherapy and embolization for 60 patients with primary hepatic carcinoma].

Sixty patients with primary hepatic carcinoma (PHC) were treated with transcatheter hepatic artery infusion chemotherapy (TAI) and embolization (TAE) from June 1988 to December 1989. There were 54 males and 6 females. Their age ranged from 22 to 72 years with an average of 52. Course of disease ranged from 1/2 to 12 months. In these 60 cases, 31 had Stage II and 29 Stage III lesions. Using Seldinger's method per femoral artery, conventional hepatic angiography was performed. Afterwards, adriamycin or cisplatin infusion was carried out, followed by chemoembolization therapy of tumor vessels using mixture of ethiodized oil or iophendylate and mitomycin C. Finally, gelatin sponge block was used for proximal arterial embolization. After the treatment procedure, abdominal pain was relieved, tumor reduced in size, AFP, r-GT, AKP and LDH declined to various degrees and the survival time was prolonged. The 3-, 6- and 12-month survival rates were 93.3% (56/60), 67.3% (37/49) and 33.3% (9/27), respectively. It is indicated that TAI and TAE, being safe and effective, is the treatment of choice for patients with unresectable PHC.

Transcatheter thoracic duct embolization in the dog. An experimental study.

Thoracic duct embolization was created by injecting an isobutyl 2-cyanoacrylate/iophendylate (IBCA) mixture through a cannulated mesenteric lymphatic vessel in eight normal dogs. Aqueous contrast lymphangiography was repeated at minute 10 and week 6. Six dogs were euthanatized at week 6 and two dogs at month 6. Embolization with 1.5 to 3.9 ml of the mixture resulted in complete obstruction of the thoracic duct in all eight dogs. Results of lymphangiography in six dogs at week 6 showed a persistent, complete obstruction of the thoracic duct in six dogs and alternate lymphaticovenous anastomoses in four dogs. Histologically, there were a sclerosing granulomatous response surrounding the lymphatic embolus, mild congestive changes in the mesenteric lymph nodes, and mild lacteal dilatation in the jejunum. The procedure was well tolerated with only a few complications. One dog suffered partial thrombosis of the cranial vena cava by the injected material with later dislodgement and embolization of a pulmonary artery branch. Modifications have been made in the injection procedure to avoid this complication. This technique for occlusion of the thoracic duct shows potential for clinical use in the management of canine chylothorax. The obstruction appears to be complete and permanent, and surgical/anesthetic time is decreased greatly from previously described procedures.

An experimental evaluation of response to contrast media: Pantopaque, iopamidol, and iohexol in the subarachnoid space.

Myelography in dogs was performed with Pantopaque, iopamidol and iohexol. The effects of these agents were evaluated by histologic study of the brain, spinal cord, and meninges four months after the procedure. Retained Pantopaque was always accompanied by some degree of arachnoidal reaction, mild in the cervical cord segment and severe in the most caudal part of the cul-de-sac. No apparent protection against Pantopaque arachnoiditis was provided by either intrathecal or intramuscular methylprednisolone. We found no histologic evidence of arachnoiditis in animals examined with iopamidol and iohexol.

Histologic analysis of tissue response to bucrylate-pantopaque mixture.

A toxicologic-pathologic study of isobutyl-2-cyanoacrylate (Bucrylate) was carried out first in dogs and then in humans whose arteriovenous malformations were infused with this embolic agent. The canine specimens obtained at 7, 18, 28, and 147 days after embolization showed the development of a mild histiocytic giant cell reaction, which evolved to end-state sclerotic arteritis. The response was confined to the vessels and did not involve contiguous parenchymal tissues. Ten human specimens, obtained from 1 hr to 7 years after treatment, showed a similar bland reaction with no evidence of suppuration or premalignant changes.

Appearance of Pantopaque on MR images.

Pantopaque was shown to be both a radiographic and magnetic resonance (MR) contrast agent in two patients with suspected cord abnormalities who underwent MR examination following myelography. The Pantopaque appeared as a linear band of high signal intensity along the dependent portion of the spinal canal on MR images obtained with a repetition time of 500 msec and an echo time of 30 msec. MR images of two dogs--one injected with Pantopaque in the cervical subarachnoid space and the other with Amipaque--confirmed that the high signal arose from the Pantopaque. This high signal intensity is due to Pantopaque's short T1 relaxation time. Although Pantopaque will probably not be used as an MR contrast agent, it is important to recognize this property so that its high signal is not mistaken for fat or hemorrhage in the subarachnoid space on MR images.

Efficacy and morbidity of water soluble and oil-based myelography. Study compares both methods in 314 patients.

Retrospective studies were carried out on 314 patients who underwent oil-based or water-soluble myelography between July 1981 and July 1982 in two community hospitals. Morbidities and efficacies were compared and it was concluded that metrizamide myelography is a preferable method.

Hydrocephalus following iophendylate injection myelography with spontaneous resolution: case report and review.

A 62-year-old patient developed severe adhesive spinal arachnoiditis and hydrocephalus with papilledema following iophendylate injection myelography. Papilledema and hydrocephalus resolved spontaneously. The possible mechanism for hydrocephalus is discussed and the literature reviewed.

[Cystography of the spinal cord for delineating tactics for surgical treatment of syringomyelia]. / Kistografiia spinnogo mozga v opredelenii taktiki khirurgicheskogo lecheniia siringogidromielii.

Radiocontrast study of cystic cavities of the spinal cord was conducted in 23 patients with the clinical picture of syringomyelia and syringobulbia. Diffuse cystic cavities were demonstrated in the cervical and thoracic segments of the spinal cord in 22 patients. In 9 patients, the spinal cysts communicated with the cavity of the fourth ventricle. In 2 cases, the cysts extended to the region of the spinal cord terminal filament. The information obtained allowed a differential approach to the choice of the method and tactics of surgical treatment of syringohydromyelia. Macrosurgical operations on the craniovertebral level with tamponade of the communication between the spinal cord cyst and the cavity of the fourth ventricle were carried out in patients with the communicating form of syringomyelia. Operations for dividing the terminal filament of the spinal cord or myelotomy with drainage of the cyst at the cervical or thoracic level were performed in other cases.

Treatment of cerebral arteriovenous malformations: combined neurosurgical and neuroradiologic approach.

Experience with 31 intraoperative embolizations performed on 23 patients is reported. The procedure involves the direct injection of embolic material into the main arterial feeders during craniotomy. The combined effort involves the exposure of the lesion at craniotomy, standard arteriotomy, and fluoroscopically monitored intravascular infusion of contrast material followed by the injection of bucrylate (IBCA, Ethicon, Somerville, NJ) mixed with tantalum or Pantopaque into the feeding vessels and into the interstices of the malformation. It was concluded that the procedure significantly diminishes operating time and blood loss for the lesions that were subsequently resected. Fluoroscopy coupled with high-quality stop-frame videotape recording allows a detailed study of the flow characteristics of the malformation so that polymerization time can be regulated appropriately. Follow-up varied from 3 months to 4 1/2 years. There were two deaths related to the procedure and one additional complication of cortical blindness that partially resolved. None of the survivors rebled. Most of the survivors improved.

Combined percutaneous diagnostic puncture and management of renal cysts.

Significant reduction in size was obtained in 12 of 14 renal cysts treated by the instillation of iophendylate. The advent of noninvasive methods has increased the number of renal cysts detected radiologically and has limited the indication for diagnostic puncturing to problematic cases only. However, if it is decided to perform diagnostic puncture of a renal cyst, the combined instillation of iophendylate into the cyst seems to be therapeutically rewarding.

[Objective evaluation of tolerance of ventriculography with different x-ray contrast media (according to the results of nystagmography)]. / Ob''ektivnaia otsenka perenosimosti ventrikulografii s razlichnymi rentgenokontrastnymi veshchestvami (po dannym élektronistagmografii).

The vestibulo-oculomotor reflex (nystagmus) was recorded by means of electronystagmography in 33 neurosurgical patients in dynamics prior to and after ventriculography. For contrasting the ventricular system a water-soluble medium (Conrey, dimer-X or Amipak) was used in 18 patients and contrast mixtures of water-soluble agents in combination with Myodil emulsion in 15. It was established that after ventriculography with water-soluble media the nystagmus hardly changed, while after the use of mixtures of radiocontrast media the trunk vestibular reactions in all types of nystagmus grew frequently and sharply and the vestibulovegetative reactions increased markedly.

Morphologic sequelae to contrast medium deposits in the kidney. An experimental investigation in the rabbit.

Various doses of Pantopaque and Vascoray were injected percutaneously into the kidneys in 17 rabbits. Histologic examination of the kidneys at different time intervals following the injection demonstrated only slight injury to the renal parenchyma which could be related to the contrast media. Therefore, it seems reasonable to assume that the risk of causing renal damage by using Pantopaque in connection with renal cyst puncture is small.

Positive contrast ventriculography in cats with experimental obstructive hydrocephalus.

Cerebrospinal fluid pathways were studied in both normal and experimental obstructed hydrocephalic cats by positive contrast ventriculography. Either water soluble or insoluble contrast material was injected into the lateral cerebral ventricles, and radiographs were taken of the head and spinal cord. In the normal cat, the contrast material freely flowed throughout the spinal fluid spaces. The contrast material accumulated in the cisterna magna, and from there extended into the cranial and spinal subarachnoid spaces. In the kaolin-induced hydrocephalic cat, the outlets from the fourth ventricle were obstructed, and direct communication between the ventricular system and the subarachnoid spaces no longer existed. In these cats, the contrast material passed directly down the central canal of spinal cord and its movement was followed throughout the entire length of the canal. At the lower lumbar-sacral regions, the material perforated the cord and flowed into the subarachnoid space. At all levels, the central canal was enlarged and local dilatations were seen extending dorsally.