Journal ofNeurology, Neurosurgery, and Psychiatry, 1978, 41, 108-112

Intraspinal arachnoiditis and hydrocephalus afterlumbar myelography using methylglucamine iocarmateT. STAEHELIN JENSEN AND 0. HEIN

From the Department of Neurology, Vejle County Hospital, and the Department of Neurosurgery,Odense University Hospital, Denmark

SUMMARY A 35 year old woman developed a severe meningeal reaction after lumbar myelo-graphy using the water-soluble contrast medium methylglucamine iocarmate. Three monthsafter myelography the findings were a transverse spinal cord syndrome corresponding to themiddle thoracic segments resulting from well developed leptomeningeal adhesions. This was

combined with a noncommunicating hydrocephalus, probably the result of leptomeningealfibrosis in the posterior fossa. After treatment with a ventriculoatrial shunt the patient isalmost free of symptoms. A possible pathogenetic relationship between the contrast medium,the chronic leptomeningeal changes, and the symptoms of our patient is discussed on the basisof the literature.

Although myelography is one of the most valuablediagnostic tests in various spinal cord lesions,several of the contrast media used in this diag-nostic procedure give rise to a broad spectrum ofside effects. Among these the most common areacute or chronic leptomeningeal reactions (Autioet al., 1972; Ahlgren, 1973; Halaburt and Lester,1973; Irstam and Rosencrantz, 1973).

Oil-based contrast media-for example, io-phendylate, Pantopaque-which are mainly usedin the cervicodorsal region, in cases of suspectedspinal cord or nerve root compression, have anirritating effect on the medulla and the nerveroots. Their use is frequently accompanied byacute mild leptomeningeal inflammation, with anincrease in cell and protein content of the cere-brospinal fluid. Although serious cases of chronicarachnoiditis or adhesive arachnoidal changesafter the use of iophendylate are uncommon, theyhave been observed both in the upper intraspinalregion and intracranially, and are occasionallyfollowed by hydrocephalus with a lethal course(Tarlov, 1945; Mason and Raaf, 1962; Mayheret al., 1971; Christy et al., 1974). In all these casesthe leptomeningeal changes were thought to be aresult of a direct inflammatory effect of the iodisedcompound.

Address for correspondence and reprint requests: Dr T. StaehelinJensen, Department of Neurosurgery, Arhus University Hospital, 8000Arhus C, Denmark.Accepted 5 August 1977

The water-soluble contrast media-for example,methylglucamine iothalamate (Conray) andmethylglucamine iocarmate (meglumine iocar-mate, Dimer-X)-are used mainly for investigationof the lumbar part of the spinal canal, giving moredetailed pictures than oil-based contrast media.However, like the oily contrast media, these agentsare more or less neurotoxic, and various compli-cations may be observed after myelography withwater-soluble contrast agents. In recent years de-layed adhesive arachnoidal changes after the useof these substances have been reported more fre-quently (Autio et al., 1972; Ahlgren, 1973, 1975;Halaburt and Lester, 1973; Irstam and Rosen-crantz, 1973). All arachnoidal changes observedto date have been located exclusively in the caudalregion of the spinal canal (Ahlgren, 1973; Hala-burt and Lester, 1973; Irstam and Rosencrantz,1973; Slatis et al., 1974). This paper describes anunusual case of intracranial and midthoracicarachnoiditis in which the clinical symptoms ap-peared shortly after lumbar myelography withthe water-soluble contrast medium meglumineiocarmate.

Case report

The patient was a 35 year old woman, with ahistory of good health, except for transient biliarytract symptoms in 1968.

In 1973 and 1974 she experienced transient re-

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Intraspinal arachnoiditis and hydrocephalus after lumbar myelography

lapsing lumbar pain, but was otherwise healthyand fit. In October 1974, without precedingtrauma, she developed acute pains in the rightlumbar region, radiating to the right leg. Threemonths later she was admitted to the localhospital with unaltered pain. Physical examinationshowed a slightly weakened right patellar reflex,but the neurological examination was otherwisenormal. A lumbar disc herniation was suspectedand lumbar myelography using meglumine iocar-mate (Dimer-X) was carried out on 31 January1975. Lumbar puncture and injection of the con-trast medium was performed with the patient in asitting position; the remaining part of the exam-ination was made with the trunk elevated 150.The cerebrospinal fluid was clear, colourless, con-tained no cells, and the protein content was 0.33g/l. Dimer-X 5 ml diluted with 4 ml cerebrospinalfluid was injected. The contrast medium was notaspirated at the end of the examination.During myelography, which showed normal

conditions, the contrast medium was seen to moveup to the level of the twelfth thoracic vertebra(Fig. 1).

After myelography the patient was kept in asitting position. A few hours after the examina-tion, while still resting with the trunk and headelevated, she complained of intense headache,

nausea, and restlessness in her legs. At this timeher temperature had fallen to 330C and later rosesteadily to 39.3°. The next day the patient wasstill in a poor condition; she was febrile with rest-less movements of all limbs, and a pronouncedneck rigidity was noted. Apart from hypaesthae-sia and hypalgesia in the perianal area, no neuro-logical deficit was found. No fluid could be re-moved in repeated lumbar punctures. After eightdays her temperature was normal, but there wasstill slight neck stiffness, and the patient com-plained of headache which persisted unchangeduntil she was discharged five weeks later.During the subsequent months, the frequency

and intensity of headaches increased. Threemonths after myelography she had bifrontal head-ache daily accompanied by repeated vomiting,and rapidly developing gait disturbances withlimb weakness and an unsteady gait. When thepatient was admitted to the neurological depart-ment of Vejle County Hospital in May 1975,physical examination revealed bilateral papil-loedema (1-2 diopters). There was moderatespastic paresis of both legs and a bilateral sensoryloss distal to the fourth thoracic dermatome. Hergait was spastic and ataxic, and a slight inco-ordination was also present in the upper extremi-ties. A provisional clinical diagnosis was made of

Fig. 1 Initial lumbar myelography with 5 mlDimer-X, showing well-filled root pockets andnormal appearances of fila radicularia.

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a space-occupying lesion in the spinal canal andin the posterior fossa, and the patient was trans-ferred to the neurosurgical department of OdenseCounty Hospital, where suboccipital ethyl mono-iodostearate (Duroliopaque) myelography revealeda complete obstruction at the level of the sixththoracic vertebra (Fig. 2). Cerebrospinal fluidfrom the suboccipital level was clear and colour-less; it contained 0.1 g/l of protein and there wereno abnormal cells.

OPERATIONLaminectomy of thoracic vertebrae 5-7 inclusivewas performed on the day of admission. Thearachnoid membrane was milky, greatly thickenedand adherent, with pouch formation partly to thespinal cord and partly between the arachnoid andthe dura mater. Adhesions continued bothcranially and caudally. A biopsy sample of the

Fig 2 Positive contrast oil myelogram showingcomplete obstruction to flow at the level of the

sixth thoracic vertebra.

T. Staehelin Jensen and 0. Hein

arachnoid membrane piece of tissue in whicharachnoid and dura mater were fused was obtained.Focal cell proliferation could be seen at the junc-tion of the two membranes. There were no malig-nant changes nor any sign of acute inflammation,and fungi and bacteria could not be demonstrated.The histological findings were thus typical of achronic adhesive arachnoiditis.

During steroid treatment (dexamethasone), witha total dose of 200 mg during and after theoperation, there was a marked but transient im-provement in the patient's condition so that shewas able to walk, but three weeks after the opera-tion there was a relapse. She had progressiveparesis of the lower extremities and headaches,culminating in unconsciousness lasting seconds tominutes accompanied by explosive vomiting. Intra-ventricular pressure was monitored continuouslyand showed that these episodes of unconsciousnesscoincided with transient increases in pressure from10-20 mmHg to some 90 mmHg. There was pro-gressive papilloedema (2-3 diopters), and freshretinal haemorrhages were seen.

Ventriculography was carried out in June 1975and showed that the supratentorial ventricularsystem was moderately dilated, whereas the fourthventricle was filled and in normal position. No airpassed into the cisterna magna or to the subarach-noid space as a whole, indicating a noncom-municating hydrocephalus.A ventriculoatrial shunt (Hakim-Cordis-

Medium) was implanted three days after ventri-culography, and her condition gradually improvedwith intensive physiotherapy. Fifteen months latershe is capable of walking with little difficulty, usinga stick, has no headache, and is neurologicallyintact apart from a slight spastic paresis of theleft lung.

Discussion

The patient presented with abrupt onset of neckrigidity, headache, drowsiness, and temperaturedisturbances, shortly after lumbar myelographywith a water-soluble contrast agent which sug-gests that the performance of this procedureplayed an important pathogenetic role.

Several reports have confirmed the neurotoxiceffect of these substances, and a series of sideeffects, usually transient and slight, such as head-ache, nausea, vomiting, dizziness, and fever havebeen reported (Gonsette, 1971; Lehtinen andSeppanen, 1972; Irstam, 1973; Ahlgren, 1975).Our patient had clear indications of meningeal

irritation after myelography. Irstam (1973) andVik-Mo and Maurer (1975) reported a similar

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Intraspinal arachnoiditis and hydrocephalus after lumbar myelography

Fig. 3 Ventriculography, anteroposterior view (left), lateral view (right). The ventricular system is enlargedwith no air passing to the basal cisterns or over the cerebral convexity.

complex of symptoms after lumbar myelographyusing Dimer-X. Sterile meningitis with moderateincreases in cell and protein content of the cere-brospinal fluid was found in these cases. It is notpossible to establish a diagnosis of aseptic menin-gitis in the present case, but the course of thedisease makes it most likely.

In addition to acute leptomeningeal changes,water-soluble contrast media may also give riseto permanent leptomeningeal alterations char-acterised by considerable thickening of the lepto-meninges and adhesions between dura andarachnoid mater (Ahlgren, 1973, 1975; Irstamand Rosencrantz, 1973; RAdberg and Wennberg,1973; Slatis et al., 1974). Previously, the develop-ment of these leptomeningeal adhesions has onlybeen demonstrated in the lower dural sac (Autioet al., 1972; Halaburt and Lester, 1973; Irstamand Rosencrantz, 1973; Suolanen, 1975), whichis related to the fact that these media have beenused exclusively in the lumbar region.Three months after the primary lumbar myelo-

graphy our patient manifested a transverse spinalcord syndrome, as a result of severe and extensivearachnoiditis in the midthoracic region of thespinal canal, together with an internal hydro-cephalus, raised intracranial pressure, andpapilloedema, due probably to an arachnoiditis inthe posterior fossa with obstruction of the outletsof the fourth ventricle.

Although the exact mechanism for developmentof leptomeningeal adhesions is not known, wethink it most probable that the arachnoiditis wascaused by primary inflammatory reaction in theleptomeninges of the posterior fossa and in thespinal canal at the midthoracic level. Dimer-Xwas not seen during myelography higher than thelevel of the twelfth thoracic vertebra, but it isknown from resorption studies (Brabrand et al.,1972; Irstam, 1973), that a subsequent diffusionof contrast medium to the circulating cerebro-spinal fluid occurs during myelography, so thatthe medium also comes into contact withmeninges in the cranial parts of the subarachnoidspace.

We are grateful to Dr S. Melsen, Chief Neur-ologist, Vejle County Hospital, and to Dr J. E.M0ller, Chief Pathologist, Gentofte, Denmark,for their advice.

References

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Ahlgren, P. (1975). Amipaque myelography. The sideeffects compared with Dimer-X. Neuroradiology,9, 197-202.

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Halaburt, H., and Lester, J. (1973). Leptomeningealchanges following lumbar myelography with water-soluble contrast media (meglumin iothalamate andmethiodal sodium). Neuroradiology, 5, 70-76.

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