Normal Pressure Hydrocephalus after Myodil Myelography

Transcription

1 Cse Norml Pressure Hydroephlus fter Myodil Myelogrphy Ezgi Akr, Mehmet Ufuk Akmil Hydrpş Numune Trining nd Reserh Hospitl, Deprtment of Neurosurgery, Istnul, Turkey Astrt Ojetive: Ft-sturted ontrst gent-enhned myelogrphy ws used for the purpose of dignosing most spinl lesions from the eginning of the 19 th entury until the end of the 20 th entury. Myodil ws mong the gents used for mny yers for this purpose. Methods: A rre long-term omplition of myodil myelogrphy is presented with ererospinl fluid (CSF) sorption disorder ourring yers fter myelogrphy tht used seondry norml pressure hydroephlus. Results: A se of norml pressure hydroephlus with slowly developing linil piture tht emerged yers fter ventriuloperitonel shunt for myodil myelogrphy 25 yers go due to suspiion of lumr spinl stenosis ws treted. Reeived: Jyly 23, 2014 Revised: Novemer 6, 2014 Aepted: Ferury 9, 2015 Conlusions: Mny ute nd hroni omplitions of ft-sturted ontrst gents were reported. Beuse of these omplitions nd with the tehnologil developments in due ourse, these gents re repled y omputerized tomogrphy (CT), mgneti resonne imging (MRI), or hydrophili ontrst gents. Keywords: Norml pressure hydroephlus, myelogrphy, myodil IJIHS. 2015;3(1):39 43 Introdution Myodil (iophendilte, ftty id tht ws formerly mnuftured y Glxo Lortories London; lso known s Pntopque in the USA) is n oil-sed positive ontrst medi. 1 The use of myodil in myelogrphy ws desried for the first time in Until the end of the 20 th entury, Myodil ws used for myelogrphy, ventriulogrphy, nd isternogrphy. Complitions used y these oil-sed ontrst gents, rnging from intermedite trnsient retions to severe meningel retions tht ould result in deth, were reported. In ddition to the omplitions tht my our during the erly period fter the pplition, some hroni omplitions my lso e oserved fter mny yers. Those hroni omplitions re onsidered to e relted to the rhnoiditis nd disorders of ererospinl fluid (CSF) sorption Correspondene: Ezgi Akr, Hydrpş Numune Trining nd Reserh Hospitl, Deprtment of Neurosurgery, Istnul, Turkey e-mil: ezgiyiek@gmil.om used y myodil. Some ses of ostrutive hydroephlus, thori rhnoiditis s well s syringomyeli in the lte period fter myodil myelogrphy were desried in litertures. 3,4 In our se, norml pressure hydroephlus (NPH) ws developed seondry to the myelogrphy using myodil performed 25 yers go. Cse An 83-yer old femle ptient ws presented to our lini with omplints of dizziness, lne impirment, mnesi, git disturne, nd urinry inontinene. These omplints hd lsted for one yer nd hd een inresing over the lst severl months. In the physil exmintion, rnil exmintion ws norml nd the ptient hd no motor defiit. Deep tendon reflexes were normotive nd plntr skin reflex ws flexor. The ptient ws wlking slowly with short steps nd slowing of the psyhomotori funtions ws determined in mentl tests. The followings were oserved on the mgneti resonne imging (MRI) result: Interntionl Journl of Integrted Helth Sienes. 2015;3(1) :

2 Norml Pressure Hydroephlus Following Myodil Myelogrphy d Fig. 1 Fig. 1,,, d: Enlrged Temporl Horns re Seen on the Axil T2-weighted Imges Inresed Curvture of Corpus Cllosum nd Norml Size 4 th Ventrile re Seen on the Sgittl MRI Imge Enlrged Lterl nd 3 rd Ventrile re Seen on the Coronl MRI Imge inresed lterl nd third ventrile sizes with fourth ventrile size within the norml rnge; mrked temporl horns; inresed Evns index; enlrged sylvin fissures on oronl setions; nd nrrowed sulus nd surhnoid spe (Fig. 1,,, d). Dynmi CSF MRI imges showed the followings: reltively deresed CSF flow; dequte flow t quedut level ut with deresed output; nd 98% regurgittion. Cererl nd ereellr trophy were seen. A lumr punture (lumr tp) test ws performed for three dys with 30 CSF extrted one dy. The CSF ppered to e ler nd its pressure ws 17 m H 2 O. The wlking speed of the ptients inresed fter the lumr tp test ws onduted nd signifint improvement ws oserved in the mentl test. Shunt surgery ws plnned for the ptient who enefited from the evutive lumr punture. A grvity ssisted medium pressure shunt ws pled through the right Frzier s point. Signifint improvement ws seen in the symptoms of the ptients fter the surgery. Postopertive ntiioti therpy ws initited. Shunt theter ws seen in its ple on the ontrol omputerized tomogrphy (CT) imge performed postopertively (Fig. 2). On the CT imge, multiple millimetersized hyperdense ovl lesions were seen in the isterns nd, espeilly, in the posterior foss (Fig. 2,, d, e). During the retrospetive MRI imge inspetions, myodil remnnts were not oserved (Fig. 3,, ). When nother inquiry were mde on the pst medil history of the ptient gin, it ws reveled tht the ptient hd undergone myodil myelogrphy proedure 25 yers go due to the suspiion of lumr spinl stenosis for k nd leg omplints. The result of the myelogrphy ws norml nd the ptient hd enefited from the onservtive tretment. Hyperdense ovl lesions seen on the CT imges were myodil remnnts. NPH developing in the ptient yers fter the proedure is quite likely to e lte omplition of myodil myelogrphy. The ptient ws dishrged on 4 dys fter the opertion. Disussion Norml pressure hydroephlus or NPH is ondition defined for the first time in 1965 y Adms nd Hkim with dementi, impirment of lne, nd urinry inontinene s the lssi linil finding trid. NPH hs een 40 Interntionl Journl of Integrted Helth Sienes. 2015;3(1) :39 43

3 Ezgi Akr, Mehmet ufuk Akmil, et l. d e Fig. 2 Shunt Ctheter ws Seen on the Postopertive CT Imge. Fig. 2,, d, e: Multiple Millimeter-sized Hyperdense Myodil Remnnts were Oserved in the Posterior Cisterns, Prepontine Cistern, Lterl Ventriles nd Sylvin Fissures. oserved with delined ognitive funtions, hene it is more frequently found in elderly ptients. It is dignosed sed on the lssi linil findings, ventriulr dilttion, nd norml CSF pressure. 5,6 It is usully seen s idiopthi NPH (inph) of unknown etiology. If it ours due to quired uses suh s meningitis, SAH, or ongenitl-developmentl uses, it is lled seondry NPH (snph). 5,6 It is ommonly mnifested y nonspeifi slow progressing symptoms in the elderly ptients. Impirment of CSF flow due to idiopthi or seondry resons uses hydroephlus. 5 The imging methods used in the dignosis inlude omputerized tomogrphy, MRI, CSF flow dynmi studies, nd isternogrphy. 5 Ventriulr dilttion, Evns index (whih is rtio of the mximum width of the frontl horns to the mximum width of the inner tle of the rnium) of more thn 0.3, nd inresed orpus llosum urvture on CT nd MRI imges support the hydroephlus dignosis. Coronl MRI setions speifilly provide useful informtion regrding NPH. In oronl imging, sylvin fissures nd lrge suli under sylvin fissures, nrrowed suli t the high ererl onvexity, nd distriution of CSF disproportiontely etween superior nd inferior rin surfes in ddition to ventriulomegly support dignosis of NPH. 5 In the se where imging findings were found together with one finding of linil trid, tp test is reommended. A positive tp test shows tht the ptient n enefit from surgil tretment. The CSF removl test is divided into two types; smll nd lrge volume removl of CSF. Smll volume (30 50 ml) nd lrge volume ( ml) of CSF removl re rried out vi lumr tp. A tp test is less invsive. Removl of lrger volumes of CSF Interntionl Journl of Integrted Helth Sienes. 2015;3(1) :

4 Norml Pressure Hydroephlus Following Myodil Myelogrphy Fig. 3 Fig. 3,,, Myodil Remnnts were not Oserved on the MRI Imges is rried out vi externl lumr dringe for few dys. 5,6 In the se where improvement in linil symptoms fter CSF removl ws oserved, tp test is onsidered to e positive. Improvement in dily life tivities n e ssessed with modified Rnkin Sle (mrs). Git n e ssessed quntittively using 3 meter timed up nd go test or the 10 meter stright wlk test. The mini-mentl stte exmintion, frontl ssessment ttery, nd/ or tril mking tests re pplied for ssessing ognition. 5 CSF is olorless nd ler nd its pressure is mximum 18 m H 2 O-20 m H 2 O. Shunt proedures re lso pplied for the other ommuniting hydroephlus types in NPH. Most ommonly, low or intermedite pressure ventriuloperitonel shunts re preferred. 5,7 A rre long-term omplition of myodil myelogrphy is presented in this se study. The Cererospinl fluid sorption disorder tht oured yers fter myelogrphy hd used seondry norml pressure hydroephlus. Myodil is n oil-sed ontrst gent tht ws mnuftured nd sold y Glxo Lortories in 1946 to After 1946, myodil ws primrily used for myelogrphy, ventriulogrphy nd isternogrphy. Myodil ws sold in pproximtely fifty ountries, inluding the United Kingdom. On Septemer 19 th 1988, Glxo Lortories delred tht sles of myodil were esed in United Kingdom in pursune to the ommeril deision of the Ministry of Helth of the ountry. However, they still held the liense for its prodution sine it ws still sold worldwide. 1 The produt is lled s iophendilte (pntopque) in USA. 2 Myodil is seen s intrdurl droplets in the rdiogrphi imges. It is seen s hyperdense, ovl, multiple droplets on the CT imges. Due to its ft-like struture, myodil is seen s ft nd ft-like strutures on the MRI imges whih is hyperintense on the T1-weighted sequenes nd iso-hypointense on the T2-weighted sequenes. 1 Therefore, its rdiologil imge hs lipom, hemorrhge, hemngiom, nd, in ft, melnom like pperne. 1 Complitions used y the use of myodil rnges from intermedite trnsient systemi retions to severe meningel retion nd deth, whih my our immeditely fter myodil myelogrphy. 2 Aute omplitions my our fter use of myodil, while hroni omplitions my develop yers fter. 1 4 This ontrst medi n e deteted in the thel s even mny yers fter myelogrphy due to its remrkly slow sorption. 1 Long- 42 Interntionl Journl of Integrted Helth Sienes. 2015;3(1) :39 43

5 Ezgi Akr, Mehmet ufuk Akmil, et l. term omplitions seen fter use of oilsed ontrst gents like myodil re relted to the development of rhnoiditis or CSF sorption disorders. The risk for developing rhnoiditis fter using myodil is very low (1%) nd rhnoiditis n develop in the spinl or rnil regions. 1,3,4,8,9 A norml pressure hydroephlus ondition hd developed seondry to the myelogrphy performed 25 yers go y using myodil in this se study. With time, CSF sorption ws impired grdully. Complitions of the oil-sed ontrst gents like myodil n still e enountered yers fter. With the lights of these ute nd hroni omplitions of the ontrst gents, ontemporry CT, MRI nd lso wter-sed ontrst gents like metrizmide (mipque) nd iohexol (omnipque) re urrently more frequently used. 3,8 10 Referenes 1. Oo M, Wng Z, Skkir T, Ksi Y. Mgneti resonne imging findings of remnnts of n intrdurl oil-sed ontst gent: report of se. J Spinl Cord Med. 2012;35(3): Jensen F, Reske-Nielsen E, Rtjen E. Ostrutive hydroephlus following pntopque myelogrphy. Neurordiology. 1979;18(3): Gnnlinghm KK, Joshi SM, Sin I. Thori rhnoiditis, rhnoid yst nd syrinx formtion seondry to myelogrphy with Myodil, 30 yers previously. Eur Spine J. 2006;15(5): Kuot M, Shin M, Tniguhi M, Tero T, Nkuhi J, Tkhshi H. Syringomyeli used y intrthel remnnts of oil-sed ontrst medium. J Neurosurg Spine. 2008;8(2): Mori E, Ishikw M, Kto T, Kzui H, Miyke H, Miyjim M, et l. Guidelines for mngement of idiopthi norml pressure hydroephlus: seond edition. Neurol Med Chir (Tokyo). 2012;52(11): Mlm J, Grff-Rdford NR, Ishikw M, Kristensen B, Leinonen V, Mori E, et l. Influene of omoridities in idiopthi norml pressure hydroephlus- reserh nd linil re. A report of the ISHCSF tsk fore on omoridities in INPH. Fluids Brriers CNS. [seril on the internet] June [ited 2014 April 12];10(22):[out 14 p.]. Aville from: ontent/10/1/ Ishikw M. Idiopthi norml pressure hydroephlus--overview nd pthogenesis. Brin Nerve. 2008;60(3): Hugh AE. The sudurl spe of spine: A lympthi sink? Myodil s lst messge. Clin Ant. 2010;23(7): Goplkrishn CV, Mishr A, Thoms B. Iophendylte myelogrphy indued thori rhnoiditis, rhnoid yst nd syrinx, four dedes lter. Br J Neurosurg. 2010;24(6): Gupt SR, Nheedy MH, O Hr RJ, Ruino FA. Hydroephlus following iophendylte injetion myelogrphy with spontneous resolution: se report nd review. Comput Rdiol. 1985;9(6): Interntionl Journl of Integrted Helth Sienes. 2015;3(1) :