Aphasia, apraxia and neurogenic stuttering as complications of metrizamide myelography (Speech deficits following myelography)

Aphasia following metrizamide myelography has been reported infrequently. During a seven-month period, we examined two patients who developed Broca's aphasia, apraxia of speech, oral-buccal-facial apraxia and neurogenic stuttering after intrathecal metrizamide administration. In each case, focal neurologic deficits were accompanied by clinical, electroencephalographic and radiologic signs of generalized neurologic disease. Serial speech and language evaluations initially revealed severe deficits that were largely resolved by the third day post-myelography. Out-patient follow-up examinations demonstrated persistence of mild speech and language abnormalities in each case. Our findings suggest that metrizamide may cause longlasting neurologic dysfunction.     

Nonconvulsive status epilepticus following metrizamide myelography

Epileptic seizures are a known complication of metrizamide myelography. To our knowledge, this is the first report of a case of nonconvulsive status epilepticus of the absence type following metrizamide myelography. There was symptomatic and electroencephalographic improvement after intravenous administration of antiepileptic drugs, and there was no neurological residual. Nonconvulsive status epilepticus should be considered when impairment of consciousness supervenes after radiographic procedures using metrizamide.     

Prolonged confusion due to absence status following metrizamide myelography

A case of absence status epilepticus resulted from metrizamide myelography. The acute confusional state following metrizamide myelography is briefly reviewed and compared with the confusional state resulting from adult-onset absence status. The similarities suggest that absence status may in fact be a relatively common cause of prolonged confusion following the use of metrizamide. Given the difficulty in clinical diagnosis and the excellent response to anticonvulsants, the possibility of absence status should be specifically excluded by EEG in any person suffering prolonged confusion following metrizamide myelography.     

The effect of metrizamide on the electroencephalogram: a prospective study in 61 patients

A prospective study was made of changes in the electroencephalogram after the use of metrizamide for myelography and posterior fossa cisternography in 61 patients (62 studies). The EEG changed in 21 patients (34%); 3 of these had had previously abnormal records, and the abnormalities were accentuated on the second recording. Eight developed paroxysmal activity, including spike and wave in 1. EEG changes appeared 24 to 48 hours after the use of metrizamide in 6 patients whose intervening EEGs were normal. The percentage of records that changed tended to increase as metrizamide was brought to more rostral levels. Symptoms following the use of metrizamide were reviewed in 58 patients. Although there were no seizures in the present series, seizures did occur with subsequent use of metrizamide in 3 other patients at our institution. Previous reports may have underestimated the frequency of EEG changes after metrizamide since these may require 24 to 48 hours to develop. The appearance of such activity suggests that the use of metrizamide in patients with known seizure disorders, the anatomical level to which metrizamide is brought during radiography, removal of contrast medium, and further investigation of premedication with anticonvulsants all require careful consideration when use of metrizamide is being contemplated.     

Unilateral scapulohumeral amyotrophy. Contribution of imaging]

A case of right scapulohumeral muscular atrophy stable after a 6 month progressive course is reported. Cervical metrizamide CT and MRI showed a flattened right cervical spinal cord regarded as a segmental atrophy. The case could belong to the Kaeser type of sporadic chronic spinal amyotrophy, or perhaps corresponds to a benign focal amyotrophy.     

Speech disturbance following myelography with iohexol: a case report]

Iohexol (Omnipaque) is a non-ionic contrast media for neuroradiology, which causes the neurological complications on rare occasions. A 63-year-old, righthanded female suffered from dysphemia 12 hours after myelography with iohexol via lumbar puncture. The initial cerebral computed tomography scan revealed the generalized contrast media uptake into the cisterns, which was typical to the finding after intrathecal iohexol injection. Although the cerebral magnetic resonance (MR) imaging 7 days after attack also demonstrated no abnormal finding, the electrical encephalogram revealed the sporadic sharp wave activity. Her nonfluent speech deficit had recovered gradually, however, the neurogenic stuttering was still remained. Some literatures previously reported the cases with speech deficits as complications of metrizamide myelography, whereas, a case manifesting as speech disturbance following myelography with iohexol has been not reported. Metrizamide is also a non-ionic agent and had a lower incidence of speech disturbance, which is supposed to be associated with a focal superficial neurotoxic reaction of the cerebrum. Therefore, our unfortunate case suggests that iohexol could rarely cause speech disturbance such as metrizamide.     

Cervical diastematomyelia. Report of a case and review of a rare congenital anomaly

Cervical diastematomyelia is a rare congenital abnormality. To our knowledge, only 18 cases have been reported. The present case was highly unusual in that it occurred in an adult. Other clinical features in the present case included symptoms that began after trauma and the presence of other associated congenital anomalies. The diastematomyelia was identified with computed tomographic metrizamide myelography and magnetic resonance imaging. The patient's neurologic deficits improved with surgery.     

Manic syndrome after metrizamide myelography

Depression, anxiety, and delirium have been associated with metrizamide myelography. The authors report a patient who developed an organic affective disorder with manic symptoms several hours after metrizamide myelography.     

Metrizamide encephalopathy in a child with hydrocephalus--effects of L-threo-DOPS on persistent disturbance of consciousness and L-dopa on extrapyramidal symptoms

This report describes a case of metrizamide encephalopathy with persistent disturbance of consciousness and extrapyramidal symptoms. These two conditions have rarely been reported among the various adverse effects of metrizamide. An 11-year-old girl had been in almost good health until she was ten years old, at which time she received a ventriculo-peritoneal shunt operation, suffering from hydrocephalus of unknown etiology. At the age of eleven, she was admitted to our hospital due to hydrocephalus recurrence. She was examined by metrizamide shunt-gram (1200 mg iodide/4 ml). On the next day, she became drowsy. The CT scan disclosed the periventricular penetration of metrizamide into the medial part of the thalamus and the caudate nucleus. Thirteen days later, disturbance of consciousness continued, and extrapyramidal symptoms, that is, rigo-spasticity and postural tremor, were observed. Oral administration of L-threo-DOPS, the direct precursor of noradrenaline, was effective against the persistent disturbance of consciousness and L-DOPA was effective against the extrapyramidal symptoms. She soon recovered almost to normal and no neurological deficit remained. We thus conclude that the CT scan findings and effects of L-threo-DOPS and L-DOPA suggest that metrizamide encephalopathy in this case were respectively due to its periventricular penetration into the medial part of the thalamus and the caudate nucleus, and the resultant deficiency of the ascending noradrenergic reticular activating system and the nigrostriatal dopaminergic system.     

Effect of radiologic contrast media and local anaesthetics on the blood-brain barrier and on the leptomeninges

The leptomeninges of cats were exposed to lidocaine, metrizamide and methiodal sodïum and compared with control brains exposed to Ringer's solution.
As a sign of blood-brain barrier damage, an increased extravasation of albumin into the cerebral cortex was recorded after exposure to methiodal sodium; lidocaine or metrizamide did not produce such damage.
Scanning electron microscopy revealed minor cellular reactions in the mesothelial cells of the leptomeninges after application of metrizamide, lidocaine and Ringer's solution. Methiodal sodium produced an extensive cellular damage of the leptomeningeal cells
The importance of testing the leptomeningeal reactions and the reactions of the blood-brain barrier to all liquid media used on the brain surface is emphasized.     

Usefulness and adverse effects of intrathecal metrizamide instillation (author's transl)]

Radiographic quality as well as adverse effects of intrathecal metrizamide instillation was prospectively investigated in thirty-three clinical cases admitted to the department of neurosurgery, University of Tokyo Hospital, and Kantoh Teishin Hospital. Metrizamide CT cisternography was performed in fifteen cases using in most cases 10 ml of 170 mg I/ml solution through lumbar route. Eleven cases exhibited "normal" pattern CSF circulation and the remaining four, "delayed" pattern. Eight cases (53%) experienced headache, nausea, and/or vomiting several hours after the instillation. All of these belong to the "normal" pattern group. Four cases of "normal" pattern received electroencephalographic examinations before and after metrizamide instillation. Three revealed appearance of negative spike and slow wave burst or sharp waves one to twenty-four hours after the instillation, along with penetration of metrizamide into brain parenchyma. Diagnostic quality was interpreted as "good" in eleven cases. Small acoustic neurinoma, pituitary adenoma, arachnoid cyst, and subdural hygroma were diagnosed among others. Metrizamide ventriculography was done in four cases. No untoward effect of significance was attributed to metrizamide per se. Cervical myelograpy and/or CT myelography was done in fourteen cases using, in most cases, 10 ml of metrizamide 170 mgI/ml. Polytome tomography with metrizamide instillation through lateral cervical puncture was highly diagnostic, whereas, ordinary X-ray with lumbar instillation yielded less satisfactory results. CT myelography in cases of subarachnoid block required good consideration on instillation site and positioning of the patient. Six cases (50%) among twelve cases where metrizamide had run into the cranial cavity experienced headache, nausea, and/or vomiting to a lesser degree than those of cisterno graphy. Metrizamide is the first contrast agent ever made which can be safely introduced into human subarachnoid space, if administered judiciously, nervous. However, metrizamide is weakly toxic to central system and provokes minor untoward effects as well as electroencephalographic abnormalities and, sometimes, clinical convulsive seizure. It would be wiser to restrict the dosage of metrizamide in cisternographic study, expecially in cases of "normal" pattern CSF circulation, to 1.2 gI or 7 ml of 170 mg I/ml solution. Routine use of X-ray cisternography should thus be discouraged because it needs higher concentration of metrizamide in the intracranial cisterns.     

EEG changes 24 hours after myelography with metrizamide

A prospective study of EEG changes following metrizamide myelography was made on 34 patients aged 17-79 years. EEGs were recorded just before and 22-26 hours after myelography. Usually 8-10 ml of metrizamide was injected by either lumbar or lateral cervical puncture. The concentration of metrizamide was relatively high. EEGs were abnormal in 15 out of the 20 patients whose baseline EEGs were normal. EEGs deteriorated in 10 of the 14 patients whose control tracings were abnormal. High voltage delta activity and/or a great deal of theta activity were common abnormalities. Three patients showed triphasic waves. No relationships were found between the EEG changes and clinical variables. But central nervous system involvements by metrizamide tended to be accompanied by a severe EEG slowing.     

Asterixis and encephalopathy following metrizamide myelography: Investigations into possible mechanisms and review of the literature

Marked asterixis occurred in two patients following metrizamide myelography. One also suffered generalized seizures and the other had severe stuttering speech for seven days. The spectrum of toxic manifestations of metrizamide is reviewed with emphasis on the unusual lethargy and other depressive effects seen with this relatively safe agent. The hypothesis that metrizamide exerts a ouabain-like effect on the cortical surface was tested. Metrizamide in concentrations as high as 20 mM had no inhibitory effect on rat cerebral K⁺-para-nitrophenylphosphatase, a partial reaction of (Na¹ + K¹)-adenosine triphosphatase. Because metrizamide is a 2-deoxyglucose analogue, a competitive inhibition of hexokinase at the first step in glycolysis was also postulated. Metrizamide was found to competitively inhibit commercial (microbial) hexokinase. The Michaelis constant for glucose rises from 0.13 to 0.25 to 0.33 to 0.91 mM in the presence of 0, 0.4, 1.0, and 2.0 mM metrizamide, respectively. Since the concentration of metrizamide over the cerebral cortex after routine myelography may be approximately 50 mM compared with a glucose concentration of only 3.6 mM (65 mg/dl), it is postulated that impaired brain glucose metabolism may be responsible for some of the toxic effects of metrizamide.     

Serial EEG recordings following intrathecal metrizamide administration

EEG recordings were obtained before and after intrathecal metrizamide injection in 50 consecutive patients who underwent metrizamide myelography or cisternography. EEG tracings were recorded daily until the pattern returned to baseline. One patient (2%) developed seizures. The most frequent EEG abnormality was generalized slowing of various degrees. In 15 patients (30%), the EEG record was normal throughout the study. In 4 patients (8%), EEG disturbances were seen up to the fifth day after the procedure. Patients who had undergone cervical myelography and cisternography had a marginally higher frequency of EEG disturbances than patients who underwent lumbar myelography. The causes inducing these time-related disturbances are discussed, as compared to pharmacokinetics of intrathecally administered metrizamide.     

Organic psychosyndrome correlated with high density of grey matter on CT following metrizamide cervical myelography

An organic psychosyndrome was observed in a young male after cervical myelography with metrizamide, correlating with enhancement of cortical grey matter on CT. These signs proved to be transient. Both were attributed to a too high dosage of metrizamide being introduced into the subarachnoid space.     

Rhinorrhoea as the presenting symptom of pituitary adenoma

A case, in which rhinorrhoea was caused by a pituitary adenoma, is presented. Leakage of CSF or metrizamide could be observed on CT.     

The effect of metrizamide on regional brain glucose metabolism in the rat

ABSTRACT— The X-ray contrast material metrizamide is structurally related to 2-deoxyglucose and inhibits brain glucose phosphorylation in vitro. In vivo , the present autoradiographic study with labeled 2-deoxyglucose revealed a global reduction of brain glucose phosphorylation after metrizamide administration in the cisterna magna of rats. The reduction averaged 18% of all regions.     

EEG Changes 24 Hours after Myelography with Metrizamide

Abstract: A prospective study of EEG changes following metrizamide myelography was made on 34 patients aged 17–79 years. EEGs were recorded just before and 22–26 hours after myelography. Usually 8–10 ml of metrizamide was injected by either lumbar or lateral cervical puncture. The concentration of metrizamide was relatively high. EEGs were abnormal in 15 out of the 20 patients whose baseline EEGs were normal. EEGs deteriorated in 10 of the 14 patients whose control tracings were abnormal. High voltage delta activity and/or a great deal of theta activity were common abnormalities. Three patients showed triphasic waves. No relationships were found between the EEG changes and clinical variables. But central nervous system involvements by metrizamide tended to be accompanied by a severe EEG slowing.     

Capgras syndrome associated with metrizamide myelography

A case of Capgras' Syndrome secondary to an Organic Mental Disorder associated with metrizamide myelography is presented. The relationship of Capgras' symptom to reduplicative paramnesia and prosopagnosia is discussed.     

The rate of CSF formation in man: preliminary observations on metrizamide washout as a measure of CSF bulk flow.

Metrizamide, a nonionic, water-soluble contrast agent, was injected into the ventricular system of 3 patients with indwelling ventricular catheters and subcutaneous cerebrospinal fluid reservoirs. A first-order rate constant, k, for metrizamide washout from the right lateral ventricle was determined with reference to mean ventricular metrizamide concentration on serial CAT scans; right ventricular volume, V, was estimated after metrizamide injection by multiplying the appropriate ventricular area on consecutive CAT slices by the nominal slice thickness. The rate of right lateral ventricular CSF formation, If, in our 3 patients was calculated as k X V and ranged from 0.083 to 0.103 ml per minute.