Cervical radiculopathy: value of oblique MR imaging

Eighteen patients with cervical radiculopathy were entered into a prospective study to compare the accuracy of surface coil magnetic resonance (MR) imaging with that of metrizamide myelography and computed tomography (CT) with metrizamide. All MR studies included tailored axial and oblique images as well as routine sagittal images. All imaging studies were evaluated for topography and type of disease. Nine of 18 patients subsequently underwent cervical surgery with an anterior interbody approach at 11 levels. The surface coil MR findings concerning disease topography and type concurred with the surgical findings at nine of 11 levels (82%). At three levels, the oblique view added important information not available on the sagittal images or clarified changes seen on the axial images. Metrizamide myelography with CT metrizamide myelography had findings concurrent with surgical findings at ten of 11 levels (91%).     

Comparison of MRI and scanning coupled with myelography in the diagnosis of cervicobrachial neuralgia

A prospective study was undertaken to compare the accuracy of surface coil magnetic resonance imaging (MRI) and computed tomography with myelography (CTM) in the determination of cervical radiculopathy with or without myelopathy. Twenty five patients underwent both imaging studies. The separately imaging diagnosis and the surgical findings were the basis of this study. The based-MRI and based-CTM predictions were not significant. MRI predicted two disc herniations that CTM did not predict. CTM predicted a combination of disk herniation and stenosis and one more lateral stenosis that MRI did not predict. Among the fourteen patients who underwent surgery, one underwent surgery only on based-MRI prediction, it was a disc herniation; one patient was operated on only on based-CTM prediction, it was a stenosis. In these operated patients, the predictive value of the both imaging modalities was not significant. In this report the diagnostic assessment of MRI and CTM was overall the same. The major advantages of MRI were its ability to display all the cervical spine, to study the disk pathology and to delineate a signal alteration within cord substance but the disadvantage was the difficulty to characterize the osteophytes made of cortical bone which did not give signal.     

Patterns of spinal cord atrophy by metrizamide CT

Forty patients with cervical myelopathy underwent high-resolution computed tomography (CT) with intrathecal administration of metrizamide for evaluation of cervical spinal cord atrophy. Thirty of them showed evidence of either focal atrophic distortion or generalized accentuation of the anatomic surface features of the spinal cord. Patients with a Chiari malformation or syringomyelia were excluded. The characteristic features in cervical spondylosis and canal deformity include flattening of the ventral surface of the cord, central infolding, beaking of the lateral funiculi, and wasting of the dorsal surface of the cord. Patients with motor neuron disease showed a combination of anterolateral and posterolateral atrophy reflecting underlying degeneration of the anterior horn cells and/or corticospinal tracts, respectively. Those with monomelic motor neuron disease had a striking ipsilateral hemiatrophy of the spinal cord. Among those presenting with spastic paraparesis, seven with clinically definite multiple sclerosis showed diffuse atrophy or focal degeneration due to a localized plaque of demyelination. Two cases of cord neoplasm showed atrophy secondary to ascending or descending degeneration of the long tracts.     

Computed tomography of the brain stem with intrathecal metrizamide. Part II: lesions in and around the brain stem

The practical usefulness of computed tomography with intrathecal metrizamide in imaging the brain stem is illustrated in six examples where the lesions were misdiagnosed on intravenously enhanced computed tomography, angiography, or air study. Focal and diffuse atrophic changes of the brain stem were demonstrated in symptomatic patients where none of the other radiographic or clinical investigations were conclusive. Metrizamide computed tomography is probably the most sensitive method for imaging lesions in and around the brain stem and cerebellopontine angle.     

CT myelography in cervical nerve root avulsion

Computed tomographic myelography (CTM) with metrizamide was performed in six patients to delineate the CTM appearance of avulsed cervical nerve roots. Twelve cervical nerve root avulsions were found and confirmed by cervical myelography and physical examination. The CTM findings in cervical nerve root avulsion closely matched those found myelographically: outpouchings of metrizamide extending ventrolaterally from the thecal sac into the neural foramen in an expanding or "mushroom-like" manner and separated from the thecal sac proximally by a 1-2 mm thick dural plane. This CTM appearance differs from that seen in such normal variants as dilated nerve root sleeves or root diverticula. We conclude that CTM is as sensitive as myelography. In addition, it can provide useful information regarding bony fragments or contiguous soft tissue injury.     

Intracranial metrizamide mimicking white matter disease

We report two patients in whom brain penetrance of grey matter by metrizamide, introduced for myelography thirty hours earlier, mimics the periventricular lucency of white matter disease on cranial computed tomography.     

Iotrol versus metrizamide in lumbar myelography: a double-blind study

In a prospective, randomized, double-blind study, 49 patients underwent lumbar myelography using iotrol (24 patients) or metrizamide (25 patients). The diagnostic imaging adequacy of iotrol was comparable with that of metrizamide. After iotrol myelography, adverse reactions were fewer, less severe, and of shorter duration than were those following metrizamide myelography. Thirteen of 24 patients (54%) receiving iotrol reported some adverse reactions compared with 24 of 25 patients (96%) receiving metrizamide. Five moderate and one severe adverse reaction occurred in the group receiving iotrol. Fourteen moderate and eight severe adverse reactions occurred in the group receiving metrizamide. Thirty-eight patients underwent electroencephalography both before and after myelography (19 iotrol and 19 metrizamide). None of the EEGs obtained after iotrol myelography changed from baseline, while seven of the EEGs obtained after metrizamide myelography showed changes from baseline. Iotrol was judged superior to metrizamide as a contrast medium in this patient population.     

Psychopathometric demonstration and quantification of mental disturbances following myelography with metrizamide and iopamidol

Summary Groups each consisting of ten patients underwent lumbar and cervical myelography with metrizamide and iopamidol, together with a control group of ten patients who underwent lumbar punctures only. These groups were studied with a psychopathometric test procedure in order to demonstrate and quantify mental disturbances. It was shown that in contrast to myelography with iopamidol, mild mental disturbances are common after myelography with metrizamide. The severity of the mental disturbances after myelography with metrizamide was dependent on the quantity of contrast medium which diffused into the intracranial space after myelography, suggesting a dose-related neurotoxic effect of this substance. Such a correlation was not found with iopamidol.     

Intracranial metrizamide following myelography

Twenty patients were studied by cranial computed tomography within 24 hours of myelography with metrizamide (Amipaque) to determine the intracranial manifestations of the use of this nonionic water soluble contrast medium. The findings ranged from relative hypodensity of the white matter due to ventricular opacification and gray matter penetration of metrizamide, to apparent trans-ependymal migration of the contrast agent resulting in what we have termed "pseudohydrocephalus." Trans-ependymal migration in normal humans has not been previously described. We were unable to establish precise radiologic correlates with the neurologic complications which some of the patients developed.     

Outpatient low-dose computed tomography metrizamide myelography and evaluation of lumbar disk disease

Outpatient low-dose computed tomography metrizamide myelography (CTMM) for the evaluation of lumbar disk disease is described in 55 patients. Ten individuals (group 1) were studied using 3.5 ml of 150 mg I/ml (525 mg I total) of metrizamide. Forty-five additional patients (group 2) were examined with 5 ml of 110 mg I/ml (550 mg I total) concentration of metrizamide. Group 2 experienced less post-procedure headache (6.6%) and nausea (2.2%) than did group 1 (30% and 10%, respectively). Group 2 demonstrated a lowered rate of headache (p less than .01) and showed a trend to less nausea (p less than .09) than a recently published study describing full-dose lumbar myelography. In addition, CTMM in group 2 produced more uniform mixing of metrizamide than in group 1. Overall, low-dose CTMM increased accuracy and reduced morbidity, patient cost, and inconvenience as compared with routine full-dose lumbar myelography.     

Cerebrospinal fluid rhinorrhea: evaluation with metrizamide cisternography

Metrizamide computed tomographic cisternography was used to examine 27 patients (19 males and eight females, 14-59 years old) clinically suspected of having cerebrospinal fluid fistulae with rhinorrhea. Twenty-one fistulae were traumatic and six were spontaneous. Five to 6 ml of metrizamide (or lopamidol, two cases) were injected by lumbar puncture at a concentration of 185-200 mg I/ml for direct coronal and axial computed tomographic sections of the skull base. Cerebrospinal fluid rhinorrhea was present at the time of examination in 12 of 27 cases. Results were evaluated according to three criteria: (1) metrizamide passage through the bony and dural defect; (2) demonstrable site of the fracture and/or bony defect; and (3) metrizamide visualized within a paranasal sinus, nasal cavity, or cotton pledget. The examination was considered positive when criterion 1 alone was present and when 2 and 3 were associated. In 15 of 27 cases, cisternography was positive, with the exact site of cerebrospinal fluid leakage demonstrated in 10 patients. In six cases, the results were not definitive; only one of the criteria (2 or 3) was fulfilled. In six cases, cisternography was normal. Seventeen patients underwent surgery. The site of cerebrospinal fistulae was ethmoidal in nine cases, frontoethmoidal in seven, sphenoidal in two, and sphenoethmoidal in one. The relative value of metrizamide computed tomographic cisternography compared with other diagnostic studies, polytomography, positive or negative contrast studies, and radionuclides, is discussed. Diagnostic pitfalls include artifacts and partial volume effect.     

Iohexol compared to metrizamide in cervical and thoracic myelography

Summary A randomized double blind study with iohexol (Omnipaque) and metrizamide (Amipaque) in cervical myelography was performed in 50 patients, 29 with iohexol and 21 with metrizamide. The myelographies were performed either with lumbar or with C₁–C₂ puncture in about equal groups, using 300 mg I/ml and 240 mg I/ml of the contrast media respectively. The image quality was equal with both contrast media, excellent in about 4/5 and good in 1/5 of the examinations. Subjective side effects were twice as frequent with metrizamide as with iohexol. The most frequent side effect was headache, occurring in 34% with iohexol and in 67% with metrizamide. Altogether 24% or the patients had EEG changes after iohexol as compared to 47% after metrizamide. All EEG changes were slight dysrythmia-except in three patients with spike activity after metrizamide. These were the only ones with mental reactions as well. It can be concluded that in this trial iohexol was better suited for cervical myelography than metrizamide.     

Iohexol vs. metrizamide: study of efficacy and morbidity in cervical myelography

A double-blind study was conducted in 60 patients undergoing either cervical or more complete myelography via C1-C2 puncture. Patients received either iohexol or metrizamide at a 300 mg l/ml concentration. The contrast media were equally efficacious in the production of high-quality radiographs and CT scans. However, the incidence of adverse reactions differed markedly. Of patients receiving metrizamide, 68% had some type of adverse reaction, whereas only 26% receiving iohexol had symptoms. The incidence of headache (metrizamide, 34%; iohexol, 26%) was not statistically different, but the quality of the headache differed: half of the metrizamide headaches were moderate or severe, whereas all iohexol headaches were mild. Nausea (31%) and vomiting (28%) were common with metrizamide but unusual (3% nausea) with iohexol. Of the metrizamide patients, 21% had overt psychologic changes that did not occur in the iohexol group.     

Value of computed tomographic myelography in the recognition of cervical herniated disk

Three patients with cervical radicular symptoms and normal metrizamide myelograms underwent thin-section high-resolution computed tomographic scanning because of a strong clinical suspicion of herniated disk. Herniated disk was demonstrated in all three cases. In two, the disk protrusions were recognized only by computed tomographic myelography, and in the third case, the diagnosis was made with plain computed tomography and confirmed by computed tomographic myelography.     

Iopamidol and metrizamide in cervical myelography: side effects, EEG, and CSF changes

Two nonionic contrast media, iopamidol and metrizamide (Amipaque), were used for cervical myelography (C1-C2 puncture) in 95 consecutive patients. Both contrast media gave excellent radiographic results. Headache and vagal symptoms were similar in both groups, whereas metrizamide produced more electroencephalographic changes and epileptic seizures. Meningeal irritation occurred in both groups and was severe in three cases. Cerebrospinal fluid showed protein and cellular changes of inflammatory type in both groups. Iopamidol is considered to be the more suitable contrast medium for cervical myelography despite its slight neurotoxicity.     

Imaging in multiple myeloma: Computed tomography or magnetic resonance imaging?

Multiple myeloma (MM) is the second most common type of hematological disease with its incidence rising in the elderly. In MM, the extent of the bone disease increases both morbidity and mortality. The detection of lytic bone lesions on imaging, especially computerized tomography (CT) and magnetic resonance imaging (MRI) is crucial to separate asymptomatic from symptomatic MM patients even when no clinical symptoms are present. Although radiology is essential in the staging and management of patients with MM there is still high variability in the choice between MRI and CT. In addition, there is still suboptimal agreement among readers. The potential of medical imaging in MM is largely under-evaluated: artificial intelligence, radiomics and new quantitative methods to report CT and MRI will improve imaging usage.     

99mTc-MIBI scintigraphy in untreated stage III multiple myeloma: comparison with X-ray skeletal survey and bone scintigraphy

Technetium-99m 2-methoxyisobutylisonitrile (99mTc-MIBI) is a lipophilic agent that has been proposed as a useful tracer for the detection of disease sites in patients with multiple myeloma (MM). We performed a prospective study to determine the potential of 99mTc-MIBI imaging for the evaluation of the extent of primary disease in patients with advanced stage MM, compared with skeletal survey and bone scintigraphy. Twenty patients with advanced stage MM at initial diagnosis underwent whole-body 99mTc-MIBI imaging, together with contemporaneous skeletal survey and bone scintigraphy. The findings of 99mTc-MIBI imaging were correlated with the results of skeletal survey and bone scan. All 99mTc-MIBI scans were positive for the presence of active MM, whereas skeletal surveys were positive in 18 patients (90%) with osteolytic lesions. Bone scintigraphy demonstrated MM in only 15 patients (75%). In two patients with no detectable lesions on skeletal survey, 99mTc-MIBI imaging revealed uptake in the spine, corresponding to the abnormalities seen on magnetic resonance imaging (MRI). With respect to the localization of bone lesions, 99mTc-MIBI imaging was superior to bone scintigraphy in 15 patients (75%) and had concordant results with bone scintigraphy in four (20%). 99mTc-MIBI imaging is a very sensitive imaging modality for the identification of the extent of disease in patients with advanced MM. It is clearly superior to bone scintigraphy and complements the results of skeletal survey by finding additional disease sites. Hence, in active MM patients, 99mTc-MIBI imaging has the potential to detect bone marrow disease that cannot be detected by skeletal survey and bone scintigraphy.     

Quantitative multiregional CSF kinetics using serial, metrizamide enhanced computed tomography.

Two rhesus monkeys studied by serial metrizamide (Amipaque) enhanced computer tomography (CT) imaging were used to quantitatively analyze cerebrospinal fluid (CSF) kinetics in multiple anatomical regions. Time--density curves were generated for the cisterna magna, suprasellar cistern, quadrigeminal cistern, and sylvian fissure, If clinical, biochemical, and routine static CT scanning indicate a profile suggesting normal pressure hydrocephalus, then CSF kinetics may be quantitatively and dynamically studied by CT imaging with metrizamide enhancement. This multiregional approach may be applied in an attempt to accurately distinguish normal pressure hydrocephalus from cerebral atrophy as a means of predicting which patients will likely profit from surgical diversionary shunting.     

Cervical spine disk herniation: comparison of CT and 3DFT gradient echo MR scans.

The purpose of this study was to compare CT and MR for the detection of cervical disk herniations. Nineteen patients suspected of harboring degenerative disk disease of the cervical spine underwent thin contiguous section CT myelography (CTM) and thin contiguous section three-dimensional Fourier transform (3DFT) gradient echo MR at 67 disk levels. Blinded readings of a high intensity CSF MR technique for the presence or absence of disk herniation were performed by three neuroradiologists. The intraobserver CT-MR concordances ranged from 84 to 89%. Using CTM as the paragon test, MR demonstrated a sensitivity of 79-91% and a specificity of 82-88% for disk herniation. Mean MR-CT concordance (86%) was nearly equivalent to that of CT-CT intraobserver concordance (88%). When consensus readings were considered, the MR-CT concordance (91%) was slightly higher than that of CT-CT intraobserver concordance (88%). We conclude that thin section 3DFT gradient echo MR with high intensity CSF is a reliable method to screen for degenerative disk disease in the cervical spine, since the agreement between MR and CTM is comparable with the intraobserver agreement of CTM.     

Spasticity complicating metrizamide myelography

Summary Temporary but considerable increase in spasticity following myelography using metrizamide at 300 mgsI/ml concentration occurred in 4 patients. In 3 of the patients the diagnosis is uncertain, but it is likely to be some form of degenerative disease involving motor pathways in two of them; the fourth case has cervical spondylotic myelopathy. The spasticity might be related to the anticholinesterase activity of metrizamide or to competitive inhibition of endogenous glucose metabolism by the deoxyglucose component of the metrizamide molecule.