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Iophendylate is an oil-based contrast agent used in conventional myelography before the 1980s. We report an unusual case of an 82-year-old woman with iophendylate migration into the intracranial cerebrospinal fluid space after myelography 40 years ago. The patient was treated conservatively and followed up regularly.

Pantopaque (iophendylate) is an oily contrast medium historically used during spine imaging. Due to its persistence in the subarachnoid space and the potential to lead to severe arachnoiditis, it is no longer used today. We present a 40-year-old male with new-onset headaches, imbalance, and vertigo. Brain magnetic resonance imaging revealed a 2-mm T1 -hyperintense intracanalicular lesion. Numerous hyperdense foci were scattered throughout the subarachnoid space on computed tomography. Further history revealed the patient received Pantopaque 30 years prior, after sustaining spinal trauma. Remnant Pantopaque contrast is an important differential when evaluating a patient with a suspected intracranial tumor in order to avoid unwarranted surgical intervention. Laryngoscope, 127:1916-1919, 2017., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: Oil-based contrast media such as Pantopaque have not used for imaging for several decades, but because these contrast media have an extremely low clearance rate, the remnant contrast media or residual sequelae of these materials may be encountered in the clinical field., Clinical Presentation: A 63-year-old woman presented to our hospital complaining of increasing lower back pain and lower extremity paresthesia with incontinence for 2 years. A plain X-ray film revealed single droplet-like mass at the lower thoracic T9-T10. A magnetic resonance image (MRI) study revealed a dorsally placed extramedullary intradural lesion, compressing the thoracic cord and minimally displacing it anteriorly. Spinal stenosis was also noted at the L4-5 level., Intervention: The patient was performed for two consecutive surgeries. Total laminectomy was performed at T9-T10 to remove mass. A 0.5 × 0.5 × 4 cm yellowish intradural extramedullary cystic mass was removed without any leakage of cystic contents. Partial hemi-laminectomy and foraminotomy was then done at L4-5 levels for radiculopathy symptom relief. The fluid from the cyst was composed mainly of iodide., Conclusion: Intraspinal masses showing metal-like density in X-ray or computed tomography but in MRI showing only lipoma or cystic lesions, not metallic characteristics, the differential diagnosis should include iophendylate (Pantopaque) cyst. Oil-based contrast medium is believed to have the potential to make a syrinx formation via arachnoiditis, which can lead to severe neurologic deteriorations, so even if the patients do not represent with an acute neurologic deficit, surgical total removal of remnant material without leaking should be considered.

Iophendylate (Myodil) was a popular oil-based contrast agent used until late 1980s for myelography, ventriculography and cisternography. Although several long-term sequelae have been reported in literature, they are extremely rare. We report a rare occurrence of symptomatic dorsal arachnoid cyst 40 years after Myodil myelography.

Iophendylate (Pantopaque or Myodil) was commonly used from the 1940s until the late 1980s for myelography, cisternography, and ventriculography. Although such instances are rare, several different long-term sequelae have been described in the literature and associated with intrathecal iophendylate. The authors describe an unusual case of arachnoiditis caused by residual thoracic iophendylate imitating an expansile intramedullary lesion on magnetic resonance images obtained 30 years after the initial myelographic injection.

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.

Spinal arachnoiditis can rarely occur following irritation from foreign body substances, including certain oil based contrast agents used for myelography. We describe a patient with thoracic arachnoiditis, arachnoid cyst and syringomyelia, 30 years following a myelogram with Myodil. A 62-year-old female presented with chronic thoraco-lumbar back pain, a spastic paraparesis and sphincter disturbance. She had undergone a myelogram with Myodil, 30 years previously for investigation of back pain. A MRI scan revealed evidence of arachnoiditis, thoracic syringomyelia (T6-T8) and an anteriorly placed, extramedullary, arachnoid cyst at T10-T12, compressing the cord. At surgery, T7-T10 thoracic laminectomies were carried out and syringo- and cysto-subarachnoid shunts were inserted. At 12 months follow-up, the sphincter disturbance, lower limb weakness and mobility problems had almost resolved. Although, the use of oil based contrast agents such as Myodil has been discontinued, the present case illustrates some of the rare sequelae of its use, manifesting decades later. Aggressive surgical intervention produced symptomatic benefit.

Objective: Although uncommon, residual effects from contrast agents used more than 2 decades ago are possible. This case report is to alert clinicians to the implications of residual oil-based ionic contrast agents in the intrathecal space., Case Report: A 70-year-old female with evidence of degenerative disc disease underwent a series of lumbar epidural steroid injections. Fluoroscopy during the procedure revealed diffuse residual intrathecal iophendylate (Pantopaque) dye. We were able to demonstrate unrestricted epidural spread of 1 mL iohexol (Omnipaque 180) alongside the preexisting dye., Conclusions: The goal of this case report is to highlight the potential of residual myelographic dye to complicate interventional procedures. Such residual dye can increase the level of difficulty in performing interventional pain treatments and perhaps the rate of complications associated with epidural injections, such as dural puncture. The presence of large amounts of residual oil-based intrathecal dye can lead to erroneous interpretations of the dye patterns as intraspinal lipoma or hemorrhage. As a consequence, the patient can be submitted to unnecessary diagnostic and therapeutic interventions. In addition, concerns of worsening oil-based dye-induced arachnoiditis with the use of epidural steroid injections can complicate the treatment of patients with back pain.

We present an unusual case of thoracic constrictive arachnoiditis after pantopaque myelography, used 10 years before in the diagnosis of intradural arachnoid cyst.

The reported incidence of clinically significant arachnoiditis following oil-based contrast media myelography is approximately 1%. The incidence of arachnoiditis in the dorsal spine is even more rare. Acquired arachnoid cyst formation can occur with arachnoiditis of various aetiologies. A case is presented of a patient with chronic backache, radiculopathy, weakness and muscle wasting, who had undergone myelography with oil-based contrast media about 28 years ago. There was no history of spinal surgery, spinal canal stenosis, disc disease or trauma, all of which are known to increase the risk of arachnoiditis. Magnetic resonance imaging features are presented in this case of arachnoiditis with arachnoid cyst formation, and cord tethering.

We report the case of a myodil cyst causing a thoracic radiculopathy in a patient who had undergone a myelogram 30 years previously. Although myodil is no longer used, sequelae can continue to be seen for many years.

Objective and Importance: We describe a unique presentation of a thoracic spinal Pantopaque cyst. Although Pantopaque is no longer used, sequelae of its long-term use may continue to surface., Clinical Presentation: Our patient presented to the emergency room with 4 months of progressive lower extremity numbness, spasticity, and incontinence and a 2-day history of left upper extremity dysesthesias. Magnetic resonance imaging at admission revealed a C7-T10 syrinx and an intrathecal extramedullary mass to the right of the spinal cord at T10-T11., Intervention: Radiographic evidence led to the initial diagnosis of hemangioblastoma. The results of a critical analysis of the preoperative studies caused us to suspect a Pantopaque cyst. This suspicion was confirmed at the time of surgery, when a cyst filled with contrast medium was revealed. T9-T11 laminectomies were performed, allowing for a 5-cm dural opening. The cyst was aspirated and excised, and then the syrinx was decompressed., Conclusion: Our patient experienced significant sensory and motor improvement postoperatively. We present a previously undescribed complication of one of the most commonly used contrast media, Pantopaque. Despite its replacement with newer agents, it may continue to play a significant role in the pathological presentation of patients in whom it was previously used.

Although there is a substantial body of evidence implicating Myodil or Pantopaque as a cause of lumbar arachnoiditis, assessment of the clinically based evidence is complicated by the additional potentially causative factors present in a high proportion of cases. These include pre-existing spinal pathology, traumatic lumbar puncture and surgery. The aim of this retrospective study was to attempt to ascertain whether Myodil introduced via ventricular catheter was associated with subsequent development of symptomatic lumbar arachnoiditis. In 222 patients in whom clinical records were reviewed there was no excess of back pain following ventriculography compared to the general population. Myodil ventriculography does not appear to be a major cause of symptomatic lumbar arachnoiditis. Several unavoidable problems with the methodology of this study are discussed.

Chronic lumbar arachnoiditis has numerous causes, including the introduction of contrast media into the lumbar subarachnoid space. The oily contrast medium Myodil (iophendylate) is often cited but the true incidence of symptomatic lumbar arachnoiditis due solely to the presence of Myodil is unknown. A retrospective review of 98 patients in whom Myodil was introduced by ventriculography or cisternography, i.e. remote from the lumbar spine, revealed no cases of chronic lumbar arachnoiditis. All patients were monitored closely for periods ranging from 1 to 28 years. We conclude that, in these circumstances, it is rare for Myodil to produce symptomatic arachnoiditis.

Two cases of vestibular disturbance caused by residual oily contrast medium in the internal auditory canals after myelography are reported. Nystagmus towards the affected side and normal caloric responses were observed; therefore, contrast media are considered to act as irritants to the vestibular nerve.

Clinical features and serial cerebrospinal fluid (CSF) samples of 50 patients who underwent myelography with iophendylate were studied. Forty two patients (84%) developed one or more features suggestive of meningism lasting for 2-4 days. There was significant rise in the average (mean) CSF counts from 9.81 in the premyelogram sample to 532.6 at the end of 24 hours (p less than 0.001). Both neutrophil and lymphocyte (p less than 000) count increased. At the end of one week, there was significant decrease of total cells in the CSF to 204 (p less than 0.001). Both, neutrophils and lymphocytes decreased. There was significant rise in total proteins in the 24 hours sample, but the fall at one week was not significant statistically. The sugar and chloride values did not change significantly. All CSF samples were negative for bacterial cultures. In conclusion, a significant proportion of the patients undergoing iophendylate myelography develop clinical features suggestive of meningeal irritation and change in the CSF fractions suggestive of meningitis: however these changes are transient and do not warrant institution of chemotherapy or steroids.

Reported is a case in which chronic arachnoiditis resulted as a complication of using Pantopaque in studying the posterior fossa. The possibility that prophylactic intrathecal injections of methylprednisolone acetate while performing Pantopaque myelography help avoid serious complications is discussed.

The diagnostic quality and side effects of Amipaque and Pantopaque as myelographic contrast agents were compared prospectively using the identical protocol in 167 cases (117 Amipaque, 50 Pantopaque). Good ratings were attained in 74% of Amipaque and 76% of Pantopaque examinations. Demonstration of nerve rootlets in the cauda equina and filling of lumbar root sleeves were superior with Amipaque. Amipaque more easily demonstrated the high posterior cervical subarachnoid space and the anterior and posterior margins of the cervical spinal cord. The incidence of postmyelographic headache was 38% with Amipaque and 32% with Pantopaque. Nausea and vomiting were more common with Amipaque. Two patients experienced grand mal seizures after examination sith Amipaque.

Opacification of the regional epidural venous plexus is an untoward circumstance of myelography. The following case reports demonstrate the epidural veins and the transient pulmonary symptoms that resulted.

Two unusual cases of constrictive arachnoiditis localized to thoracic levels after Pantopaque myelography and unrelated to any operation, trauma, or disc disease at these levels are presented. The pertinent literature is reviewed.

Aqueous myelographic contrast media are needed that are less expensive and better tolerated than metrizamide. This study compares two new, nonionic aqueous contrast media, ioglunide and iopamidol, with two previously developed contrast media, metrizamide and iocarmate. Myelography was performed with one of the contrast media in monkeys; four weeks later the degree of arachnoid fibrosis was determined in each animal by myelographic and histologic studies of the dural sac. Iopamidol, ioglunide, and metrizamide produced no more arachnoid changes than were found in the control animals. Iocarmate produced moderate to severe arachnoiditis.

A case in which a remarkable series of CT studies demonstrated a dermoid cyst is reported. There was leakage of fat into the ventricular system which caused hydrocephalus due to adhesions partly obstructing the fourth ventricular outlets. The latter was confirmed by a ventriculogram using Myodil which dissolved in, or combined with, the fat produced by the tumour. This resulted in a high attenuation substance of lower specific gravity than CSF, which appeared to cause acute ventriculitis.

The introduction of computerized axial tomography (C.T.) in 1973 completely changed the diagnostic evaluation of acoustic neuromas. Seventy to eighty percent of all acoustic neuromas can be diagnosed with intravenous enhanced C.T. scan. Acoustic tumors with a diameter of less than 1.5 cm, however, are not consistently seen on C.T. scan. Twenty-six consecutive patients were evaluated by C.T. scan with air contrast posterior fossa myelography (C.T. air cisternography). Nineteen studies were normal, with complete air filling of the internal auditory canal. Surgically verified acoustic neuromas were demonstrated in four patients. Two studies were inconclusive and there was one false positive. Other than headaches, there is no morbidity associated with this technique. C.T. air cisternography should be considered as the definitive study for evaluating patients for acoustic neuromas who have normal intravenous contrast enhanced C.T. scans. This study reports the first intracanalicular tumor diagnosed with this technique.

Extensive examinations after couple of months or years after pantopaque-cisternography were performed in 20 patients, in whom no central nervous system diseases were known and in whom no surgery of CNS was previously performed. With only one exception the contrast medium was found intracranially with preference to the sella and to the region of the frontobasis. No connection was found between the amount of pantopaque and the length of time since the performance of cisternography. No late neurological complications were observed.

Two cases of complete and permanent paraplegia following lumbar myelography using iophendylate are reported. Both patients had had syphilis many years earlier.

It is reported on three patients which suffered from severe side effects after cervical myelography using Amipaque (cases 1 and 3) and Pantopaque (case 2). In 2 cases death occurred after 13 days (case 2) respectively 17 days (case 3). Worsening of the clinical symptoms appeared in all cases within four days after myelography. In the first 2 cases inflammatory alterations prevailed whereas in the third case complications probably based on mechanical irritations of nerval and vascular structures. In the 2 lethal cases autopsy offered a prostatic cancer with vertebral and intraspinal metastases respectively syringobulbia and cervical syringomyelia beside an ependymoma of the cervical spinal cord as incurrable complaints. The various side effects and complications after myelography using positive contrast media as well as their causes are discussed.

A retrospective survey was made of 57 consecutive patients referred for myelography by one neurological team. Reactions occurred in patients with multiple sclerosis significantly more often than in all other patients (P=0.01). This finding appears to support the belief that demyelination may be associated with more severe reactions to iophendylate myelography.

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.

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.

Local Pantopaque instillation receives continued support in the urologic and radiologic literature as a method for treating benign renal cysts. If benign renal cysts are a common lesion with an exceedingly small complication rate, what is the rationale for such treatment with a potentially hazardous substance?

Metrizamide is an attractive myelographic agent with several advantages over other available myelographic agents. Radiographic detail is generally superior to Pantopaque and gas myelography, the material need not be aspiradted and does not appear to result in long-term complicaitons. Because of its low neuro-toxicity, it may be allowed to come into contact with the spinal cord and brain, unlike other water-soluble agents. Its main disadvantages are its tendency to diffuse into the CSF when run from one portion of the spinal canal to another and the occurrence of acute toxic effects such as vomiting and, rarely, seizures.

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.

Late sequelae (adhesive arachnoiditis) have been reported following myelography with the oily contrast medium (Pantopaque) and with the ionic water-soluble contrast media methiodal sodium (Abrodil, Conturex, Kontrast U) meglumine iothalamate (Conray Meglumine) and meglumine iocarmate (Bis-Conray, Dimer-X). Adhesive arachnoiditis has not yet been reported after the use of the nonionic water-soluble contrast medium metrizamide (Amipaque). Thus, this is considered the contrast medium of choice for lumbar myelography. Using the recommended dose of 10 ml with an iodine concentration of 170 mg/ml for this examination, adhesive arachnoiditis is unlikely to occur. Increased osmolality of spinal fluid after injection of contrast medium is related to increased frequency of arachnoiditis.

Arachnoiditis occurring after myelography is well recognized and the mechanism is understood. Three cases of arachnoiditis caused by oily myelographic contrast media are presented. This complication of myelography may occur even if recognized precautions are observed. The general problem of encystment of dye with a chronic inflammatory process, fibrosis and granuloma formation is described.

In a case of chronic, severe urticaria and intermittent episodes of anaphylaxis due to an iophendylate injection (Pantopaque) given in the course of myelography, almost complete relief was obtained from the removal of approximately 8 ml of residual iophendylate from the spinal canal. Data obtained from direct skin testing, Prausnitz-Küstner testing, peptide inhibition of Prausnitz-Küstner testing, and IgE levels quantitated before and after removal of iophendylate indicate that these symptoms were mediated via an IgE anti-iophendylate reaction.

A case with delayed development of obstructive hydrocephalus most probably caused by Pantopaque myelography is reported. At autopsy it was found that the foramina of Magendi and Luschka were occluded by granulation tissue in which the most common findings were multinucleated giant cells containing calcareous and unstained vacuoles, frequently surrounding empty hollows, many lymphocytes and plasma cells. As compared with two other similar cases and several animal investigations this shows that the reaction of the tissue is typical of a Pantopaque reaction.

Ioglunide, a new nonionic contrast medium, has attracted attention by its virtual absence of immediate or delayed effect on brain electrical activity in animal studies. After 126 myelographies or cisternographies with ioglunide, routine electroencephalograms (EEG) and brain potential frequency analyses were performed in 109 and 73 patients, respectively. EEG changes were noted in 3.7% of subjects. Moderate meningeal signs were present in 16% of subjects. No severe adverse reactions (psychoorganic syndrome, asterixis, or hallucination) were observed. Ioglunide appears to represent a marked advance in neuroradiology in providing for the comfort of patients and the safety of the radiological procedures.