Neuroradiology
The Effect of Hydration on the Acute and Chronic Complications of Aqueous Myelography An Experimental Study 1 O. Petter Eldevik, M.D., 2 and Victor M. Haughton, M.D.
The effect of hydration on the incidence ofcomplications from myelography with aqueous media Was studied. Myelography was performed with rnethylqlucarnlne iocarmate indehydrated and vigorously hydrated monkeys. the incidence of seizures and the severity of arachnoiditis were significantly greater inthe dehydrated animals. The authors suggest that patients be permitted fluids ad lib. prior tomyelography with aqueous media, orinsome cases begiven fluids intravenously. INDEX TERMS: Arachnoid, inflammation. Myelography, complications, 3[0].440 • Myelography, contrast media, 3 [0] .1222 • (Spine and contents, myelography, 3 [0] .122) Radiology 129:713-714;
December
1978
deprived of food and water prior to the study; Group II animals were given water ad lib. and hydrated with intravenous fluids. The animals were again observed for seizures. The niyelograms were studied for evidence of arachnoiditis and scored on a scale of 0 (normal) to 36 (presence of severe constriction of the arachnoid sac or blunting of the axillary pouch). Eighteen hours after taking the second myelogram, the animals were killed and the dural sac was removed, fixed, embedded, stained, and examined for arachnoid fibrosis. Histological evidence of arachnoiditis was also scored on a scale of 0 (normal) to 36 (severe fibrosis of the arachnoid, subarachnoid, and subdural space).
ATIENTS ARE customarily denied food or liquids for several hours prior to myelography with aqueous contrast media (1-4,8,9; 11-14, 16-19). However, dehydration resulting from an overnight fast increases the incidence and severity of side effects (7). Since the effect of dehydration on serious complications has not been investigated in an experimental model to our knowledge, we conducted a study of seizures and arachnoiditis resulting from experimental myelography with aqueous contrast media.
P
MATERIALS AND METHODS
Eight tuberculin-negative, healthy macaque monkeys (5-8 kg) were used. Four animals (Group I) were deprived of food and water for 18 hours prior to and 18 hours after myelography. Four animals (Group II) were permitted water ad lib. before and after myelography and received an intravenous infusion of 500 ml of 5 % dextrose in water just before and during myelography. The same myelographic technique was used in both groups. Lumbar puncture was performed at the L3-L4 interspace and 1.2 ml of methylglucamine iocarmate" was injected intrathecally under fluoroscopic monitoring. Radiographs were taken, after which the animals were placed in primate chairs for 18 hours and observed for seizures. Twelve weeks later, myelography was repeated. Group I animals were again
RESULTS
Two animals in Group I had seizures 6 to 12 hours after the second myelogram was obtained. None of the animals in Group II had seizures (TABLE I). This difference is statistically significant (p < 0.05). All four animals in Group I and one of those in Group II had complete blockage of the subarachnoid space, consistent with arachnoiditis. Three animals in Group II had evidence of mild arachnoiditis. Myelographic scores in Group I and Group II differed significantly (p < 0.05). Histological examination of all eight animals revealed evidence of arachnoiditis of varying degree. The dehydrated
TABLE I: EFFECT OF HYDRATION ON ACUTE AND CHRONIC COMPLICATIONS OF AQUEOUS MYELOGF3APHY
Group I (Dehydrated) II (Hydrated) *
No. of Animals
Seizures (% of Animals)
4 4
50
o
Severity of Arachnoiditis Myelographic Histological Evidence Evidence 36, * 36, * 36, * 36* 11,27,31,36*
12;18, 19,20 8,15,18,19
Blockage of the subarachnoid space
1 From the Department ofRadiology, Milwaukee County General Hospital, Milwaukee, Wisc. Received March 23,1978; accepted and revision requested June 16; revision received July 10. 2 Present address: Department of Neuroradiology, Ulleval Hospital, Oslo, Norway. 3 Dimeray, Mallinckrodt Pharmaceutical Co., St. Louis, Mo. sjh 713
714
O. PETTER ELDEVIK AND VICTOR M. HAUGHTON
animals received higher scores (Jl = 17)than the hydrated 15), but the difference was not statistically ones (Jl significant.
December 1978
REFERENCES
=
DISCUSSION
'Seizures occurred only in the dehydrated animals and only after repeated myelography. This suggests that animals undergoing repeat myelography have a higher risk of seizures than animals undergoing initial myelography (5). Also, animals with arachnoiditis have a significantly higher risk of seizures from aqueous myelography than normal animals. Because of arachnoiditis and previous myelography, all animals were at risktor seizures from the second study. However, hydration significantly reduced the incidence of seizures in Group II animals. This may be due to (a) less severe arachnoiditis, (b) more rapid excretion of contrast medium, or (c) a higher seizure threshold. Experimental evidence (5, 6) supports the first two conclusions. The present study suggests that hydration decreases the incidence of serious complications from myelography with methylglucamine iocarrnate. It is not yet clear whether acute complications (seizures) or chronic complications (arachnoiditis) are more markedly affected by hydration. The dehydration produced in these monkeys is more severe than in patients undergoing myelography after an overnight fast. The severe experimental conditions were selected so that significant results could be obtained without sacrificing a large number of animals. Nevertheless, the conclusions of the experimental study may be valid for patients 'with less severe degrees of hydration. Optimal hydration would appear to be conducive to safe myelography with aqueous media. The dehydrated patient should be hydrated prior to myelography, using either oral or intravenous fluids. The effect of hydration on the complications from myelography with metrizamide may be more difficult to measure, because the risk of seizures (5, 15, 18) or arachnoiditis (10) from metrizamide is low. Nevertheless, hydration is recommended for the patient undergoingmyelography with metrizamide to minimize any risk of complications and side effects. Department of Neuroradiology Ulleval Hospital Oslo 1 . Norway
1. Ahlgren P: Amipaque myelography. The side effects compared with Dimer X. Neuroradiology 9: 197-202, 29 Aug 1975 2. Ahlgren P: Long term side effects after myelography with watersoluble contrast media: Conturex, Conray Meglumin 282 and Dimer-X. Neuroradiology 6:206-211, Dec 1973 3. Autio E, Suolanen J, Norrback S, et al: Adhesive arachnoiditis after lumbar myelography with meglumine iocarmate (Conray). Acta Radiol (Diag) 12:17-24, Jan 1972 4. Dullerud R, M0rland TJ: Adhesive arachnoiditis after lumbar radiculography with Dimer-X and Depo-Medrol. Radiology 119:153-155, Apr 1976 5. Eldevik OP, Haughton VM: Risk factors in complications of aqueous myelography. Radiology 128:415-416, Aug 1978 6. Eldevik OP, Haughton VM: Unpublished data 7. Eldevik OP, Nakken KO, Haughton VM: The effect of dehydration on the side effects of metrizamide myelography. Radiology 129:715-716~ Dec 1978 8. Halaburt H, Lester J: Leptomeningeal changes following lumbar myelography with water-soluble contrast media (meglumine iothalamate and methiodal sodium). Neuroradiology 5:70-76, Apr
1973 9. Hansen EB, Praestholm J, Fahrenkrug A, et al: A clinical trial of Amipaque in lumbar myelography. Br ,J Radiol 49:34-38, Jan
1976 10.
Haughton VM, Ho K-C, Larson SJ, et al: Experimental production of arachnoiditis with water-soluble myelographic media. Radiology 123:681-685, Jun 1977 11. Irstam L: Side effect of water-soluble contrast media in lumbar myelography. Acta Radiol (Diag) 14:647-656, Nov 1973 12. Irstam L, Rosencrantz M: Water-soluble contrast media and adhesive arachnoiditis. I. Reinvestigation of nonoperated cases. Acta Radiol (Diag) 14:497-506, Sep 1973 13. Irstam L, Rosencrantz M: Water-soluble contrast media and adhesive arachnoiditis. II. Reinvestigation of operated cases. Acta Radiol (Diag) 15:1-15, Jan 1974 14. lrstam L, Sundstrom R, Sigstedt B: Lumbar myelography and adhesive arachnoiditis. Acta Radiol (Diag) 15:356-368, Jul 1974 15. Oftedal S-I: Toxicity of water-soluble contrast media injected suboccipitally in cats. [In] Metrizamide. A non-ionic water-soluble contrast medium. Experimental and preliminary clinical investigations. Acta Radiol {Suppl 335):84-92, 1973 . 16. Radberg C, Wennberg E: Late sequelae following lumbar myelography with water-soluble contrast media. Acta Radiol (Diag) 14:507-512, Sep 1973 17. Skalpe 10: Adhesive arachnoiditis following lumbar radiculography with water-soluble contrast agents. A clinical report with special reference to metrizamide. Radiology 121:647-651, Dec
1976 18.
Skalpe 10: Myelography with metrizamide, meglumine iothalamate and meglumine iocarmate. An experimental investigation in cats. [In] Metrizamide. A non-ionic water-soluble contrast medium. Experimental and preliminary clinical investigations. Acta Radiol {Suppl
335):57 -66, 1973 19. Skalpe 10, Torbergsen T, Amundsen P, et al: Lumbar myelography with metrizamide. [In] Metrizamide. A non-ionic water-soluble contrast medium. Experimental and preliminary clinical investigations. Acta Radiol {Suppl 335):367~379, 1973
The Effect of Hydration on the Acute and Chronic Complications of Aqueous Myelography An Experimental Study 1 O. Petter Eldevik, M.D., 2 and Victor M. Haughton, M.D.
The effect of hydration on the incidence ofcomplications from myelography with aqueous media Was studied. Myelography was performed with rnethylqlucarnlne iocarmate indehydrated and vigorously hydrated monkeys. the incidence of seizures and the severity of arachnoiditis were significantly greater inthe dehydrated animals. The authors suggest that patients be permitted fluids ad lib. prior tomyelography with aqueous media, orinsome cases begiven fluids intravenously. INDEX TERMS: Arachnoid, inflammation. Myelography, complications, 3[0].440 • Myelography, contrast media, 3 [0] .1222 • (Spine and contents, myelography, 3 [0] .122) Radiology 129:713-714;
December
1978
deprived of food and water prior to the study; Group II animals were given water ad lib. and hydrated with intravenous fluids. The animals were again observed for seizures. The niyelograms were studied for evidence of arachnoiditis and scored on a scale of 0 (normal) to 36 (presence of severe constriction of the arachnoid sac or blunting of the axillary pouch). Eighteen hours after taking the second myelogram, the animals were killed and the dural sac was removed, fixed, embedded, stained, and examined for arachnoid fibrosis. Histological evidence of arachnoiditis was also scored on a scale of 0 (normal) to 36 (severe fibrosis of the arachnoid, subarachnoid, and subdural space).
ATIENTS ARE customarily denied food or liquids for several hours prior to myelography with aqueous contrast media (1-4,8,9; 11-14, 16-19). However, dehydration resulting from an overnight fast increases the incidence and severity of side effects (7). Since the effect of dehydration on serious complications has not been investigated in an experimental model to our knowledge, we conducted a study of seizures and arachnoiditis resulting from experimental myelography with aqueous contrast media.
P
MATERIALS AND METHODS
Eight tuberculin-negative, healthy macaque monkeys (5-8 kg) were used. Four animals (Group I) were deprived of food and water for 18 hours prior to and 18 hours after myelography. Four animals (Group II) were permitted water ad lib. before and after myelography and received an intravenous infusion of 500 ml of 5 % dextrose in water just before and during myelography. The same myelographic technique was used in both groups. Lumbar puncture was performed at the L3-L4 interspace and 1.2 ml of methylglucamine iocarmate" was injected intrathecally under fluoroscopic monitoring. Radiographs were taken, after which the animals were placed in primate chairs for 18 hours and observed for seizures. Twelve weeks later, myelography was repeated. Group I animals were again
RESULTS
Two animals in Group I had seizures 6 to 12 hours after the second myelogram was obtained. None of the animals in Group II had seizures (TABLE I). This difference is statistically significant (p < 0.05). All four animals in Group I and one of those in Group II had complete blockage of the subarachnoid space, consistent with arachnoiditis. Three animals in Group II had evidence of mild arachnoiditis. Myelographic scores in Group I and Group II differed significantly (p < 0.05). Histological examination of all eight animals revealed evidence of arachnoiditis of varying degree. The dehydrated
TABLE I: EFFECT OF HYDRATION ON ACUTE AND CHRONIC COMPLICATIONS OF AQUEOUS MYELOGF3APHY
Group I (Dehydrated) II (Hydrated) *
No. of Animals
Seizures (% of Animals)
4 4
50
o
Severity of Arachnoiditis Myelographic Histological Evidence Evidence 36, * 36, * 36, * 36* 11,27,31,36*
12;18, 19,20 8,15,18,19
Blockage of the subarachnoid space
1 From the Department ofRadiology, Milwaukee County General Hospital, Milwaukee, Wisc. Received March 23,1978; accepted and revision requested June 16; revision received July 10. 2 Present address: Department of Neuroradiology, Ulleval Hospital, Oslo, Norway. 3 Dimeray, Mallinckrodt Pharmaceutical Co., St. Louis, Mo. sjh 713
714
O. PETTER ELDEVIK AND VICTOR M. HAUGHTON
animals received higher scores (Jl = 17)than the hydrated 15), but the difference was not statistically ones (Jl significant.
December 1978
REFERENCES
=
DISCUSSION
'Seizures occurred only in the dehydrated animals and only after repeated myelography. This suggests that animals undergoing repeat myelography have a higher risk of seizures than animals undergoing initial myelography (5). Also, animals with arachnoiditis have a significantly higher risk of seizures from aqueous myelography than normal animals. Because of arachnoiditis and previous myelography, all animals were at risktor seizures from the second study. However, hydration significantly reduced the incidence of seizures in Group II animals. This may be due to (a) less severe arachnoiditis, (b) more rapid excretion of contrast medium, or (c) a higher seizure threshold. Experimental evidence (5, 6) supports the first two conclusions. The present study suggests that hydration decreases the incidence of serious complications from myelography with methylglucamine iocarrnate. It is not yet clear whether acute complications (seizures) or chronic complications (arachnoiditis) are more markedly affected by hydration. The dehydration produced in these monkeys is more severe than in patients undergoing myelography after an overnight fast. The severe experimental conditions were selected so that significant results could be obtained without sacrificing a large number of animals. Nevertheless, the conclusions of the experimental study may be valid for patients 'with less severe degrees of hydration. Optimal hydration would appear to be conducive to safe myelography with aqueous media. The dehydrated patient should be hydrated prior to myelography, using either oral or intravenous fluids. The effect of hydration on the complications from myelography with metrizamide may be more difficult to measure, because the risk of seizures (5, 15, 18) or arachnoiditis (10) from metrizamide is low. Nevertheless, hydration is recommended for the patient undergoingmyelography with metrizamide to minimize any risk of complications and side effects. Department of Neuroradiology Ulleval Hospital Oslo 1 . Norway
1. Ahlgren P: Amipaque myelography. The side effects compared with Dimer X. Neuroradiology 9: 197-202, 29 Aug 1975 2. Ahlgren P: Long term side effects after myelography with watersoluble contrast media: Conturex, Conray Meglumin 282 and Dimer-X. Neuroradiology 6:206-211, Dec 1973 3. Autio E, Suolanen J, Norrback S, et al: Adhesive arachnoiditis after lumbar myelography with meglumine iocarmate (Conray). Acta Radiol (Diag) 12:17-24, Jan 1972 4. Dullerud R, M0rland TJ: Adhesive arachnoiditis after lumbar radiculography with Dimer-X and Depo-Medrol. Radiology 119:153-155, Apr 1976 5. Eldevik OP, Haughton VM: Risk factors in complications of aqueous myelography. Radiology 128:415-416, Aug 1978 6. Eldevik OP, Haughton VM: Unpublished data 7. Eldevik OP, Nakken KO, Haughton VM: The effect of dehydration on the side effects of metrizamide myelography. Radiology 129:715-716~ Dec 1978 8. Halaburt H, Lester J: Leptomeningeal changes following lumbar myelography with water-soluble contrast media (meglumine iothalamate and methiodal sodium). Neuroradiology 5:70-76, Apr
1973 9. Hansen EB, Praestholm J, Fahrenkrug A, et al: A clinical trial of Amipaque in lumbar myelography. Br ,J Radiol 49:34-38, Jan
1976 10.
Haughton VM, Ho K-C, Larson SJ, et al: Experimental production of arachnoiditis with water-soluble myelographic media. Radiology 123:681-685, Jun 1977 11. Irstam L: Side effect of water-soluble contrast media in lumbar myelography. Acta Radiol (Diag) 14:647-656, Nov 1973 12. Irstam L, Rosencrantz M: Water-soluble contrast media and adhesive arachnoiditis. I. Reinvestigation of nonoperated cases. Acta Radiol (Diag) 14:497-506, Sep 1973 13. Irstam L, Rosencrantz M: Water-soluble contrast media and adhesive arachnoiditis. II. Reinvestigation of operated cases. Acta Radiol (Diag) 15:1-15, Jan 1974 14. lrstam L, Sundstrom R, Sigstedt B: Lumbar myelography and adhesive arachnoiditis. Acta Radiol (Diag) 15:356-368, Jul 1974 15. Oftedal S-I: Toxicity of water-soluble contrast media injected suboccipitally in cats. [In] Metrizamide. A non-ionic water-soluble contrast medium. Experimental and preliminary clinical investigations. Acta Radiol {Suppl 335):84-92, 1973 . 16. Radberg C, Wennberg E: Late sequelae following lumbar myelography with water-soluble contrast media. Acta Radiol (Diag) 14:507-512, Sep 1973 17. Skalpe 10: Adhesive arachnoiditis following lumbar radiculography with water-soluble contrast agents. A clinical report with special reference to metrizamide. Radiology 121:647-651, Dec
1976 18.
Skalpe 10: Myelography with metrizamide, meglumine iothalamate and meglumine iocarmate. An experimental investigation in cats. [In] Metrizamide. A non-ionic water-soluble contrast medium. Experimental and preliminary clinical investigations. Acta Radiol {Suppl
335):57 -66, 1973 19. Skalpe 10, Torbergsen T, Amundsen P, et al: Lumbar myelography with metrizamide. [In] Metrizamide. A non-ionic water-soluble contrast medium. Experimental and preliminary clinical investigations. Acta Radiol {Suppl 335):367~379, 1973
