J Neurosurg 49:607-609, 1978
Traumatic cerebrospinal fluid-lymphatic fistula Case report
ZELIMIR K o z l c , M . D . , AND LAWRENCE H . ZINGESSER, M . D .
Radiology Department, Division of Neuroradiology, Albert Einstein College of Medicine, New York, New York
~" A case is presented of lymphatic intravasation of Pantopaque during myelography in a patient with a gunshot injury to the sacrum. KEY WORDS extravasation
*
myelography 9 complication 9 Pantopaque 9 9 traumatic fistula 9 cerebrospinal fluid-lymphatic fistula
T
HIS report concerns a patient with a traumatic cerebrospinal fluid (CSF)lymphatic fistula resulting from a gunshot wound. To our knowledge this type of fistula has not been previously reported. There are several reports in the literature 1 3 describing venous intravasation of Pantopaque during myelography.
Case Report
This 15-year-old girl was accidentally shot in the pelvis. The bullet entered above the left iliac crest anteriorly, went diagonally through the vertebral body of S-l, through the sacral canal, and lodged in the soft tissue to the right of the midline. Immediately after the accident, the patient developed numbness and foot drop on the left side. Sagittal tomographic cuts through the sacral region revealed multiple metallic fragments within the vertebral body of S-1 and sacral canal, outlining the bullet's path. Neurological exJ. Neurosurg. / Volume 49 / October, 1978
amination revealed sensory and motor loss over the L5-S 1 area. Bladder and rectal functions were intact. Myelography was performed 2 days after the injury, with 12 cc of Pantopaque. While the contrast material was being administered, fluoroscopy showed that it was leaking through the bullet's path at S-1 and filling the parailiac lymphatic channels bilaterally. The lymphatic channels filled in antegrade and retrograde fashion with visualization of the parailiac lymph nodes (Fig. 1). Retrograde filling of the lymphatic channels and nodes is explained by the patient's semi-erect position during the procedure and high specific gravity of Pantopaque. Several interval films were obtained and showed progressive diminution of contrast material in the subarachnoid space (Fig. 2). Within 10 minutes, approximately 10 cc of Pantopaque drained from the subarachnoid space through this traumatic fistula. A 4-hour film showed no Pantopaque material within the subarachnoid space. 607
Z. Kozie a n d L. H. Zingesser
FIG. 1. Left." Myelographyshowingretrograde fillingof the lymphatic channels and nodes bilaterally. Note the bullet. Right." Lateral view shows leakage of Pantopaque into the sacral bullet tracks and filling of the lymphatic channels. Posteroanterior films of the chest were taken immediately, at 4 hours, and at 24 hours after Pantopaque administration. The immediate films showed several transient fine linear streaks in the right upper lobe. The 4hour film revealed a fine reticular pattern mostly in the right lung field which had cleared completely on the 24-hour film. Our patient did not have clinical manifestation of pulmonary oil embolization such as non-productive cough, chest pain, or fever. She was treated conservatively with considerable improvement in her deficit and was later discharged. Discussion Venous intravasation of Pantopaque is an infrequent complication of myelography and occurs when a needle is placed in ventral or dorsal peridural veins. Actual entrance of the FIG. 2. Five minutes later. Disappearance of contrast material can be seen by fluoroscopy subarachnoidal Pantopaque with proximal filling or from cineroentgenographic recording. It was estimated by Steinbach and HilP that of lymph nodes and channels. 608
J. Neurosurg. / Volume 49 / October, 1978
Traumatic CSF-lymphatic fistula approximately 4 to 7.5 cc of the Pantopaque has to enter the venous system to gwe radiographic visualization of the pulmonary embolization. In our patient 12 cc of the Pantopaque was administered over a 4-hour period, with radiographic but not clinical evidence of pulmonary embolization. This is probably due to the prolonged introduction of Pantopaque via an inherently slow lymphatic route and retention by lymphatic nodes. Introduction of Pantopaque into venous or lymphatic vessels carries the danger of pulmonary embolization. Clinical manifestation of pulmonary embolization is probably related to the volume and speed by which Pantopaque enters the venous circulation.
J. Neurosurg. / Volume 49 / October, 1978
References
1. Epstein BS, Epstein JA: The cineroentgenographic observation of Pantopaque intravasation during myelography. Am J Roentgenol Radium Ther Nuel Med 94:576-579, 1965 2. Keats TE: Pantopaque pulmonary embolism. Radiology 67:748-750, 1956 3. Steinbach HL, Hill WB: Pantopaque pulmonary embolism during myelography. Radiology 56:735-738, 1951 Address reprint requests to: Zelimir Kozic, M.D., Radiology Department/Division of Neuroradiology, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, New York 10461.
609
Traumatic cerebrospinal fluid-lymphatic fistula Case report
ZELIMIR K o z l c , M . D . , AND LAWRENCE H . ZINGESSER, M . D .
Radiology Department, Division of Neuroradiology, Albert Einstein College of Medicine, New York, New York
~" A case is presented of lymphatic intravasation of Pantopaque during myelography in a patient with a gunshot injury to the sacrum. KEY WORDS extravasation
*
myelography 9 complication 9 Pantopaque 9 9 traumatic fistula 9 cerebrospinal fluid-lymphatic fistula
T
HIS report concerns a patient with a traumatic cerebrospinal fluid (CSF)lymphatic fistula resulting from a gunshot wound. To our knowledge this type of fistula has not been previously reported. There are several reports in the literature 1 3 describing venous intravasation of Pantopaque during myelography.
Case Report
This 15-year-old girl was accidentally shot in the pelvis. The bullet entered above the left iliac crest anteriorly, went diagonally through the vertebral body of S-l, through the sacral canal, and lodged in the soft tissue to the right of the midline. Immediately after the accident, the patient developed numbness and foot drop on the left side. Sagittal tomographic cuts through the sacral region revealed multiple metallic fragments within the vertebral body of S-1 and sacral canal, outlining the bullet's path. Neurological exJ. Neurosurg. / Volume 49 / October, 1978
amination revealed sensory and motor loss over the L5-S 1 area. Bladder and rectal functions were intact. Myelography was performed 2 days after the injury, with 12 cc of Pantopaque. While the contrast material was being administered, fluoroscopy showed that it was leaking through the bullet's path at S-1 and filling the parailiac lymphatic channels bilaterally. The lymphatic channels filled in antegrade and retrograde fashion with visualization of the parailiac lymph nodes (Fig. 1). Retrograde filling of the lymphatic channels and nodes is explained by the patient's semi-erect position during the procedure and high specific gravity of Pantopaque. Several interval films were obtained and showed progressive diminution of contrast material in the subarachnoid space (Fig. 2). Within 10 minutes, approximately 10 cc of Pantopaque drained from the subarachnoid space through this traumatic fistula. A 4-hour film showed no Pantopaque material within the subarachnoid space. 607
Z. Kozie a n d L. H. Zingesser
FIG. 1. Left." Myelographyshowingretrograde fillingof the lymphatic channels and nodes bilaterally. Note the bullet. Right." Lateral view shows leakage of Pantopaque into the sacral bullet tracks and filling of the lymphatic channels. Posteroanterior films of the chest were taken immediately, at 4 hours, and at 24 hours after Pantopaque administration. The immediate films showed several transient fine linear streaks in the right upper lobe. The 4hour film revealed a fine reticular pattern mostly in the right lung field which had cleared completely on the 24-hour film. Our patient did not have clinical manifestation of pulmonary oil embolization such as non-productive cough, chest pain, or fever. She was treated conservatively with considerable improvement in her deficit and was later discharged. Discussion Venous intravasation of Pantopaque is an infrequent complication of myelography and occurs when a needle is placed in ventral or dorsal peridural veins. Actual entrance of the FIG. 2. Five minutes later. Disappearance of contrast material can be seen by fluoroscopy subarachnoidal Pantopaque with proximal filling or from cineroentgenographic recording. It was estimated by Steinbach and HilP that of lymph nodes and channels. 608
J. Neurosurg. / Volume 49 / October, 1978
Traumatic CSF-lymphatic fistula approximately 4 to 7.5 cc of the Pantopaque has to enter the venous system to gwe radiographic visualization of the pulmonary embolization. In our patient 12 cc of the Pantopaque was administered over a 4-hour period, with radiographic but not clinical evidence of pulmonary embolization. This is probably due to the prolonged introduction of Pantopaque via an inherently slow lymphatic route and retention by lymphatic nodes. Introduction of Pantopaque into venous or lymphatic vessels carries the danger of pulmonary embolization. Clinical manifestation of pulmonary embolization is probably related to the volume and speed by which Pantopaque enters the venous circulation.
J. Neurosurg. / Volume 49 / October, 1978
References
1. Epstein BS, Epstein JA: The cineroentgenographic observation of Pantopaque intravasation during myelography. Am J Roentgenol Radium Ther Nuel Med 94:576-579, 1965 2. Keats TE: Pantopaque pulmonary embolism. Radiology 67:748-750, 1956 3. Steinbach HL, Hill WB: Pantopaque pulmonary embolism during myelography. Radiology 56:735-738, 1951 Address reprint requests to: Zelimir Kozic, M.D., Radiology Department/Division of Neuroradiology, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, New York 10461.
609
