2017 Volume 18 Issue 1 Pages 2-7
Use of ionic contrast medium in myelography is known to cause a serious state, sometimes leading to death. This type of accident has been repeatedly occurring in Japan and overseas even in the 2010s. Incidental intrathecal injection of contrast medium in epidurography also causes similar adverse events. These cases with the pathology called ascending tonic-clonic seizure syndrome (ATCS syndrome) have been summarized in foreign countries but not in Japan. We therefore collected Japanese cases for review and identified 21 cases, of which 18 (86%) were ATCS syndrome. The outcome was death in 5 cases and recovery in 16 cases, resulting in a recovery rate of 76%. Of these cases, 5 cases were contrast medium selection error, 2 of which were fatal. System factors underlie these cases in that conventional measures such as warning label were insufficient to prevent them. As countermeasures against these catastrophic adverse events, which involve human errors, it is considered necessary for each medical institution to take new expanding prevention and recurrence prevention measures, including review of contrast medium control, education of medical staff involved in testing, and total switch to nonionic contrast medium. Further verification in the academic societies concerned and discussion on recurrence prevention with manufacturers will make these measures more effective.
