Inadvertent intrathecal use of ionic contrast media for myelography.

PurposeTo describe instances of inadvertent intrathecal injection of ionic contrast media and to consider treatment approaches, and diagnostic and medicolegal issues.MethodsTen cases of inadvertent injection, of which nine were reported to the manufacturers/authors and one appeared in the literature, are related with emphasis on similarity of reactions.ResultsSix criteria are enumerated and used to coin the term "ascending tonic-clonic seizure syndrome."ConclusionsTherapeutic possibilities seem limited, but several methods for controlling seizures are suggested. The importance of identifying the contrast material is underscored. Awareness of the grave possibility of administering the wrong contrast material is the first step in avoiding this problem; awareness of the symptoms is the first step toward therapy.