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Imaging Appearance of Intrathecal Catheter Tip Granulomas: Report of Three Cases and Review of the Literature

Jinnah A. Phillips1, Edward J. Escott2, John J. Moossy3 and Harry C. Kellermier4

1 Department of Radiology, University of Pittsburgh Medical Center, UPMC Presbyterian, 200 Lothrop St., Pittsburgh, PA 15213.
2 Division of Neuroradiology, Department of Radiology, University of Pittsburgh Medical Center, UPMC Presbyterian, Pittsburgh, PA.
3 Department of Neurological Surgery, University of Pittsburgh Medical Center, UPMC Presbyterian, Pittsburgh, PA.
4 Division of Neuropathology, Department of Pathology, University of Pittsburgh Medical Center, UPMC Presbyterian, Pittsburgh, PA.


Figure 1
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  		Fig. 1A —70-year-old man with progressive back pain and neurologic decline. Axial CT myelogram depicts nearly complete myelographic block. Spinal cord (asterisk) is compressed and displaced to right of canal by mass (arrowhead) near catheter tip (arrow).

 

Figure 2
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  		Fig. 1B —70-year-old man with progressive back pain and neurologic decline. Sagittal T1-weighted image without contrast enhancement performed 4 months after myelogram shows lamellated-appearing lesion (arrow) at T12-L1 level with components of intermediate and high signal intensity. Artifact is from previous posterior fusion.

 

Figure 3
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  		Fig. 1C —70-year-old man with progressive back pain and neurologic decline. Contrast-enhanced sagittal T1-weighted image shows rim enhancement of lesion (arrowhead) with inner hypointense nonenhancing ring (arrow), which may represent lamellated collagen or devitalized fibrous tissue.

 

Figure 4
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  		Fig. 1D —70-year-old man with progressive back pain and neurologic decline. Sagittal T2-weighted image shows central hyperintensity (arrow) and peripheral hypointensity (arrowhead). These regions may correspond to central necrotic debris and lamellated collagen or devitalized fibrous tissue, respectively. Second, outer hypointense rim of unknown causation also is evident.

 

Figure 5
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  		Fig. 1E —70-year-old man with progressive back pain and neurologic decline. Axial T2-weighted image though mass depicts lamellated appearance of lesion with central hyperintensity (arrow) and peripheral hypointensity (arrowhead). Arrowhead indicates inner of two hypointense rings, better depicted in D. Punctuate area of hypointensity at tip of arrow is catheter. Asterisk indicates compressed and displaced spinal cord.

 

Figure 6
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  		Fig. 1F —70-year-old man with progressive back pain and neurologic decline. Photograph shows area of devitalized fibrous tissue (thin arrow) adjacent to somewhat lamellated collagen with admixed chronic inflammatory cells (thick arrow). (H and E, x100)

 

Figure 7
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  		Fig. 2A —66-year-old woman with 0 of 5 lower extremity motor strength score and loss of bowel and bladder control. Coronal reconstruction from CT myelogram performed with injection by pump. Catheter is looped within thecal sac, extending superiorly along left side of spinal canal and inferiorly along right side (arrowheads). Contrast material is pooled near catheter tip (arrow).

 

Figure 8
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  		Fig. 2B —66-year-old woman with 0 of 5 lower extremity motor strength score and loss of bowel and bladder control. Axial CT myelogram at T10 level after intrathecal contrast injection with intrathecal pump. Contrast material (arrow) is pooled near catheter tip, and spinal cord is mildly displaced posteriorly and toward left, causing concern about area of loculation or adhesions, which can correspond to area of chronically increased concentration of opioid. Arrowhead indicates catheter where it loops near inflammatory mass.

 

Figure 9
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  		Fig. 2C —66-year-old woman with 0 of 5 lower extremity motor strength score and loss of bowel and bladder control. Sagittal T1-weighted contrast-enhanced MR image of thoracic spine performed 6 months after myelogram shows rim enhancement of lesion (arrow) at T10.

 

Figure 10
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  		Fig. 2D —66-year-old woman with 0 of 5 lower extremity motor strength score and loss of bowel and bladder control. Sagittal T2-weighted MR image of thoracic spine shows lesion has central hyperintensity (arrow) and peripheral hypointense rim (arrowhead).

 

Figure 11
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  		Fig. 2E —66-year-old woman with 0 of 5 lower extremity motor strength score and loss of bowel and bladder control. Axial T2-weighted MR image through lesion in C and D shows lesion is centrally hyperintense, rim is hypointense, and spinal cord (asterisk) is displaced posteriorly toward left and compressed by lesion. Low signal intensity of catheter (arrowhead) is evident along periphery of mass. Mass (arrow) has formed in area of contrast pooling present in A and B.

 

Figure 12
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  		Fig. 2F —66-year-old woman with 0 of 5 lower extremity motor strength score and loss of bowel and bladder control. Photograph shows necrotic material (thin arrow) with adjacent chronically inflamed fibrous tissue (thick arrow), imparting appearance similar to necrobiotic granuloma. (H and E, x100)

 

Figure 13
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  		Fig. 3A —43-year-old man with increasing back pain, new-onset difficulty urinating, and severe constipation. T1-weighted sagittal MR image of lumbar spine depicts small mass (arrow) of intermediate signal intensity within thecal sac at T12-L1 level.

 

Figure 14
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  		Fig. 3B —43-year-old man with increasing back pain, new-onset difficulty urinating, and severe constipation. Sagittal T1-weighted contrast-enhanced MR image of lumbar spine shows lesion (arrow) undergoing brisk peripheral enhancement.

 

Figure 15
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  		Fig. 3C —43-year-old man with increasing back pain, new-onset difficulty urinating, and severe constipation. Sagittal T2-weighted MR image shows lesion (arrow) has central hyperintensity and peripheral hypointensity. Low signal intensity with associated susceptibility artifact of catheter tip above lesion (arrowhead) is evident.

 

Figure 16
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  		Fig. 3D —43-year-old man with increasing back pain, new-onset difficulty urinating, and severe constipation. Photograph shows one area of specimen appears to consist of three zones arranged in layers: area of devitalized and necrotic fibrous tissue (thin arrow), intervening layer of fibrosis and chronic inflammation (thick arrow), and third layer of prominent vascularity (medium arrow). (H and E, x40)

 

Figure 17
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  		Fig. 3E —43-year-old man with increasing back pain, new-onset difficulty urinating, and severe constipation. Photograph of section through mass shows intrathecal catheter embedded in chronically inflamed fibrous matrix. Fibrous tissue (thick arrow) surrounds catheter. Necrotic and necrobiotic-like areas are present (thin arrow), and fibrin and devitalized material extend into catheter fenestration (medium arrow). (H and E, x40)

 

Figure 18
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  		Fig. 4A —57-year-old woman with intrathecal catheter. Sagittal T2-weighted image with fat saturation of lumbar spine. Metallic tip (arrow) at distal aspect of closed-end catheter can be mistaken for inflammatory mass at catheter tip on MRI. However, recognition of associated susceptibility artifact (arrowhead) enables correct identification of catheter tip.

 

Figure 19
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  		Fig. 4B —57-year-old woman with intrathecal catheter. Sagittal reformatted CT scan of lumbar spine shows CT with or without myelography can easily depict nature of catheter tip (arrow) and better delineate catheter itself (arrowheads). CT myelography has additional advantage of more clearly identifying presence or absence of catheter tip mass than CT without intrathecal contrast enhancement.

 

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