PMC7652765_01
Frontal view of fluoroscopic images during inguinal injection of Lipiodol. At abdominal level there is opacification of lymph vessels with drainage of Lipiodol into the cysterna chyli and thoracic duct (TD). Image of occlusion of the TD on the passage from abdominal to thoracic level. Black arrow: droplets of ethiodized oil at the passage from the inferior caval vein to the TCPC conduit, revealing early lymphovenous shunting. At thoracic level there is drainage of Lipiodol through multiple collaterals to hilar, peribronchial, mediastinal, and axillar dilated lymph vessels. Right mediastinum is more affected than the left.
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F1
The progression of Lipiodol through the iliac and retroperitoneal lymph vessels, the cisterna chyli and the beginning of the TD was observed under fluoroscopic guidance (Figure 1); there was no evidence of a TD at thoracic level, excluding direct targeting of the thoracic duct.
Cone-beam computed tomography image during Lipiodol-based lymphangiography shows filling of several mediastinal abnormal dilated lymph vessels, predominantly peribronchial right (yellow arrows). This is similar to the fluoroscopic image of Figure 1.
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F2
Multiple lymphatic collaterals that drained to hilar, peribronchial, mediastinal and axillar regions were demonstrated (Figure 2).
(A,B) Unenhanced head CT images with "lacher de ballons." Lipiodol is shown as diffuse high-density lesions in cortical, subcortical region and more profound in the white substance and in cerebral and cerebellar gray cores. (A) axial, (B) sagittal section.
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F3
Other cerebral insults such as different types of stroke were excluded by the very disseminated topography of the lesions (Figure 3).
(A,B) Cerebral MRI 14 days after Lipiodol embolism. (A) Axial T2-weighted magnetic resonance imaging of the basal ganglia, showed diffuse high signal lesions, for example in the left putamen (arrow). Also, periventricular and subcortical white matter hyperintensities in both hemispheres, corresponding to edema after recent ischemia. (B) Susceptibility-weighted imaging (SWI) highlighted the presence of hemorrhagic components within the infarcted zones and diffuse, countless residual (micro-) hemorrhages (arrow) in supra- and infratentorial cerebral parenchyma.
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F4
Cerebral MRI was performed 14 days later and confirmed multiple diffuse bilateral lesions of the cerebral parenchyma, yet less extended than on the previous CT (Figure 4).