Urgent Magnetic Resonance Imaging Research Articles

Spinal Epidural Hematoma Following Epidural Anesthesia Managed Safely Without Surgery: A Case Report

Spinal Epidural Hematoma (SEH) is known to occur as a complication of invasive spinal procedures, such as epidural anesthesia, and can cause dramatic neurologic deficits if not diagnosed and treated immediately. The present report describes the case of a gynecologic patient who presented with weakness and numbness of both lower limbs soon after an epidural test bolus was injected. Urgent magnetic resonance imaging of the thoracic spine demonstrated an epidural hematoma at T12/L1 with slight spinal cord compression. The patient demonstrated significant improvement in neurologic deficits within a short time. Therefore, general anesthesia was induced, and the scheduled operation was performed uneventfully. After the operation, the patient had no detectable neurologic abnormality, and repeat imaging showed almost complete resolution of the hematoma. Although urgent decompression is the treatment of choice for SEH, conservative management may be indicated if the patient demonstrates rapidly improving neurologic deficits.

Spontaneous Delayed Brain Herniation through a Subdural Membrane after Tumor Surgery

We report on a rare case of spontaneous cerebral herniation through a subdural membrane in a 54-year-old patient. Brain herniation in adults as a complication of chronic subdural hematomas shortly after a neurosurgical intervention is rare. We are the first to report a case of delayed local herniation in an adult patient more than 1 year after a neurosurgical procedure. The patient suffered from a low-grade oligodendroglioma since 1993. Radiotherapy was then applied, followed by resective surgery and chemotherapy in 2008 because of tumor progression. Subsequently, he developed a symptomatic subdural hygroma treated with a subduro-atrial cerebrospinal fluid shunt. In January 2010, the shunt was occluded. Follow-up brain imaging showed a stable situation after tumor resection, with a cyst in the temporal resection cavity and a stable subdural hygroma. In February 2011, the patient visited the emergency department because of an acute right hemiparesis and progressive motor aphasia. Urgent magnetic resonance imaging was suspicious of a herniation of brain parenchyma in the left middle cranial fossa. Explorative surgery showed a locally incarcerated brain herniation through a membrane with a ring-like aperture. Resection of this membrane led to normalization of the position of the brain tissue and to clinical improvement. Brain herniation through a subdural membrane is an extremely rare complication, but must be a differential diagnosis in patients with a known chronic subdural hematoma or hygroma and clinical deterioration, even in the absence of recent surgery. Urgent surgical intervention of the herniated brain is recommended to reduce the risk of permanent neurological damage.

Pediatric Regional Anesthesia

Two articles in this month’s Anesthesia & Analgesia address safety of regional anesthesia and analgesia in pediatrics.1,2 At first glance, one is very reassuring, the other is frightening. In this Editorial, we will recommend a middle ground. Practitioners of pediatric regional anesthesia should be careful and vigilant but can be confident that many types of complications can be made extremely rare by adopting some recommended practice patterns. Over the past 30 years, pediatric applications of postoperative regional anesthesia and analgesia have expanded rapidly.3 There is now a substantial body of studies regarding techniques, pharmacokinetics, and clinical outcomes. Agerelated trends in local anesthetic pharmacokinetics have been characterized, and safe dosing guidelines have been established.4 Most regional anesthesia in adults is performed awake or with doses of sedatives and analgesics that maintain verbal responsiveness, permitting patient reporting of paresthesias, severe pain with needle movement or injection, immediate symptoms of systemic local anesthetic effect, and progression of sensory and motor blockade over the minutes after injections. Textbooks, review articles, and consensus documents often strongly criticize performing most types of major peripheral or neuraxial blocks in adults under deep sedation or general anesthesia.5 In contrast, most, but not all, regional anesthesia in children is performed under either deep sedation or general anesthesia. Advocates of pediatric regional anesthesia have cited a series of retrospective and prospective safety studies to support their contention that the widespread practice of performing regional anesthesia under general anesthesia is safe.6–8 Polaner et al. report on the first 3 years of prospective registry data from PRAN, the Pediatric Regional Anesthesia Network, a consortium of North American pediatric centers. This report has a number of strengths. The data collection and analysis plan was generally thoughtfully constructed. There is a good degree of detail and new information regarding how procedures are performed and regarding most adverse events. The methodology for data gathering is likely to be fairly complete for intraoperative serious adverse events and for events occurring during patients’ inpatient stay. There are several scenarios that could potentially lead to underreporting of peripheral nerve injuries, most notably partial nerve injuries in nonverbal or nonambulatory children that might evade detection by parents and physicians. For example, a thoracic nerve root or an intercostal nerve injury following thoracic epidural or thoracic paravertebral block might not be detected in a preverbal child. In addition, for a patient in a cast, a deficit might not be apparent until days to weeks postoperatively. The methodology for postoperative surveillance in this registry is likely to omit some cases with delayed detection. Despite these possible sources for underreporting, the PRAN investigators make a good case for the overall very good safety of pediatric neuraxial and peripheral blocks as performed by clinicians in these hospitals. In contrast to the conclusion of the PRAN investigators that “nothing really bad happened,” Meyer et al. showed admirable courage and forthrightness in reporting on 4 cases of neurologic injury following epidural anesthesia in children. All 4 cases involve care by experienced anesthesiologists with extensive experience in pediatric epidural analgesia and acute and chronic pain management. Based on the incomplete information available in this case report, we would tend to agree with the authors’ general contention that there was “absence of proof of medical negligence.” A more important question, which the authors have addressed in their discussion, might be phrased as follows: “Based on these cases and other available knowledge, do we have ways to modify our practice to prevent similar complications in the future?” We consider the 4 cases in this light, taking advantage of “20–20 hindsight.” Among the 4 cases, case 1 was perhaps the most frightening, because the patient was healthy and uncomplicated, the epidural catheter placement proceeded uneventfully at a lumbar level below the terminus of the spinal cord, the duration of general anesthesia was short, and there were no hemodynamic clues intraoperatively to raise concerns. The test dose was appropriate (0.1 mL/kg). E EDITORIAL

Complex regional pain syndrome following protracted labour*

Obstetric nerve palsies are common and long-term sequelae are fortunately rare. The development of a complex regional pain syndrome is an unusual and less reported complication of labour-related neuropathy. A 28-year-old primigravida who experienced prolonged labour and instrumental delivery under spinal anaesthesia complained of persisting weakness and numbness postpartum, affecting the left lower limb. Urgent magnetic resonance imaging demonstrated no abnormality and a common peroneal nerve injury was later confirmed by nerve conduction studies. Unfortunately, the neuropathy did not resolve as expected and oedema, burning paraesthesia and allodynia affecting the left foot developed within two weeks. She was treated with gabapentin, ibuprofen, topical capsaicin and regular physiotherapy. After six months, the foot drop had resolved and the chronic pain element was significantly diminished.

FDG‐PET guided diagnosis of vaginal intravascular diffuse large B‐cell lymphoma

A 76-year-old woman presented with a 6-month history of progressive bilateral lower limb weakness, anorexia and weight loss and the recent onset of urinary and faecal incontinence with saddle anaesthesia. There was no palpable lymphadenopathy. Urgent magnetic resonance imaging (MRI) ruled out spinal cord or cauda equina compressive lesions. Blood tests showed a raised lactate dehydrogenase (LDH) and erythrocyte sedimentation rate with an IgM paraprotein of 7 g/l; immunoglobulins were otherwise normal. Cerebrospinal fluid analysis showed a reactive lymphocytosis on morphology and by flow cytometry. Bilateral bone marrow aspirates and trephine biopsies were normal. Computed tomography (CT) was entirely normal but a repeat MRI with gadolinium showed enhancement of lumbosacral nerve roots suggestive of infiltrative disease. [F]fluorodeoxyglucose (FDG) positron emission tomography (PET) showed diffuse uptake in the uterus, cervix, vagina and numerous groups of lymph nodes throughout the body. The FDG-PET findings led to a vaginal mucosal biopsy, which showed subepithelial capillaries packed with neoplastic lymphoid cells (left) expressing CD20 (right), CD79a and CD5 with a Ki-67 index of 100%; the histological features were those of intravascular diffuse large B-cell lymphoma (DLBCL). At the time of diagnosis the patient had a performance score of 4 and she remained an inpatient. She received twice weekly intrathecal methotrexate, followed by one cycle of CVP (cyclophosphamide, vincristine and prednisolone combination chemotherapy). Rituximab was given 1 week later due to the high risk of tumour lysis syndrome, which has been reported previously. Unfortunately she developed neutropenic sepsis and died 2 weeks after diagnosis. Despite extensive prior investigations it was the results of the FDG-PET scan that eventually guided the biopsy site. The lack of solid lesions makes routine CT and MRI unhelpful in diagnosing this rare subtype of extranodal DLBCL; approximately 50% of patients are diagnosed at autopsy. This case highlights how the nonspecific and diverse symptoms, in the absence of significant lymphadenopathy, can result in critical delays in diagnosing this clinically aggressive lymphoma and how the use of FDG-PET scanning in such patients can guide the biopsy site.

Urgent MRI with MR cholangiopancreatography (MRCP) of acute cholecystitis and related complications: diagnostic role and spectrum of imaging findings

Acute cholecystitis, which is usually associated with gallstones, is one of the commonest surgical causes of emergency hospital admission and may be further complicated by mural necrosis, perforation, and abscess formation. Magnetic resonance imaging (MRI) is increasingly available in the emergency setting. Technically improved equipment and faster acquisition protocols allow excellent tissue contrast and MRI is now an attractive modality for imaging acute abdominal disorders. The use of MRI with MR cholangiopancreatography in the emergency setting provides rapid, noninvasive, and confident diagnosis or exclusion of acute cholecystitis and of coexistent choledocholithiasis. To familiarize the reader with these cross-sectional imaging appearances, this paper reviews MRI findings consistent with uncomplicated cholecystitis. These include gallbladder distension, intraluminal sludge and gallstones, impacted stones obstructing the gallbladder neck or cystic duct, thickening of the gallbladder wall, abnormal signal intensity and edematous stratification, and pericholecystic and perihepatic fluid, plus increased enhancement of the gallbladder wall and adjacent liver parenchyma when intravenous paramagnetic contrast is used. Furthermore, MRI allows prompt detection and comprehensive visualization and characterization of cholecystitis-related complications such as gangrene, perforation, pericholecystic abscess, and intrahepatic fistulization. Some previous literature reports, and our experience, suggest that, when available, MRI should be recommended to provide prompt and efficient triage of patients with suspected cholecystitis and inconclusive clinical, laboratory, and sonographic findings. It facilitates appropriate therapeutic planning, including the timing of surgery (emergency or delayed), approach (laparoscopic or laparotomic), and need for preoperative or intraoperative removal of stone(s) in the common bile duct.

Sudden loss of sensation

A 33 year old female teacher presented to hospital with a 10 day history of reduced sensation in both legs. She reported tingling in the left lower leg progressing overnight to involve both legs reaching mid-thigh level. Over the following 24 hours, the sensory loss had ascended to the level of the umbilicus and she was unable to feel her underwear. Her symptoms progressed throughout the next seven days until the reduced sensation extended to just beneath her breasts. She denied any visual disturbance, limb stiffness or weakness, or urinary or faecal incontinence. She developed a shuffling gait because of reduced sensation in her feet. On examination, she had no meningeal signs such as neck stiffness or photophobia, and examination of her cranial nerves, motor system, and coordination were normal. She had brisk lower limb reflexes and down going plantars. Sensation to soft touch and pinprick was reduced bilaterally below the level of T5. She had normal anal tone on rectal examination. An urgent magnetic resonance imaging (MRI) scan of her spine was arranged (figure).⇓ MRI spine (whole) with gadolinium (1) What is …

Acute symptomatic seizures as a complication of rhinosinusitis in children

When an otorhinolaryngologist thinks of acute seizures in children, what comes to mind are intracranial complications of infection within the sinuses or the temporal bone. Complications of rhinosinusitis, both in children and adults, may involve the orbit, soft tissues surrounding the nose and sinuses, and intracranial spread of the infection. Intracranial complications secondary to rhinosinusitis, intracranial abscesses and/or thrombophlebitis, occur sporadically and, although it appears that they cannot be prevented, early recognition and treatment are essential to reduce any subsequent morbidity or mortality [1]. The commonest presenting symptoms of intracranial complications are headaches (80%) followed by vomiting (45%) and swelling of the forehead (45%), an altered mental state, fever, seizure, unilateral weakness or hemiparesis, or a cranial nerve sign [1,2]. Exact pathogenesis of intracranial abscesses remains unclear [3]. Apart from rhinosinusitis, congenital cyanotic heart disease was identified as a predisposing factor, likewise otitis media or mastoiditis, dental abscesses and immunodeficiency [3]. The diagnosis of cerebral abscess is often difficult. The classical intracranial hypertension associated to high fever is usually incomplete and sometimes absent [4]. In most cases (60%), it is from the frontal sinus that the infection spreads intracranially [2]. In patients with intracranial complications of rhinosinusitis, frequency of seizures reaches 10–25% [1,3,5]. Epilepsy caused by intracranial complications is usually a long-term morbidity [1]. Above enumerated presenting symptoms justify an urgent magnetic resonance imaging (MRI) or computed tomography (CT) scan. The importance of imaging before a lumbar puncture cannot be overemphasized [1,6]. Since the availability of CT, both diagnostic delay after hospital admission and mortality were substantially reduced: mean delay from 8 to 3 days, andmortality from 25% to almost 0% [3]. In patients with intracranial complications, acute symptomatic seizures are usually accompanied by other neurological symptoms: fever in 50% of cases, headache in 75% of cases, and intracranial hypertension syndrome in 25% of cases [4]. The condition requires sinus surgery in order to drain the primary focus of the infection [2,7]. At the same time, prompt and aggressive medical and neurosurgical intervention is required, aiming tominimize the morbidity and mortality and to maximize the favorable outcome in those children [2]. The neurosurgical procedures aim to drain the abscess and include burr whole drainage or aspiration of abscess, craniotomy and evacuation of empyema, or craniotomy [2]. Central nervous system scars with subsequent seizures can be sequels of intracranial abscess therapy and are more common after excision of the brain abscess when compared to patients treated by aspiration and/or antibiotics alone [2,3,7]. Therefore, excision of brain abscess should be avoided *Address for correspondence: Olaf Zagolski, ENT, St. John Grande’s Hospital, Krakow, Poland. Tel.: +48 12 3797377; Fax: +48 12 4305491; E-mail: olafzag@poczta.onet.pl. Journal of Pediatric Epilepsy 1 (2012) 73–74 DOI 10.3233/PEP-2012-012 IOS Press 73

Clinical Application of18F-FDG-PET/CT in Multiple Myeloma

Multiple myeloma (MM) is a plasma cell malignancy and is characterized by the presence of lytic bone disease causing severe bone pain, pathological fractures and spinal cord compression. Up to 80% of myeloma patients develop osteolytic lesions during the course of their disease. Appropriate use of imaging techniques is essential in the identification and characterization of the skeletal complications resulting from MM and in determination of the extent of intramedullary bone disease. Despite many weaknesses, conventional radiography still remains the standard for the staging procedure of newly diagnosed and relapsed myeloma patients. Magnetic resonance imaging (MRI) is recommended for MM patients with normal conventional radiography and for all patients with an apparently solitary plasmacytoma of bone. Urgent MRI is the diagnostic procedure of choice to assess suspected cord compression. Although Positron emission tomography/CT (PET/CT) is a useful method to assess the patient's response to the treatment and diagnose the extent of bone involvement and extramedullary disease in the patient, PET/CT is not recommended for routine use in myeloma patients. However, further studies are needed before the recommendation of using PET/CT as a standard tool in both diagnosis and follow-up of MM patients. (Korean J Med 2012;82:686-688)

Periferik ve Santral Vertigo Ayırımında Odyoloji ve Manyetik Rezonans Görüntülemenin Acil Serviste Kullanımının Değeri

Objective: Vertigo is a common complaint in the emergency room. Vertigo can be central or peripheral in origin and it is important for an emergency physician to make a correct differential diagnosis. The purpose of our study was to emphasize the role of cranial magnetic resonance imaging (MRI) and audiological tests in differential diagnosis of patients who present with vertigo to the emergency room. Material and Methods: Fifty patients (31 female, 19 male, mean age 50.84 years) with vertigo who were admitted to the Hacettepe University Faculty of Medicine Emergency Room (ER) between 01.10.2004 and 31.01.2005 were included in the study. Physical and neurological examinations of all patients were performed by senior residents and all patients were evaluated by Ear Nose Throat specialists. Audiologic and vestibular tests and MRI with 3T (Tesla) magnetic field power were performed in all patients. Results: Among 29 patients with normal neurological examination, only 3 (10.3%) had lesions on MRI. MRI scans revealed lesions suggesting central vertigo etiology in six (18.2%) patients out of 33 with abnormal audiological test suggesting peripheral vestibulopathy. Conclusion: In conclusion, in our prospective study, urgent cranial MRI technique in patients presenting to the emergency room with vertigo may reveal significant findings regarding the differential diagnosis and concomitant pathologies. However, meticulous neurological examination can exclude central vertigo in the majority of the patients.

Acute Brown-Séquard Syndrome following Brachial Plexus Avulsion Injury. A Report of Two Cases

Introduction Brown-Séquard syndrome is an unusual sequelae of pre-ganglionic brachial plexus injury. There have been sporadic case reports indicating that the cause of this condition is due to tethering of the cord, vascular ischaemia or direct avulsion injury of the nerve roots. This is a report of two patients with complete pre-ganglionic brachial plexus avulsion injuries who developed acute partial Brown-Séquard syndrome due to haematoma. Cases Two patients developed acute partial Brown-Séquard syndrome associated with complete pre-ganglionic brachial plexus avulsion injuries. In the first case the neurology recovered fully after the evacuation of the large subdural hematoma. Whereas, in the second case the neurology only recovered after 4 weeks closed observation in view of the compression was due to small epidural haematoma. Conclusion Acute Brown-Séquard syndrome occurring in association brachial plexus injury should be investigated with urgent magnetic resonance imaging to exclude any reversible haematoma compression.

Equipment changes and magnetic resonance imaging compatibility

We wish to highlight the wider consequences caused by a simple equipment change made in our hospital. A patient developed severe back pain following the removal of an epidural catheter. We duly requested an urgent magnetic resonance imaging (MRI) scan to exclude an epidural haematoma. Of note, there was a large wound extending close to the pelvis that had been closed using metal skin staples. A new brand of skin staples (Autosuture Appose™ ULC 35W; Covidien (UK) Commercial Ltd, Gosport, Hampshire, UK) had been introduced to our hospital without communication with the anaesthetic or radiology departments. The equipment information leaflet contained no information on MRI compatibility. We contacted the manufacturer and were told that the staples were composed of steel, and categorically not MRI compatible. This uncertainty resulted in a delay to the imaging procedure and potential haematoma evacuation. The radiologist had to make a clinical decision, balancing the risk of missing an epidural haematoma against potential complications relating to the metal staples. The scan was performed without incident. Ferromagnetic implants are subject to a number of forces in the presence of strong magnetic fields. On the periphery of the field, they are attracted towards the centre and may be displaced in that direction. At the centre of the field, implants are subject to torque and may rotate, loosening them [1]. Implants may also be heated, in extreme cases causing burns [2]. These problems are magnified as the magnetic field strength increases. Current guidelines from the Medicines and Healthcare products Regulatory Agency (MHRA) recommend that medical implants be classed as MR safe, MR conditional or MR unsafe in accordance with international labelling and summarised in the AAGBI guidelines in 2010 [3, 4]. The MR conditional label means that an implant is safe within a specified magnetic field strength, amongst other factors. The MHRA recommends that if there is any doubt, assume that the implant is MR unsafe [3, 5]. We later discovered (via the Internet) a manufacturer’s document stating that the staples were MR conditional to a magnetic field strength of 3 Tesla [6]. We communicated this information to the company which finally established that the implants were, after all, MR conditional. Increasingly, it has been shown that skin staples may be safe within the MR scanner, though this may depend upon the field strength of the magnet, amongst other factors. As scanning equipment increases in strength, implants deemed MR safe under prior testing regimens may become less so [3].

Advances in Imaging and the Management of Myeloma Bone Disease

Osteolytic disease is a major complication of multiple myeloma that may lead to devastating skeletal-related events (SREs). Conventional radiography remains the gold standard for the evaluation of bone disease in patients with myeloma. However, whole-body magnetic resonance imaging (MRI) is recommended in patients with normal conventional radiography and should be performed as part of staging in all patients with a solitary plasmacytoma of bone. Urgent MRI is also the diagnostic procedure of choice to assess suspected cord compression, whereas computed tomography can guide tissue biopsy. Positron emission tomography with computed tomography can provide complementary information to MRI, but its use in multiple myeloma must be better defined by further studies. The incorporation of abnormal MRI findings into the definition of symptomatic myeloma also needs to be clarified. Bisphosphonates remain the cornerstone for the management of myeloma bone disease. Intravenous pamidronate and zoledronic acid are equally effective in reducing SREs, whereas zoledronic acid seems to offer survival benefits in symptomatic patients. Caution is needed to avoid adverse events, such as renal impairment and osteonecrosis of the jaw. Novel antiresorptive agents, such as denosumab, have given encouraging results, but further studies are needed before their approval for managing myeloma bone disease. Combination approaches with novel antimyeloma agents, such as bortezomib (which has anabolic effects on bone) with bisphosphonates or with drugs that enhance osteoblast function, such as antidickkopf-1 agents, antisclerostin drugs, or sotatercept, may favorably alter our way of managing myeloma bone disease in the near future.

Quiste sinovial lumbar como causa de síndrome de cauda equina. Presentación de un caso y revisión de la literatura

We report the case of a 77-year-old woman who was admitted to our hospital with cauda equina syndrome. An urgent magnetic resonance imaging scan showed lumbar spinal canal compression at L4-L5 and L5-S1. An urgent laminectomy was performed and cystic lesions were extracted. On pathological examination, the lesions were identified as synovial cysts. The patient required rehabilitation and achieved good functional recovery, although sensory deficit remains in the sacral segments.

Today or tomorrow? A retrospective analysis of the clinical indications used to request urgent magnetic resonance imaging of the spine

The finite resources available to National Health Service institutions require clinicians to order investigations that are not readily available appropriately. This is particularly true for the radiological assessment of patients presenting with features pertaining to acute spinal cord dysfunction. Such cases conventionally require urgent magnetic resonance imaging (MRI) which is sometimes performed 'out-of-hours'. There is evidence to suggest, however, that a high proportion of patients do not have a structural abnormality on MRI to account for their clinical findings, and consequently the majority of scans that are requested urgently are normal. The primary aim of this study was to determine whether any clinical feature(s) could accurately predict the presence of a structural abnormality on MRI. As a secondary objective, the ability of such features to predict the need for spinal surgery was assessed. A retrospective analysis of consecutive patients who warranted urgent MRI was conducted. Eighty-one patients were eligible for study. The Fisher's test was used for statistical analysis of all data. A P-value of less than 0.05 was considered to be significant. MRI was performed within 24 h of admission in 16 patients, and of these, seven had surgery within 24-48 h. Only two patients were found to have significant neurological compromise. Despite both a history and examination suggesting otherwise, MRI was normal in 10 patients (12%). We were unable to elucidate any clinical features that were able to predict the presence of an abnormal MRI. We did find, however, that patients with a combination of both subjective neurological findings and positive neurological signs (P = 0.02), saddle anaesthesia and/or decreased anal tone (P = 0.03) or sciatica (P = 0.02) had pathology on MRI that warranted surgical intervention. The authors recommend that the aforementioned features formulate the basis of guidelines used to request and/or perform MRI urgently since they are highly suggestive of surgical intervention. Conversely, patients who do not exhibit the above examination findings might not require either an urgent or 'out-of-hours' scan, but could potentially be investigated less expediently and/or wait until 'normal working hours'.

DuraSeal-Hematoma

Case description. To present a case report which highlights a complication following the use of Duraseal in posterior cervical surgery. Duraseal is increasingly used to repair cranial and spinal dural defects to prevent cerebrospinal fluid leakage. Although it is well established that the hydrogel expands after implantation and may result in compressive effects, the phenomenon of Duraseal-entrapped hematoma has not previously been reported. The authors report a 80-year-old woman who presented with cervical myelopathy secondary to canal stenosis. The patient underwent decompressive cervical laminectomies. The surgery was complicated by an unintended durotomy. A thin layer of Duraseal was applied over the dural surface and a suction drain placed before wound closure. The patient awoke from surgery without any new neurologic deficits but experienced delayed functional deterioration. Urgent magnetic resonance imaging demonstrated an extradural hematoma with severe cord compression. The patient underwent urgent surgery. Intraoperatively, the Duraseal was found to have formed a restrictive layer, completely entrapping the extradural hematoma with resultant spinal cord compression. Minimal blood clot was found external to the hydrogel layer. Although Duraseal can provide an effective and water-tight dural repair, it also has the potential to "entrap" extradural bleeding which otherwise may have been evacuated by a wound drain placed under suction. Our experience has shown that Duraseal should be used judiciously with recognition of this potential complication.

Incomplete Cauda Equina Syndrome Presenting with Acute Urinary Retention in the Emergency Department

Cauda equina syndrome (CES) is a rare but serious neurosurgical emergency that can have devastating long-lasting neurologic consequences. CES caused by herniated lumbar discs is rare in the literature. We report an unusual case of incomplete CES due to lumbar disc herniation. The patient presented to our emergency department with acute onset of low back pain, saddle (perineal) anaesthesia, urinary retention and constipation without motor deficit or sciatica. Magnetic resonance imaging (MRI) revealed a large herniated disc originated from the L5-S1 disc space with compression of the cauda equina. This case illustrates that patients with CES accompanying a disc herniation may not have all the characteristic features of CES such as pain radiating to the legs or muscle weakness. We recommend that urgent MRI assessment should be performed in all patients who present with sudden onset of urinary symptoms in the context of lumbar back pain or loss of perineal sensation.

Tako-tsubo cardiomyopathy after administration of ergometrine following elective caesarean delivery: a case report

IntroductionTako-tsubo cardiomyopathy (stress-induced cardiomyopathy or transient left ventricular ballooning) is characterized by clinical suspicion of an acute myocardial infarction with transient apical or midventricular dyskinesia of the left ventricle without significant coronary stenosis on angiography. The etiology of this disease remains obscure. One of the possible causes is myocardial ischemia induced by coronary vasospasm due to sympathetic activation. It has been hypothesized that the application of ergometrine could induce tako-tsubo cardiomyopathy.Case presentationWe report the case of a 28-year-old Turkish woman who developed tako-tsubo cardiomyopathy after administration of ergometrine for release of placenta and prevention of bleeding during the post-partum phase in the course of an elective caesarean delivery. Tako-tsubo cardiomyopathy was diagnosed by echocardiography and urgent cardiac magnetic resonance imaging. A coronary angiography was not performed because of the absence of myocardial necrosis or ischemia and signs of myocarditis on cardiac magnetic resonance imaging.ConclusionThis life-threatening disease should be excluded in the differential diagnosis by comparing the symptoms with those of typical heart failure, particularly after use of ergometrine.

Reliability of clinical assessment in diagnosing cauda equina syndrome

Cauda equina syndrome (CES) is a neurological syndrome presenting with non-specific symptoms and signs that often leads to diagnostic confusion and delay. Acute onset CES is a surgical emergency. The common aetiology is a prolapsed lumbar disc. If the diagnosis is missed, it can have devastating consequences for the patient and a high financial cost to healthcare providers. The objective of this study was to evaluate the efficacy of clinical assessment in clinching the diagnosis. Eighty patients who underwent urgent clinical assessment and magnetic resonance imaging (MRI) for suspected CES over a 1-year period (from January 1st 2008 to 31 December 2008) were included in the study. Fifteen of these patients had a CES and underwent urgent lumbar discectomy and decompression. Medical notes and MRI scans of all these patients were reviewed. The presenting symptoms and signs were analysed against a positive MRI scan. Chi-square test with Yates correction was used to test association of each clinical symptom and sign for a positive MRI. In this study, only 18.8% of assessed patients had a CES producing compression seen on the MRI. Presence of saddle sensory deficit was the only clinical feature with a statistically significant association with MRI positive CES (p = 0.03). This series shows that saddle sensory deficit has a higher predictive value than other clinical features in diagnosing a CES. However, as there is no symptom or sign which has an absolute predictive value in establishing the diagnosis of CES, any patient in whom a reasonable suspicion of CES arises must undergo urgent MRI to exclude this diagnosis.

Brain Apparent Water Diffusion Coefficient Magnetic Resonance Image During a Prolonged Visual Aura

Reversible changes in brain magnetic resonance imaging (MRI) weighted in diffusion-weighted images (DWI) and apparent water diffusion coefficient (ADC) maps have been reported in acute stroke, epilepsy, eclampsia, and hypoglycemia, but they are contradictory regarding to migraine aura. A 41-year-old woman with known basilar migraine for 5 years consulted about a persistent visual aura (visual snow phenomenon) plus bilateral paresthesias in the extremities for 4 days. The headache was treated with success with 10 mg of wafer rizatriptan and 600 mg of ibuprophen. The neurologic and ophthalmologic examination were normal. An urgent brain MRI detected no lesions in T1, T2, fluid-attenuated inversion recovery, and DWI, but an abnormal signal appeared in the left occipital lobe in ADC and (r)ADC maps. The brain MRI angiography, carotid ultrasound study, transesophageal echocardiography, 24-hour cardiac Holter monitoring, and thrombophilia study were normal. A new brain MRI 8 days after did not show any previous lesion in the same sequences. We present a patient with migraine and transitory abnormal signals in the ADC map of an occipital region during persistent visual aura. The clinical-radiological relationship is congruent. Some similar cases have showed these MRI signals during the aura, suggesting cytotoxic edema, without ischemic lesions in the MRI controls. Theses ADC images probably appear in complex auras.