Urgent Magnetic Resonance Imaging Research Articles

The Intracranial Complications of Rhinosinusitis: Can They Be Prevented?

Reference textbooks on the intracranial complications of rhinosinusitis imply that many of the intracranial complications of rhinosinusitis can be prevented. We sought to examine whether or not this is true. A retrospective case series. The study included 47 consecutive patients presenting with intracranial complications secondary to rhinosinusitis between 1992 to 1999 with a mean follow-up of 5 years and 1 month. The most common presenting symptoms of intracranial involvement were an altered mental state, headache, fever, seizure, vomiting, a unilateral weakness or hemiparesis, or a cranial nerve sign. These justify an urgent magnetic resonance imaging or computed tomography scan. The importance of imaging before a lumbar puncture cannot be overemphasized. Of particular note was the finding that 21 patients (45%) presented with a periorbital cellulitis or frontal swelling. Therefore, it does not follow that because a collection of pus presents anteriorly it precludes any intracranial involvement. More than half of our patients (55%) had visited their primary care physician with an upper respiratory tract infection and had been treated appropriately. Once any central symptoms or signs developed, there was little evidence of any significant delay in referral to our unit. Only six patients had a history of nasal disease, three having had recent sinus surgery and three having had nasal polyps. Nine patients had significant long-term morbidity, seven patients had epilepsy, one patient had dysphasia, and one patient had right arm weakness. The single death in our series was associated with a cavernous sinus thrombosis. The report emphasizes the need for surgeons to be alert to the diagnosis, particularly in patients with a periorbital abscess or frontal swelling. Sinus surgery has a role in obtaining pus for culture, as well as draining the sinus if it is in continuity with an intracranial collection. Intracranial infections secondary to rhinosinusitis occur sporadically and, although it appears that this cannot be prevented, early recognition and treatment are essential to reduce any subsequent morbidity or mortality.

Traumatic spinal epidural hematoma of a 10-month-old male: a clinical note

Traumatic spinal epidural hematoma (TSEH) is rare in children. Only three cases of TSEH were documented in the pediatric literature. This clinical note presents an infant with TSEH but no risk factors. Without magnetic resonance imaging examination, children with TSEH and minor symptoms may be missed and under reported. Signs such as irritability and neck pain should alert the clinician to consider TSEH and the need for urgent magnetic resonance imaging of the spine for early diagnosis and treatment to minimize morbidity.

A case of spinal cord compression syndrome by a fibrotic mass presenting in a patient with an intrathecal pain management pump system

A 45-year-old woman presented with increasing low back pain, progressive anesthesia in her lower extremities and difficulty ambulating. She had a history of chronic low back pain problems for which, 26 months earlier, she had an intrathecal infusion pump permanently placed for pain and spasm control. Urgent magnetic resonance imaging (MRI) of the lumbar spine revealed a mass at the site of the tip of the intrathecal catheter with high grade spinal cord compression at the level of L-1. At surgical laminectomy the compressing lesion was found to be a reactive tissue fibroma. As more patients receive these devices the physician should consider cord compression syndrome in patients presenting with symptoms of increasing low back pain, anesthesia and progressive proprioceptive loss.

Spontaneous spinal epidural hematoma in children

Spontaneous spinal epidural hematoma is rare in children. It is usually confined to the dorsal epidural space. Ventral spontaneous spinal epidural hematoma (SSEH) is rarer, with only two previous reports. The authors present three children, two with dorsal and one with ventral spinal epidural hematoma, and review the literature. No etiology of the hematoma was found in the authors’ patients and there was no history of trauma. A review of 24 patients of children younger than 18 years of age reported in the literature and the authors’ three patients revealed that the cervicothoracic region was the most common site of SSEH, the mode of onset was frequently subacute, and there was no male preponderance as has been reported in adults. We found that the initial symptoms were often nonspecific, leading to a delay in diagnosis, especially in younger children. Follow-up data revealed that 15 of the 27 patients recovered completely, 11 had residual neurologic deficits, and one patient died. Irritability and neck pain with restricted movements of the cervical spine in an afebrile child may be early signs of SSEH and often precede onset of neurologic deficits by several hours to days. These signs should alert the clinician to consider spinal epidural hematoma and the need for urgent magnetic resonance imaging (MRI) of the spine for early diagnosis and treatment to minimize morbidity.

Acute primary cerebral angiitis mimicking basilar artery dissection.

Two patients presented with acute severe occipital headache, neck pain, nausea, vomiting and blurred vision. In both patients angiograms of the posterior circulation showed focal narrowing of the basilar artery, thus basilar artery dissection was considered. Urgent magnetic resonance imaging (MRI) was unavailable. On the basis of additional angiography of the anterior circulation and control angiograms after 4 and 6 weeks, primary cerebral angiitis was the most probable diagnosis. Treatment with corticosteroids resulted in rapid clinical and angiographic improvement. We conclude that, when MR techniques are unavailable or inconclusive, presumption of basilar dissection on the base of clinical features, Doppler studies, Duplex scanning and angiography of the vertebro-basilar system should be confirmed by additional carotid angiography in order to exclude diffuse cerebral angiitis.