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The dilemma of early postoperative magnetic resonance imaging: when efficiency compromises accuracy: case report
Hasan A Zaidi1, Shakeel A Chowdhry, David A Wilson
1Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.
Background And Importance:
Postoperative magnetic resonance imaging (MRI) is critical to the clinical decision-making process for patients undergoing resection of intracranial tumors. The accuracy of immediate postoperative MRI in determining the presence of residual disease following intracranial tumor resection, however, has not been studied.
Clinical Presentation:
A 57-year-old man underwent an uncomplicated retrosigmoid craniotomy for the resection of a cystic vestibular schwannoma. Immediate gadolinium-enhanced postoperative MRI, performed within 1.5 hours of surgery, was notable for a plaquelike, lobular, avidly enhancing collection with MRI characteristics consistent with fluid density extending from the porus acusticus into the cerebellopontine angle. This anomalous lesion disappeared upon repeat imaging 48 hours later, and the patient had no attributable clinical sequelae. He was discharged home without issues within 12 hours of repeat imaging.
Conclusion:
We demonstrate here that immediate postoperative, gadolinium-enhanced MRI scans after tumor resection may result in avid enhancement in the region of surgical manipulation, likely due to leakage of gadolinium chelates into the subarachnoid space from residual compromise of the blood-brain barrier immediately following surgical manipulation. Early imaging is no longer routinely performed at our institution unless otherwise clinically indicated.
Abbreviations:
FLAIR, fluid-attenuated inversion recoveryIAC, internal auditory canal.
Insights
Immediate postoperative MRI after intracranial tumor resection may show false-positive enhancement due to surgical manipulation. This finding can mimic residual tumor, highlighting the importance of careful interpretation of early postoperative imaging.
Area of Science:
- Neurosurgery
- Neuroradiology
- Oncology
Background:
- Postoperative magnetic resonance imaging (MRI) is crucial for assessing intracranial tumor resection outcomes.
- The accuracy of immediate postoperative MRI in detecting residual tumor has not been established.
Observation:
- A patient with vestibular schwannoma showed an unusual enhancing lesion on immediate postoperative MRI.
- This lesion, consistent with fluid density, resolved on imaging 48 hours later without clinical impact.
Findings:
- Immediate gadolinium-enhanced MRI post-tumor resection can exhibit avid enhancement at the surgical site.
- This enhancement is likely due to gadolinium leakage into the subarachnoid space from a transiently compromised blood-brain barrier.
Implications:
- Immediate postoperative MRI findings may be misinterpreted as residual tumor, affecting clinical decisions.
- Routine early postoperative MRI is no longer standard practice at the institution unless clinically indicated.
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