Iatrogenic Brainstem Injury During Cerebellomedullary Cistern Puncture

Abstract

Cerebrospinal fluid collection is fundamental to the investigation of central nervous system disorders although it carries potential risks. Herein we report the clinical signs and magnetic resonance (MR) imaging findings associated with needle injury to the brainstem during cerebellomedullary cistern puncture in four dogs. Three dogs were nonambulatory tetraparetic with cranial nerve deficits and one dog had unexplained left thoracic limb paresis. In MR images, there were conspicuous T2 hyperintensities in the myelencephalon in all dogs. In T2* gradient echo images, the lesions were hypointense in two dogs with multiple cranial nerve deficits, and hyperintense in another dog. One dog was euthanized due to sudden neurologic deterioration 12 days later, one died shortly after MR imaging, and a third was euthanized due to concurrent cervical spondylomyelopathy. The fourth dog recovered gradually. Diagnosis was confirmed histopathologically in one dog and was presumptive based on clinical signs and MR findings in three dogs. None of the dogs with cranial nerve deficits recovered, only the one dog with left thoracic limb paresis and concurrent syringomyelia.

Optimal Magnetic Resonance Imaging of the Spine

“…T2 * GE sequences should be used before paramagnetic contrast medium administration 24 . The T2 * GE sequence aids detection of hemorrhagic spinal lesions including disc extrusions accompanied by rupture of the venous sinuses, 25 hematomyelia secondary to lumbar puncture, 26 iatrogenic brainstem injury during cisternal puncture, 27 hemorrhagic myelomalacia, 28 and intramedullary disc extrusion 29 . However, calcified disc material cannot be accurately distinguished from blood because both produce signal void.…”

Use of the T2*‐weighted Gradient Recalled Echo Sequence for Magnetic Resonance Imaging of the Canine and Feline Brain

“…In veterinary patients, the use of T2 * -weighted gradient recalled echo imaging to detect hemorrhage has been reported in cases of primary cerebral hemangioma, metastatic hemangiosarcoma, pituitary adenoma and adenocarcinoma, astrocytoma, oligodendroglioma, intravascular lymphoma, meningioma, Angiostrongylus vasorum infection, bacterial septicemia, hemorrhagic infarction, hemorrhagic stroke, cerebral microbleeds, subdural hematoma, spinal extradural hematoma associated with intervertebral disk herniation, hemorrhagic myelomalacia, traumatic intramedullary spinal cord hemorrhage, ischemic myelopathy, acute noncompressive nucleus pulposus extrusion, and necrotizing myopathy. [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22] However, the routine use of T2 * -weighted gradient recalled echo pulse sequences in a large series of canine and feline patients has not been reported.…”

Intra-parenchymal brainstem haemorrhage secondary to iatrogenic needle injury after a parenteral injection in a cat

“…5 Overall the outcome within this small cohort of cases is poor. We report a good outcome in this cat.…”

“…However, the acute onset after the neck parenteral injection attempt, the skin lesion, the orientation of the suspected muscle needle tract and the similar imaging findings to the previously described iatrogenic traumatic brainstem and lumbar needle injuries in dogs strongly support our presumptive diagnosis. 5,6 …”