Supplemental Oxygen Causes Increased Signal Intensity in Subarachnoid Cerebrospinal Fluid on Brain FLAIR MR Images Obtained in Children during General Anesthesia

Frigon, Chantal; Shaw, Dennis; Heckbert, Susan R.; Weinberger, Edward; Jardine, David S.

doi:10.1148/radiol.2331031375

Cited by 44 publications

(32 citation statements)

References 5 publications

(2 reference statements)

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“…CSF hyperintensity on FLAIR has been related to blood, proteinaceous content, inflammatory exudates or pyogenic material, anesthesia, and/or high inspired fractional oxygen concentrations (Ͼ50%). 2 None of these conditions were contributory in the current patient. Single-shot, fast spin-echo FLAIR, which has been noted to result in spuriously high signal intensity in the CSF spaces, was not used in this case.…”

Section: Discussionmentioning

confidence: 80%

“…Increasing contrast dosage and delay in imaging are additional factors that contribute to extracellular contrast accumulation. 2,3,7 Animal studies have shown that gadolinium agents cross the BBB in healthy dogs, a phenomenon that is more evident with higher contrast agent concentrations. 8 Most previously reported cases of CSF gadolinium enhancement in clinical patients are seen in conjunction with higher than usual contrast doses and in the setting of poor renal clearance.…”

Section: Discussionmentioning

confidence: 99%

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Delayed CSF Enhancement in Posterior Reversible Encephalopathy Syndrome

Hamilton¹,

Nesbit²

2008

AJNR Am J Neuroradiol

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SUMMARY:We present a case of increased fluid-attenuated inversion recovery signal intensity in the subarachnoid spaces on 6-hour delayed enhanced MR imaging in a patient with posterior reversible encephalopathy syndrome (PRES) in the setting of acute hypertensive encephalopathy. This hyperintensity was believed due to CSF gadolinium enhancement, a finding that would be anticipated in light of the suspected pathogenesis of increased microvascular permeability in PRES. Posterior reversible encephalopathy syndrome (PRES) is theorized to result from an abnormally leaky blood-brain barrier (BBB) at the level of the microvasculature. MR perfusion studies to date have unsuccessfully clarified the site of abnormally increased vascular permeability as capillary, arteriolar, or venular.1 Increased permeability to small molecules such as water explain the interstitial accumulation of fluid in areas affected by PRES; however, larger molecules such as gadolinium chelates might also cross an abnormally permeable BBB. Because this leak may occur slowly for minutes to hours, it is difficult to capture with dynamic contrast-enhanced perfusion techniques or even immediate postcontrast sequences. We report a case of abnormal fluid-attenuated inversion recovery (FLAIR) hyperintensity in the subarachnoid spaces in a patient with PRES and normal renal function. The hyperintensity was due to delayed CSF gadolinium accumulation, a finding that supports the concept of slow BBB leakage in this syndrome. Case ReportA 77-year-old woman with a medical history significant for chronic hypertension and dementia presented to the emergency department with headache, obtundation, and markedly elevated blood pressures as high as 230/120 mm Hg. Unenhanced FLAIR imaging of the brain performed at this time demonstrated extensive confluent areas of white matter hyperintense signal intensity in both cerebral hemispheres (Fig 1). Diffusion-weighted images and apparent diffusion coefficient maps (not shown) demonstrated increased diffusion in the affected areas and no restricted diffusion. The clinical presentation and MR imaging findings were consistent with PRES in the setting of hypertensive encephalopathy.The patient underwent a second contrast-enhanced MR imaging examination, including perfusion imaging 6 hours later on the same date. Axial FLAIR images of the brain obtained immediately following the second dose of contrast revealed markedly elevated signal intensity throughout the subarachnoid spaces, which had not been present on the first study (Fig 2). CT was not performed due to no clinical concern for subarachnoid hemorrhage and given the normal-appearing FLAIR images at the time of initial presentation and imaging. A CSF assay for gadolinium was also not performed to confirm the suspicion that FLAIR hyperintensity was due to enhancement because no other indications for the procedure were sufficient to warrant consideration of this mildly invasive test.The patient's admission and subsequent laboratory values revealed no evidence for renal compr...

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Section: Discussionmentioning

confidence: 80%

Section: Discussionmentioning

confidence: 99%

Delayed CSF Enhancement in Posterior Reversible Encephalopathy Syndrome

Hamilton¹,

Nesbit²

2008

AJNR Am J Neuroradiol

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“…Daha sonra yapılan bazı klinik çalışmalar da, HSA'nın oksijenle bağlantılı olduğu varsayımını destekler niteliktedir. [8][9][10][11][12] Örneğin bir çalışmada, azot protoksit kullanılan ve inspire edilen oksijen fraksiyonun düşük olduğu gruptaki hiçbir hastada HSA görülmemiştir. 8 Dolayısıyla artık yaygın kabul gören görüş, MR'daki FLAIR görüntülerde HSA'ya yolaçan nedenin oksijen olduğu şeklindedir.…”

Section: J Clin Exp Invest Wwwjceionlineorg Vol 3 No 4 December 2012unclassified

“…Daha önce gerçekleştirilen çalış-malar da, hem yüz maskesiyle hem de endotrakeal tüp ya da larengeal maske gibi havayolu gereçleriy-le verilen oksijenin HSA'ya neden olduğunu göster-mişlerdir. [8][9][10][11][12] Ancak bu konuda yapılan diğer yayınlar incelendiğinde, çalışma dizaynları arasında farklılıklar olduğu göze çarpmaktadır.…”

Section: J Clin Exp Invest Wwwjceionlineorg Vol 3 No 4 December 2012unclassified

“…Ayrıca bu çalışmada, anestezi idamesi tüm hastalarda propofolle sağlanmış olsa da, indüksiyon bazı hastalarda inhalasyon anestezikleriyle gerçekleşti-rilmiş, havayolu sağlanması için de laringeal maske veya endotrakeal tüp kullanılmıştır. 11 Anzai ve ark. nın çalışmasında ise anestezi uygulanmamış, altı gönüllüde yüz maskesiyle elde edilen sonuçlar yorumlanmıştır.…”

Section: J Clin Exp Invest Wwwjceionlineorg Vol 3 No 4 December 2012unclassified

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Does oxygen use during general anesthesia cause an artifact in magnetic resonance images?

Acar¹,

Yiğit²,

Korkulu³

et al. 2012

J Clin Exp Invest

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Objectives: In this study our aim was to compare possible effects of two different oxygen concentrations (100% vs. 50%) on hyperintense signal abnormality (HSA) in pediatric patients undergoing cranial magnetic resonance imaging (MRI) under sevoflurane anesthesia. Materials and methods:Thirty pediatric patients undergoing cranial MRI were studied. Sevoflurane was used for induction and maintenance of anesthesia with an MRcompatible anesthesia machine. Patients, whose airway patency was maintained with laryngeal mask, were divided randomly in two groups. 100% oxygen and 50% oxygen/50% nitrous oxide was used for maintenance of anesthesia in Group I and II, respectively. FLAIR sequence images were analyzed by a radiologist who was unaware of the groups and were evaluated for HSA in 11 different brain regions in cerebrospinal fluid neighborhood. A three-point scale was used for evaluation. Results:HSA was seen in all study patients at least in one brain region. However, no significant difference was obtained between two groups in almost all brain regions (p>0.05).Conclusions: Use of oxygen in pediatric patients undergoing cranial MRI under sevoflurane anesthesia caused a low grade HSA. However, concentration of oxygen had no significant effect on the severity of HSA. J Clin Exp Invest 2012; 3(4): 477-482

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The safety of anakinra in high‐risk patients with active rheumatoid arthritis: Six‐month observations of patients with comorbid conditions

Schiff¹,

DiVittorio²,

Tesser³

et al. 2004

Arthritis & Rheumatism

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Objective. To determine in a placebo-controlled, double-blind trial the safety profile of daily anakinra (Kineret) use in patients with active rheumatoid arthritis (RA) and concurrent comorbid conditions.Methods. In 169 centers in 9 countries, 1,414 patients with active RA were randomly assigned to receive either anakinra (100 mg) or placebo treatment (4:1 anakinra-to-placebo allocation ratio), with study drug administered by daily subcutaneous injection for 6 months. The current post hoc analysis assessed baseline comorbid conditions, and patients were considered at high risk for the occurrence of adverse events if they had a history of at least one of the following: cardiovascular event, pulmonary event, central nervous system-related event, infection, diabetes, malignancy, or renal impairment. Within each treatment group (anakinra or placebo), incidence rates were summarized for serious adverse events, infectious events, and serious infectious events in high-risk patients and compared with these incidence rates in patients without comorbid conditions.Results. The majority of patients in the trial had one or more comorbid conditions. In these high-risk patients, there were no differences in the incidence of serious adverse events or infectious events between treatment groups. The incidence of serious infectious events with anakinra use was similar between high-risk patients (2.5%) and the entire study population (2.1%) and was not attributable to any single comorbidity. Conclusion.Results of the analysis of adverse events in patients with active RA and coexisting comorbidities suggest that the favorable safety profile of anakinra is maintained in a high-risk patient population.

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Supplemental Oxygen Causes Increased Signal Intensity in Subarachnoid Cerebrospinal Fluid on Brain FLAIR MR Images Obtained in Children during General Anesthesia

Abstract: These findings are consistent with the hypothesis that increased arterial oxygen tension and consequently increased CSF Po(2) resulting from administration of high Fio(2) during general anesthesia are responsible for the increased CSF signal intensity noted on brain FLAIR MR images.

Cited by 44 publications

References 5 publications

Delayed CSF Enhancement in Posterior Reversible Encephalopathy Syndrome

Delayed CSF Enhancement in Posterior Reversible Encephalopathy Syndrome

Does oxygen use during general anesthesia cause an artifact in magnetic resonance images?

The safety of anakinra in high‐risk patients with active rheumatoid arthritis: Six‐month observations of patients with comorbid conditions

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