Postoperative annular pseudocyst: report of two cases with an unusual complication after microdiscectomy, and successful treatment by percutaneous aspiration and steroid injection.

BACKGROUND CONTEXT: After microdiscectomy for extruded disc fragments, patients may develop recurrent symptoms from numerous causes. Postoperative annular pseudocysts represent a unique entity not previously described in the medical literature. PURPOSE: To report unique imaging findings in two patients who presented with recurrent radiculopathic symptoms after microdiscectomy. To report successful percutaneous aspiration and steroid injection in one of these cases. STUDY DESIGN/SETTING: Report of two cases. METHODS: Two patients underwent preoperative imaging with noncontrast magnetic resonance imaging (MRI) and postoperative imaging with pre- and postcontrast MRI. One of these patients underwent therapeutic computed tomography (CT)-guided aspiration and injection. RESULTS: MRI demonstrated T2 hyperintense and enhancing collections, which conformed to the shape of the resected disc fragment and communicated with the disc annulus. One of these cases demonstrated enlargement over several months with worsening of symptoms. Aspiration of the lesion produced thick fluid. The patient experienced marked relief of symptoms after the aspiration and injection of steroid into the lesion. CONCLUSIONS: The unique imaging findings in these patients represent a previously undescribed complication of microdiscectomy, which we have termed "postoperative annular pseudocyst." We have successfully treated one case with CT-guided percutaneous aspiration and injection.

Fat-saturated MR imaging in the detection of inflammatory facet arthropathy (facet synovitis) in the lumbar spine.

OBJECTIVE: The objectives of the study were: to illustrate the magnetic resonance (MR) imaging appearance of facet synovitis in the lumbar region using an MR fat-saturation technique; to determine how commonly facet synovitis is encountered when fat-saturation techniques are used; to classify the MR appearance of facet synovitis; and to test the correlation between the location of a lesion and the site of the patient's pain. DESIGN: In total, 209 consecutive MR studies of the lumbar spine were retrospectively reviewed to document the prevalence of lumbar facet synovitis in daily imaging practice. The degree of facet synovitis was graded. Medical records of 30 additional symptomatic patients with MR evidence of unilateral, single-level facet synovitis were reviewed to determine the side of the patient's clinical symptoms. RESULTS: Facet synovitis occurred in 41% of lumbar MR studies reviewed. No patient reviewed had evidence of active infection. Most often, signal changes were restricted to the affected joint. The side of the facet synovitis correlated with the side of the patient's clinical symptoms. CONCLUSION: Facet synovitis is a common condition and appears to correlate with the patient's pain. Detection of active inflammatory facet osteoarthropathy (facet synovitis) within and surrounding the facet joints is possible with MR imaging using a fat-saturation technique.

Transient vertical diplopia and nystagmus associated with acute thalamic infarction.

We describe a patient who presented with a 1-h history of vertical diplopia and nystagmus and was found to have acute left ventrolateral thalamic infarction on the diffusion-weighted magnetic resonance imaging (DWI MRI). This is the first case report demonstrating that vertical diplopia and nystagmus, which typically suggest a lesion in the brainstem or cerebellum, may also occur in acute thalamic infarction. DWI MRI can detect thalamic infarction as early as 1 h after its clinical manifestations.

Recombinant factor VIIa for rapid reversal of warfarin anticoagulation in acute intracranial hemorrhage.

OBJECTIVE: To assess the effects of recombinant factor VIIa (rFVIIa) on hemorrhage volume and functional outcomes in warfarin-related acute intracranial hemorrhage (ICH), which has a 30-day mortality of more than 50%. PATIENTS AND METHODS: We reviewed the clinical, laboratory, and radiographic features of a consecutive series of 7 patients (median age, 87 years; 5 women) with symptomatic, nontraumatic warfarin-related acute ICH treated with intravenous rFVIIa at St. Luke's Hospital in Jacksonville, Fla, between December 2002 and September 2003. Prestroke baseline functional status was assessed with the modified Rankin Scale. Outcome was assessed with the Glasgow Outcome Scale. RESULTS: The international normalized ratio decreased from a mean of 2.7 before administration of rFVIIa to 1.08 after administration of rFVIIa. The median prestroke score on the modified Rankin Scale was zero. The median presenting score on the Glasgow Coma Scale was 14 (range, 4-15). The mean time from onset to treatment was 6.2 hours. The mean initial dose of rFVIIa was 62.1 microg/kg. One patient underwent placement of an external ventricular drain, and another underwent craniotomy and hematoma evacuation. Five of the 7 patients survived and were dismissed from the hospital with severe disability (Glasgow Outcome Scale, 3); 2 patients died during hospitalization. CONCLUSIONS: Intravenous bolus administration of rFVIIa can rapidly lower the international normalized ratio and appears to be safe for patients with warfarin-related ICH. Prospective controlled studies are needed to determine whether rFVIIa can prevent hematoma expansion and improve neurologic outcomes in patients with warfarin-related ICH.