Case Study 1 – Clues in Brain MRI for Craniocervical Junction Abnormalities, and then Dynamic Imaging Studies Show a Bigger Picture of Patient’s Condition
SUMMARY
Jane Dow’s case underscores the importance of thorough diagnostic assessment, particularly in cases where symptoms persist despite initial “normal” findings. Her case also highlights that while not common, radiologists can use MRI Brain to help identify craniocervical abnormalities. The first MRI scan focused solely on the brain, and the subsequent dynamic radiology studies emphasize the craniocervical junction, highlighting the need for comprehensive evaluation by CCI experts, especially where symptoms like headaches, relentless fatigue and neck pain are involved.
Case Study 1 – Jane Dow
In this case study, the patient’s clinical history noted the following: Headaches, sensitivity to light and sound, memory loss, post-COVID syndrome, fatigue, sleep disturbances, and pain and stiffness in the neck radiating to the hands with tingling sensation and numbness, tinnitus and blurred vision.
An MRI brain scan is a special picture-taking process used to check if everything is normal inside your head. Sometimes, when people feel unwell, doctors ask for an MRI Brain study to see if there are any problems in the brain and most times these studies include the area where the head meets the neck, called the craniocervical junction (CCJ).
The original report from the MRI brain showed that the brain looked “normal”. This means there were no big problems in the brain, like growths or changes in the way the brain looked. Even though the report said “normal,” this patient felt unwell. This is where it gets tricky. While the report says everything is okay, it might not tell the whole story. Sometimes (or perhaps even majority of times), doctors might not look closely enough at the CCJ, especially if they weren’t asked to. This is important because problems in this area could cause symptoms like headaches, neck pain, or trouble remembering things. Sometimes, radiologists might miss these problems because they weren’t told to look for them, others think that they don’t need to measure and can see “keep an eye out” for obvious abnormalities in the craniocervical junction (but according to our stats, this is a massive error on there part). That’s why it’s good to get a second opinion from radiologists who know all about the brain, neck and the craniocervical junction. They can look at the MRI again and pay special attention to the CCJ to make sure nothing was missed.
Jane’s MRI Brain Study 2nd Opinion Radiology Report Findings:
- No significant neuroparenchymal or intracranial abnormality is seen.
- No evidence of any intracranial hypotension.
- No evidence of any abnormal white matter signal abnormalities or delayed ischemic or encephalitis sequelae.
- Borderline clivo-axial angle and Grabb-Oakes measurement. Needs further evaluation with MRI/CT cervical spine flexion and extension study.
Dynamic uMRI Cervical Spine and CCJ Study
The patient obtained a dynamic upright MRI cervical spine and craniocervical junction (CCJ) study. A dynamic uMRI takes pictures of the neck in different positions: straight, bent forward, and bent backward. The patient went forward with the dynamic uMRI and submitted the study for 2nd radiology opinion. The ensuing report from this supplementary test unveiled more intricate details, particularly regarding the region where the head and neck meet. This supplementary study showed some interesting findings particularly regarding the region where the head and neck meet: The clivo-axial angle (CXA) showed abnormal measurement in flexion position, however there was no overt radiological evidence to support any brainstem compression. There was also increased translational BDI measurement, indicating ligamentous laxity, however no brainstem compression was seen. The report also noted borderline range of Grabb-Oakes measurement on neutral, flexion and extension images, as well as increased posterior occipital – cervical angle and occipito-axial angle, mild cervical spondylotic changes at C2-C3, C3-C4, C4-C5 and C5-C6 levels with mild diffuse disc bulge at C5-C6 intervertebral disc level which causes mild indentation on the anterior subarachnoid space. However, no evidence of spinal canal compromise or any nerve root compression was seen, and there was no radiological evidence to suggest Chiari malformation.
Jane’s Dynamic uMRI Cervical Spine & CCJ Study 2nd Opinion Radiology Report Findings:
- The bony clivo-axial angle shows borderline abnormal measurement in flexion position with borderline abnormal soft tissue clivo-axial angle, however there is no overt radiological evidence to support any brainstem compression.
- There is increased translational BDI indicating ligamentous laxity, however no brainstem compression is seen.
- Borderline range of Grabb-Oakes measurement on neutral, flexion and extension images.
- Increased posterior occipital-cervical angle and occipito-axial angle. (Note: this is an important finding.)
- Mild cervical spondylotic changes at C2-C3, C3-C4, C4-C5, and C5-C6 levels with mild diffuse disc bulge at C5-C6 intervertebral disc level which causes mild indentation on the anterior subarachnoid space. However, no evidence of spinal canal compromise or any nerve root compression is seen.
- No radiological evidence to suggest Chiari malformation.
Dynamic CT Scan Cervical Spine (or it could have been a Cone Beam CT Scan by an Upper Cervical Chiropractor)
Then, Jane brought the MRI Brain and uMRI 2nd Opinion Reports to her primary care physician (PCP) and the PCP ordered a dynamic CT cervical spine study in neutral, flexion, extension and rotation, left and right. This type of CT scan provides more detailed information about the bones, offering precise measurements.
The subsequent dynamic CT in flexion, extension and rotation views 2nd Opinion Radiology Report highlighted several significant findings:
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- Foramen Magnum and Cerebellar Tonsils: The size and position of the foramen magnum were normal, and the cerebellar tonsils were positioned above a specific reference line, indicating no abnormal descent or compression in the posterior fossa.
- Atlanto-Occipital and Atlanto-Axial Segments: Some measurements, such as the translational BAI and BDI, Grabb-Oakes and the bony Clivo-axial angle, were borderline pathological, indicating potential minor instability in the craniocervical region (skull to C1 and C1-C2).
- Sub-Axial Cervical Spine: Flattening of the upper cervical lordosis was observed, indicating changes in the curvature of the spine. However, there were no significant abnormalities noted in the individual vertebral bodies or posterior elements.
- Temporomandibular Joints and Styloid Processes: These structures appeared normal, with no signs of joint space narrowing or abnormal elongation of the styloid processes.
- The report recommended further consultation with a neurosurgeon for management, considering the patient’s condition and the observed abnormalities.
In essence, the dynamic CT cervical spine study provided crucial insights into the patient’s condition, shedding light on potential structural abnormalities and guiding the next steps in their medical management. The patient is current waiting for CT angiogram and venogram studies of the head and neck, and an appointment with a neurosurgeon.
Conclusion
In closing, it’s crucial to recognize that a standard MRI Brain study can sometimes (but not always) yield valuable insights into the craniocervical junction, given the expertise of a skilled radiologist. This case study 1 of Jane Dow underscores the significance of thorough evaluation and specialized knowledge in uncovering potential issues in this critical region, often overlooked in routine radiology reporting.
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