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15b - Answer: 42-year-old male presents with pain in right face for six months

Pomeranz, Stephen
Stephen J Pomeranz, MD
Chief Medical Officer, ProScan Imaging. Founder, MRI Online
Includes DICOM files

HISTORY: 

This 42-year-old male presents with pain in the right face for six months. Right retroorbital and ear pain.

(QUIZ ANSWER) POTENTIAL CONTRIBUTOR TO INDICATED PAIN: 

Microvascular compression.

Using the diagnostic web viewer, we have provided images that assist in telling our clinical story. Areas of significance are indicated below.

FINDINGS:

The calvarium is intact. 

No Chiari malformation. 

Partial empty sella was present on prior MRI. 

No orbital or retroorbital masses. 

Temporomandibular joints are symmetric. 

Carotid and basilar artery flow voids are intact. 

No internal auditory canal or cerebellopontine angle masses. 

Venous sinuses are patent. 

Masticator, parapharyngeal, pharyngeal mucosal, prevertebral and parotid spaces are without masses or adenopathy. 

Susceptibility within the right maxillary sinus may be related to prior intervention. 

No posterior cervical adenopathy. 

No extraaxial collections or hemorrhage. No obstructive hydrocephalus. 

Cerebral hemispheres and deep nuclei are without hemorrhage, mass or edema. 

Diffusion-weighted images are without a diffusion-restrictive defect. 

No orbital or retroorbital masses. Extraocular muscles are symmetric. No masses within the 5th nerve complexes, Meckel's caves or cavernous sinuses. Tiny vessel best appreciated on axial water-weighted T2 drive series demonstrates tiny vessel in proximity to the right trigeminal entry zone, may represent a distal tributary of the superior cerebellar artery. 

Brainstem and cerebellum are without hemorrhage, mass, edema or gliosis. No evidence of posterior fossa demyelination. No clival masses. No mass within the interpeduncular fossa. 

No enlargement of the extraocular muscles or the lacrimal apparatus. Orbital apices, optic chiasm, optic tracts, lateral geniculate and visual cortices are unremarkable. 

No suprasellar masses or chiasmal compression. 

CONCLUSION

1. Small vessel which may be a distal tributary of the superior cerebellar artery is in proximity to the right trigeminal entry zone. Finding may be relevant if trigeminal neuralgia is of clinical concern and may have been present on prior MRI. 

2. No orbital or retroorbital masses. No supportive findings of orbital pseudotumor or thyroid orbitopathy. 

3. No intracranial hemorrhage, neoplasm or obstructive hydrocephalus. 

4. No air-fluid levels within the paranasal sinuses. 

5. No intracranial hemorrhage, neoplasm or obstructive hydrocephalus. 

6. No evidence of acute supra- or infratentorial ischemia or demyelination. 

7. Findings otherwise appear stable in comparison to prior MRI. 

ADDENDUM

Examination was re-reviewed with clinical discussion. Patient apparently has presented with right ear pain which has been described as being secondary to compressive vascular loop related to the nervus intermedius. On review of the MRA and heavily water-weighted T2 drive sequences there is a potential area of microvascular compression at the origin of the right 7th and 8th nerve complexes which may represent a distal tributary of the anteroinferior cerebellar artery. Finding is best seen on the MRI on T2 DRIVE series and on the MRA on raw data series. Findings could provide a substrate for neurovascular compression syndrome in the appropriate clinical setting.

LESSON 3, TOPIC 15

Case Challenge: Brain MRI Cases

Case Challenge

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Content reviewed: July 23, 2021

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