Overheated and melted intracranial pressure transducer as cause of thermal brain injury during magnetic resonance imaging

Case report

Reiichiro Tanaka M.D.1, Tetsuya Yumoto M.D.2, Naoki Shiba M.D.1, Motohisa Okawa M.D., Ph.D.3, Takao Yasuhara M.D., Ph.D.4, Tomotsugu Ichikawa M.D., Ph.D.5, Koji Tokunaga M.D., Ph.D.5, Isao Date M.D., Ph.D.5, and Yoshihito Ujike M.D., Ph.D.1
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  • 1 Department of Critical Care and Emergency Medicine, Okayama University Hospital;
  • | 3 Department of Health Science, College of Life Science, Kurashiki University of Science and The Arts;
  • | 5 Department of Neurological Surgery, Okayama University Graduate School of Medicine, Okayama;
  • | 2 Department of Surgery, National Hospital Organization Mito Medical Center, Ibaraki; and
  • | 4 Spinal Cord Treatment Center, Shin Komonji Hospital, Fukuoka, Japan
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Magnetic resonance imaging is used with increasing frequency to provide accurate clinical information in cases of acute brain injury, and it is important to ensure that intracranial pressure (ICP) monitoring devices are both safe and accurate inside the MRI suite. A rare case of thermal brain injury during MRI associated with an overheated ICP transducer is reported.

This 20-year-old man had sustained a severe contusion of the right temporal and parietal lobes during a motor vehicle accident. An MR-compatible ICP transducer was placed in the left frontal lobe. The patient was treated with therapeutic hypothermia, barbiturate therapy, partial right temporal lobectomy, and decompressive craniectomy. Immediately after MRI examination on hospital Day 6, the ICP monitor was found to have stopped working, and the transducer was subsequently removed. The patient developed meningitis after this event, and repeat MRI revealed additional brain injury deep in the white matter on the left side, at the location of the ICP transducer. It is suspected that this new injury was caused by heating due to the radiofrequency radiation used in MRI because it was ascertained that the tip of the transducer had been melted and scorched. Scanning conditions—including configuration of the transducer, MRI parameters such as the type of radiofrequency coil, and the specific absorption rate limit—deviated from the manufacturer's recommendations. In cooperation with the manufacturer, the authors developed a precautionary tag describing guidelines for safe MR scanning to attach to the display unit of the product.

Strict adherence to the manufacturer's guidelines is very important for preventing serious complications in patients with ICP monitors undergoing MRI examinations.

Abbreviations used in this paper:

DBS = deep brain stimulation; FDA = US Food and Drug Administration; GCS = Glasgow Coma Scale; ICP = intracranial pressure; RF = radiofrequency; SAR = specific absorption rate; WBC = white blood cell.

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Contributor Notes

Address correspondence to: Reiichiro Tanaka, M.D., Department of Critical Care and Emergency Medicine, Okayama University Hospital, 2-5-1 Shikata-Cho, Kita-ku, Okayama 700-8558, Japan. email: Rtanaka17@aol.com.

Please include this information when citing this paper: published online October 12, 2012; DOI: 10.3171/2012.9.JNS12738.

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