1/
A #ContinuumCase to start the week off!
21 yo👨 w/ a hx of traumatic brain & spinal cord injury presents to the ED for post-traumatic seizures.
MRI is ordered.
“No known implanted devices” is checked ✅
Then...The patient nearly suffers a life-threatening complication.
A #ContinuumCase to start the week off!
21 yo👨 w/ a hx of traumatic brain & spinal cord injury presents to the ED for post-traumatic seizures.
MRI is ordered.
“No known implanted devices” is checked ✅
Then...The patient nearly suffers a life-threatening complication.
2/
What device was present?
What device was present?
3/
⛔️ANY of these devices can be MR-unsafe! ⛔️
Many are also MRI-conditional and can result in life-threatening emergencies if the conditions are not followed!
....A further clue🕵️
Several days later the patient has fever, altered mental status, rigidity and another seizure.
⛔️ANY of these devices can be MR-unsafe! ⛔️
Many are also MRI-conditional and can result in life-threatening emergencies if the conditions are not followed!
....A further clue🕵️
Several days later the patient has fever, altered mental status, rigidity and another seizure.
4/
What device was it...?
What device was it...?
5/
Yes an IT baclofen pump!
Some IT pumps will stop infusing during MRI, and a select number will *never* resume after the scan is complete unless reprogramed
It is of extreme importance to know which device the patient has so that the conditions can be followed!
Yes an IT baclofen pump!
Some IT pumps will stop infusing during MRI, and a select number will *never* resume after the scan is complete unless reprogramed
It is of extreme importance to know which device the patient has so that the conditions can be followed!
6/
Acute baclofen withdrawal can put the patient at risk for serious withdrawal complications such as
- respiratory failure
- refractory seizures
- blood pressure lability
- delirium
- fever
- rigidity
emcrit.org/ibcc/baclofen/
Acute baclofen withdrawal can put the patient at risk for serious withdrawal complications such as
- respiratory failure
- refractory seizures
- blood pressure lability
- delirium
- fever
- rigidity
emcrit.org/ibcc/baclofen/
7/
Why?
Because Downregulation of GABA type B occurs with prolonged use, allowing tolerance.
When IT baclofen decreases--> hyperactivity of afferent nerve impluses.
Why?
Because Downregulation of GABA type B occurs with prolonged use, allowing tolerance.
When IT baclofen decreases--> hyperactivity of afferent nerve impluses.
8/
What to do??
There is not a definitive treatment. but oral baclogen, bentos, propofol, cyroheptadine, dantrolene have all been tried.
unfortunately, oral baclofen takes a long time to reach steady-state and is inconsistently absorbed even at large doses (>120mg/day).
What to do??
There is not a definitive treatment. but oral baclogen, bentos, propofol, cyroheptadine, dantrolene have all been tried.
unfortunately, oral baclofen takes a long time to reach steady-state and is inconsistently absorbed even at large doses (>120mg/day).
9/
In cases where the IT pump must be withdrawal, it may be necessary to have a temporary IT catheter to prevent severe withdrawal.
this is an EXCELLENT review:
pubmed.ncbi.nlm.nih.gov/20717751/
In cases where the IT pump must be withdrawal, it may be necessary to have a temporary IT catheter to prevent severe withdrawal.
this is an EXCELLENT review:
pubmed.ncbi.nlm.nih.gov/20717751/
10/
It is believed that IT pumps cause the greatest number of MRI device complications.
So while we think of pacemakers as the big MR concern, these might be even more important to eval for.
It is believed that IT pumps cause the greatest number of MRI device complications.
So while we think of pacemakers as the big MR concern, these might be even more important to eval for.
11/
Speaking of cardiac devices..
Many newer cardiac devices are MR-conditional. The ENTIRE system: leads+the pulse generator must be MR-conditional to be so.
If medically necessary, even *some* MR-unsafe cardiac devices can be scanned if there are appropriate teams in place.
Speaking of cardiac devices..
Many newer cardiac devices are MR-conditional. The ENTIRE system: leads+the pulse generator must be MR-conditional to be so.
If medically necessary, even *some* MR-unsafe cardiac devices can be scanned if there are appropriate teams in place.
12/
Other important devices to consider:
-VNS (particularly for lumbar spine MR)
-Deep brain stimulators
-Spinal cord stimulators
-Hypoglossal nerve stimulators
-Cochlear implants
Other important devices to consider:
-VNS (particularly for lumbar spine MR)
-Deep brain stimulators
-Spinal cord stimulators
-Hypoglossal nerve stimulators
-Cochlear implants
‼️NEVER, never just check "no device" without actually talking to a reliable surrogate, reviewing the history!
For more great tips about maintain MR-safety, check out by Drs Robert Watson and Lifeng Yu @AANmember @ContinuumAAN @LyellJ
journals.lww.com/continuum/Full…
For more great tips about maintain MR-safety, check out by Drs Robert Watson and Lifeng Yu @AANmember @ContinuumAAN @LyellJ
journals.lww.com/continuum/Full…
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