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Magnetic Susceptibility Artifacts on
MRI: A Hairy Situation
A 15-year-old black boy was admitted to
the hospital with headache, fever, proptosis of
the left eye, and restricted gaze. He had presented to an emergency department the previous day with a 5-day history of a headache.
After physical examination had revealed no
significant findings and CT of the head reportedly had shown normal findings, the patient
had been discharged home. MRI and repeated
head CT performed at admission (Fig. 1A and
1B) revealed acute sinusitis complicated by a
left periorbital abscess and multiple subdural
empyemas. The patient then underwent bur
hole drainage of the subdural empyemas, incision and drainage of the periorbital abscess,
and endoscopic sinus surgery. After these procedures, the patient made a full recovery.
Of particular interest in this case was the
unusual artifact seen on gadolinium-enhanced MRI. The appearance of the artifact
suggested that it was caused by the patients

hair twists, a style popular in the black

community. Twisting the hair requires the use
of products such as gel or beeswax to hold
the hair in place. Hair stylists use either
untinted beeswax or black beeswax tinted
with pigments containing iron oxide. Further
investigation revealed that our patient used
black beeswax in his hair, causing the observed paramagnetic effect. Similar artifacts
are commonly known to be caused by cosmetics containing iron and cobalt pigments.
This case is similar to one that Duncan
[1] previously described in AJR as a culturally linked imaging artifact: an MR artifact
was seen in a traditional healer in South Africa who used a clay paste containing iron
oxide to dress her braids. However, cases
such as ours are more likely to be encountered by radiologists in the United States, especially considering the growing popularity
among American blacks of hair styles
such as twists and dreadlocksthat require
the use of beeswax.

Robert C. McKinstry III

Mallinckrodt Institute of Radiology
St. Louis, MO 63110
Delma Y. Jarrett
Memorial Sloan-Kettering Cancer Center
New York, NY 10021

1. Duncan IC. The aura sign: an unusual cultural variant affecting MR imaging. (letter) AJR 2001;177:1487

Pyelovenous Backflow Seen on CT

A 32-year-old woman who underwent a
cesarean-section delivery and subsequent
hysterectomy presented 2 weeks after surgery with fever, tachycardia, lower back
pain, diffuse abdominal pain, and hematuria.
Contrast-enhanced CT of the abdomen and
pelvis revealed a large abdominopelvic abscess with thrombus in the right renal vein

Fig. 1.15-year-old boy with acute sinusitis and

subdural empyemas.
A and B, Gadolinium-enhanced sagittal (A) and
coronal (B) T1-weighted images show left subdural
empyema and image distortion from susceptibility
artifacts caused by iron oxide particles suspended
in beeswax dressing in patients hair.


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that extended into the inferior vena cava
(Fig. 2A). Calicectasis was also seen in the
right kidney, presumably related in part to
the patients postpartum state but also to a
mass effect from the large abscess. Excretory
phase scans (Figs. 2B and 2C) showed contrast material in the right renal collecting system also exiting into the right renal vein and
inferior vena cava, findings that are compatible with pyelovenous backflow.
In acute ureteral obstruction, the kidney
resorbs urine as a compensatory mechanism
to allow continued excretion. The resorption
of urine in the setting of acute obstruction
is termed renal backflow, a phenomenon
that occurs via one of five pathways:
pyelovenous, pyelolymphatic, pyelotubular,
pyelointerstitial, or pyelosinus [1, 2]. All five
types of renal backflow are well depicted on
retrograde urography and result from the
force of injection. During vigorous injection,
contrast material may flow into the tubules or
may rupture a fornix and flow into the
venous plexus, lymphatics, interstitium, or
sinus to form a urinoma [1, 2].
Pyelolymphatic and pyelosinus backflow
may also be seen on excretory urography, but
neither pyelovenous nor pyelotubular can be
diagnosed using this technique [3]. To the best
of our knowledge, pyelovenous backflow visualized on CT urography has never been reported. In our patient, the postpartum state and
large pelvic abscess caused a right-sided ureteral obstruction with subsequent pyelovenous
backflow. If there had been no thrombus in the

right renal vein and inferior vena cava, CT

urography would not have revealed the
pyelovenous backflow. The high flow rate in a
patent renal vein and inferior vena cava would
have diluted the small amount of resorbed contrast medium before the backflow could be revealed [4]. In our patient, the thrombus in the
right renal vein and inferior vena cava sufficiently slowed the flow to allow visualization
of pyelovenous backflow on CT.
Alexander J. Nemeth
Suresh K. Patel
Rush University Medical Center
Chicago, IL 60612-3864

1. Fuchs F. Pyelovenous backflow in the human kidney. J Urol 1930;23:181216
2. Thomsen HS. Pyelorenal backflow: clinical and
experimental investigations. Dan Med Bull
3. Olsson O. Studies on back-flow in excretion
urography. Acta Radiol Suppl 1948;70:180
4. Imray TJ, Lieberman RP, Pollack HM. Retrograde
pyelography. In: Pollack HM, McClennan BL,
Dyer R, Kenney PJ, eds. Clinical urography, 2nd
ed. Philadelphia, PA: Saunders, 2000:282302

Peritumoral Fatty Infiltration of the

Liver Associated with Venous Drainage
from Metastatic Liver Tumor
A 54-year-old woman underwent distal gastrectomy for advanced gastric carcinoma. Five

months after surgery, sonography showed multiple liver tumors, each with a highly echoic
rim. In addition to a diffuse fatty infiltration of
the liver, unenhanced CT revealed five liver tumors, each of which measured 1.01.8 cm in
diameter (mean, 1.2 cm). Each tumor displayed a peritumoral hypoattenuating band
that was thought to be fatty infiltration (Fig.
3A). On arterial phase CT, all tumors showed
rim enhancement, and metastases from gastric
carcinoma were suspected, although the patient also had hepatitis C.
The level of carcinoembryonic antigen
was elevated at 15 ng/dL, but levels of -fetoprotein and protein induced by vitamin K
antagonist II were normal. The patient had
no history of alcoholism or diabetes mellitus.
The serum triglyceride level was normal, and
the total cholesterol level was slightly low
(142 mg/dL).
On angiography, all tumors showed rim enhancement. CT during arterial portography
showed multiple nodular perfusion defects including a peritumoral hypoattenuating band
around each tumor (Fig. 3B). Early phase images of single-level dynamic CT during hepatic arteriography showed a hyperattenuating
rim within the peritumoral hypoattenuating
band around each tumor (Fig. 3C). On late
phase images, the peritumoral hypoattenuating
bands were gradually enhanced by direct
drainage from the tumors (Fig. 3D).
The patient refused needle biopsy, and the
diagnosis of metastatic liver tumor from gastric carcinoma was established clinically. The

Fig. 2.32-year-old woman with pyelovenous backflow.

A, Contrast-enhanced axial CT scan obtained during parenchymal phase shows thrombus (arrow) in inferior
vena cava.
B, Contrast-enhanced multiplanar reformatted oblique axial CT scan obtained during excretory phase shows
contrast material (long arrow) in right renal vein and thrombus (short arrow) in inferior vena cava.
C, Contrast-enhanced multiplanar reformatted coronal CT scan obtained during excretory phase shows contrast
material in inferior vena cava (long arrow) and right ureter (short arrow). Abscesses are visible in right lower
quadrant of abdomen and in pelvis.

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patient began arterial hepatic infusion chemotherapy, but on 6-month follow-up CT, the
size of tumors had increased, and both the
diffuse fatty infiltration and the peritumoral
hypoattenuating bands had disappeared. The
patient died of tumor progression 17 months
after the discovery of the liver metastases.
Locally decreased portal blood flow causes
focal fatty liver infiltration in some cases [1, 2]
and focal sparing of normal parenchyma by
fatty infiltration in others [3, 4]. The reason
these converse conditions develop in the same
variant blood supply is unknown. In our patient, the portal vein perfusion defect seen on
CT during arterial portography included the
area of peritumoral fatty infiltration and corresponded to late peritumoral enhancement on
single-level dynamic CT during hepatic arteriography. This finding suggested that the portal
blood did not enter the area of peritumoral
fatty infiltration and that this area received
blood that had passed through the tumor sinusoids. We speculate that decreased portal blood
flow due to tumor draining may cause peritumoral fatty infiltration, although it usually
causes peritumoral sparing of normal parenchyma by fatty liver infiltration [4].
To our knowledge, there have been no previous reports about peritumoral fatty infiltration in
the liver. We believe that this lack of documen-

tation indicates that the condition is rare and that

factors in addition to regionally decreased portal
blood flow must be present for peritumoral fatty
liver infiltration to occur. It may be that this condition is transient and may be affected by nutritional conditions. Other researchers [2] have
reported that fatty liver infiltration distal to a
liver metastasis from an insulin-producing islet
cell tumor could possibly be caused by insulin
production and decreased portal blood flow. In
our patient, however, a specific cause could not
be found other than slight malnutrition.

3. Matsui O, Kadoya M, Takahashi S, et al. Focal

sparing of segment IV in fatty livers shown by
sonography and CT: correlation with aberrant gastric venous drainage. AJR 1995;164:11371140
4. Gabata T, Kadoya M, Matsui O, et al. Peritumoral
spared area in fatty liver: correlation between
opposed-phase gradient-echo MR imaging and CT
arteriography. Abdom Imaging 2001;26:384389

1. Kawamori K, Matsui O, Takahashi S, Kadoya M,

Takashima T, Miyayama S. Focal hepatic fatty
infiltration in the posterior edge of the medial
segment associated with aberrant gastric venous
drainage: CT, US, and MR findings. J Comput
Assist Tomogr 1996;20:356359
2. Hoshiba K, Demachi H, Miyata S, et al. Fatty
infiltration of the liver distal to a metastatic liver
tumor. Abdom Imaging 1997;22:496498

Peripheral Schwannoma Lacking

Enhancement on MRI
Schwannomas (neurilemmomas) are benign
nerve sheath tumors that arise from the epineurium of the peripheral nerves. They most commonly affect patients in their third decade of
life and show no preference for occurrence in
either sex [1]. Schwannomas are often
grouped together with neurofibromas, which
are benign nerve sheath tumors arising centrally from a peripheral nerve. The MR appearance of a benign nerve sheath tumor has been
well described: a smooth, well-defined, fusiform mass that enters and exits the nerve.
Schwannomas generally display intermediate
to low signal on T1-weighted images but show
a diffuse increase in signal on T2-weighted images. Enhancement on contrast-enhanced T1weighted images is considered to be a defining
feature of schwannomas. The enhancement
pattern is typically inhomogeneous, with

Shiro Miyayama
Hiroto Nishida
Fukuiken Saiseikai Hospital
Fukui 918-8503, Japan
Osamu Matsui
University of Kanazawa
Kanazawa 920-8641, Japan


Fig. 3.54-year-old woman with metastatic liver tumors from gastric carcinoma and peritumoral fatty infiltration.
A, Unenhanced CT scan shows 1.8-cm-diameter tumor with peritumoral hypoattenuating band.
B, CT during arterial portogram shows portal perfusion defect, including tumor and peritumoral hypoattenuating
band. Another tumor is also seen in lateral segment of liver.
C, Image from single-level dynamic CT during hepatic arteriography obtained 4 sec after contrast administration
shows hyperenhancing tumor with central necrosis.
D, Image from single-level dynamic CT during hepatic arteriography obtained 20 sec after contrast administration shows rim enhancement corresponding to peritumoral fatty infiltration.


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Fig. 4.23-year-old woman with peripheral nerve sheath tumor of median nerve.
A, T1-weighted image (TR/TE, 400/11) reveals intermediate signal of lesion (asterisk) in expected position of median nerve.
B, Fat-suppressed proton densityweighted image (TR/ effective TE, 2000/34) shows homogeneously increased signal of mass.
C, Contrast-enhanced fat-suppressed T1-weighted image (TR/TE, 300/11) reveals complete
lack of enhancement in lesion. Mass is slightly hypointense relative to adjacent muscle. Fat
suppression is slightly inhomogeneous but could be expected to affect only small part of periphery of mass.
D, In gross pathologic specimen obtained during resection, fibers of median nerve (arrow)
are displaced by mass, as would be expected with schwannoma.

stronger enhancement peripherally, but it is often homogeneous [24].

We report a case of a 23-year-old woman
who presented with a slow-growing mass at her
elbow. A preoperative MRI was obtained that
clearly revealed a lesion in the course of the median nerve, with the classic appearance of a
fusiform mass that entered and exited the nerve.
The mass was hypointense relative to muscle on
T1-weighted images (Fig. 4) and showed an
overall increased signal on T2-weighted images. The contrast-enhanced T1-weighted images, however, revealed no enhancement of the
lesion. Findings were interpreted as indicative
of a nonenhancing nerve sheath tumor of the
median nerve. To our knowledge, the only prior
description of a nerve sheath tumor that did not

AJR:182, February 2004

show enhancement was reported by Zbar et al.

[5], who described two intralabyrinthine acoustic schwannomas, each smaller than 5 mm. In
our patient, the large size of the schwannoma
prevented any volume-averaging loss of signal,
and there definitely was no enhancement. The
2.7-cm mass was excised; the histologic diagnosis was a schwannoma, including S-100 protein staining. We believe that this schwannoma
is by far the largest nonenhancing nerve sheath
tumor that has been described as well as the
only reported nonenhancing peripheral nerve
sheath tumor.
Jonathon A. Lee
Carol A. Boles
Wake Forest University Baptist Medical Center
Winston-Salem, NC 27157-1088

1. Murphey MD, Smith WS, Smith SE, Kransdorf
MJ, Temple HT. From the archives of the AFIP:
imaging of musculoskeletal neurogenic tumors
radiologicpathologic correlation. RadioGraphics 1999;19:12531280
2. Varma DG, Moulopoulos A, Sara AS, et al. MR
imaging of extracranial nerve sheath tumors. J
Comput Assist Tomogr 1992;16:448453
3. Soderlund V, Goranson H, Bauer HC. MR imaging of benign peripheral nerve sheath tumors.
Acta Radiol 1994;35:282286
4. Beggs I. Pictorial review: imaging of peripheral
nerve tumours. Clin Radiol 1997;52:817
5. Zbar RI, Megerian CA, Khan A, Rubinstein JT.
Invisible culprit: intralabyrinthine schwannomas
that do not appear on enhanced magnetic resonance imaging. Ann Otol Rhinol Laryngol