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The scanning parameters for 10-min delayed CE 3D FLAIR sequence were TR, 8000 ms TEeff, 268 ms inversion time, 2400 ms FOV, 200 × 200 mm voxel size, 0.8 × 0.8 × 0.8 mm acquisition time, 4 minutes 48 seconds reconstruction matrix, 256 × 256 slice thickness, 1.6 mm echo-train length, 80 flip angle, 90 degree. The 10-min delayed CE 3D FLAIR was obtained in the axial plane at 10 minutes after the injection of intravenous contrast material, different from the CE T1WI, which are immediately acquired after IV contrast material injection. IAC MRI was performed for further evaluation using a Philips Achieva 3T 16 Channel MRI System (Philips Healthcare, Best, The Netherlands), including axial T1-weighted images (T1WI), T2-weighted images (T2WI), diffusion-weighted imaging (DWI), 3D FLAIR, CE T1WI, 10-min delayed CE 3D FLAIR, coronal T1WI, T2WI, and CE T1WI. During hospitalization, the patient complained of new-onset dizziness and headache. Physical examination showed that the vesicular rashes were in the right external auditory canal, and the tympanic membrane was displaying erythematous changes. Upon evaluation four days later, he had developed right facial pain and peripheral facial paralysis. We report a case of RHS in which the patient was early diagnosed with aseptic meningitis using 10-min delayed CE 3D-FLAIR sequences on IAC MRI.Īn 18-year-old man with no previous medical history experienced sudden right otalgia, ear fullness, and fever for three days. Contrast-enhanced (CE) delayed 3D FLAIR using low concentrations of gadolinium contrast material can detect blood-labyrinth barrier breakdown with high sensitivity ( 6, 7), while 10-min delayed CE 3D-FLAIR images can be useful for diagnosing inner ear abnormalities and related central nervous system (CNS) complications ( 5). Until now, while it is not routine to use three-dimensional fluid-attenuated inversion recovery (3D-FLAIR) sequence, the 3D FLAIR sequence is used, and has the role of evaluating different fluid compositions in the inner ear structure, compared to the standard sequence ( 5). Recent advances in MRI techniques have enabled assessment of the internal auditory canal (IAC). Among the published reports, three cases of RHS complicated by meningoencephalitis and meningitis were reported in 20 ( 1, 3, 4). By 2020, a few reports of complication in RHS, such as encephalitis, meningitis, brain stem involvement, and cerebellar involvement, had been published ( 1, 2, 3, 4). RHS presents with a triad of characteristic manifestations: ipsilateral facial paralysis, ear pain, and vesicles on the face. Ramsay Hunt syndrome (RHS) is caused by the reactivation of varicella-zoster virus (VZV) in the geniculate ganglion. We report an RHS patient with CN VII, VIII, and leptomeningeal enhancement within the cerebellar folia on 10-min delayed, contrast-enhanced (CE), three-dimensional fluid-attenuated inversion recovery (3D-FLAIR) imaging. Therefore, magnetic resonance imaging (MRI) is necessary to detect both abnormal signal intensity in the IAC, CN VII, CN VIII, inner and ear structure, and CNS complications. Neurologic complications, such as encephalitis and meningitis, are rare in RHS, but are known to occur. In some patients, inner ear structure (cochlear and vestibular apparatus) is involved in RHS. The typical features of RHS on imaging evaluation include signal changes and enhancement in the internal auditory canal (IAC) nerves, and the labyrinthine segment of cranial nerve VII (CN VII) and cranial nerve VIII (CN VIII). Ramsay Hunt syndrome (RHS) is a disease caused by varicella-zoster virus (VZV) infection that can be diagnosed through clinical symptoms with or without imaging evaluations.
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