We got a case of MRI of brain today. As usual i went to them and enquired about the history of the case. She was a female roughly in her late 30s and complained of severe neck pain. She could turn the head to one side freely but could not do so on the other side. She also told me that there were visual disturbances in one eye, and she had hazy vision in that eye. She also told me that this particular vision disturbance would exaggerate when she sat down and washed her vessels (here i mean the household utensils :-) ) and suddenly got up after finishing the washing.
My stupid brain started to think about all the differential diagnoses. In the mean time i took the letter which was written by their neurophysician consultant to us requesting for an MRI. The lines went like this "MRI Brain for Optic nerve evaluation".
I think i should not have read this above sentence, because that was where all the trouble started. I started thinking about all the optic nerve and orbit pathologies; all the occipital lobe disorders and other stuff.
I went and told my Head of the Department that the MRI was ready and he arrived into the MRI console room. I sat beside with a note pad to take down the findings, like i always do. I gave him the history (i think i stressed on the neck pain and vision loss but didnot stress on the vision disturbance exaggeration after getting up finishing her cleaning of utensils). He looked for a long time at all the sections and we discussed about any hyperintense or hypointense signal in the occipital lobe. We could not find that in any plane or any section. Then our interest shifted to the optic nerves. The eye in which she complained of the defect; the optic nerve on that side showed a small kink when compared to the other side. I thought we nailed the diagnosis. But still my HOD kept telling me that it could be normal.
After sometime i suggested him that we do a B-scan (USG of eye), which we did and found nothing significant. Both of us left for our afternoon meals thinking. Later after our afternoon meals, we had to perform a contrast pelvis CT on the wife of a retired medicine HOD. We did that too and the discussion about the PELVIS CT was going on in the chamber of our HOD, where the retired medicine HOD was also seated. I asked my HOD about the brain MRI case we did earlier that day, and what we were going to do about it.
He said "I think there is a special term in medicine for the complaint the woman was mentioning in the morning (about the getting up after cleaning utensils and exaggeration of the visual blurring) and i don't remember it. Do you?". The retired medicine HOD who was sitting beside us (hearing the complaint) said "Yeah! that is condition called the VBI, also known as Vertebro basilar insufficiency and it is seen in certain conditions like cervical spondylosis (funny he mentioned cervical spondylosis first) and blah blah .blah ....."
For me then everything started to fall in place and i felt stupid, but was still not convinced. I arrived home and searched for vertebrobasilar insufficiency on wikipedia. I felt ashamed of myself after reading the article, because the woman was actually giving me the diagnosis, and i could not get it.
But then i thought "what can u expect from a postgraduate student of radiology who is just 2 months into the course". And then i thought "may be i ought to have known that". And i remembered what my HOD always said "Ask detailed history of every case you deal with and always refer to the old literature".
But then again, experience is what counts. "A man who does not make mistakes does not usually make anything".
LOOK AT THIS IMAGE AND READ THESE LINES FROM WIKIPEDIA and you will know what i am talking about ...
click on the image below for a larger picture ..
Here is a link to the whole article on Vertebrobasilar insufficiency. CLICK HERE
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