AJR 2003; 180:843-845
© American Roentgen Ray Society
Extension of Pancreatic Pseudocysts into the Neck: CT and MR Imaging Findings
A. H. Karantanas1,
V. Sandris2,
A. Tsikrika1,
K. Karakousis3 and
E. Karaiskou1
1 Department of CT—MRI, Larissa General Hospital, 1 Tsakalof Str., Larissa
41221, Greece.
2 Department of Otolaryngology—Head and Neck Surgery, Larissa General
Hospital, Larissa 41221, Greece.
3 Department of Internal Medicine, Larissa General Hospital, Larissa 41221,
Greece.
Received June 14, 2002;
accepted after revision August 6, 2002.
Address correspondence to A. H. Karantanas.
Introduction
Cranial extension of pancreatic necrosis into the neck is extremely rare.
One such case involving both the mediastinum and the neck is described, and
the CT and MR imaging findings are presented.
Case Report
A 50-year-old man was admitted to the hospital because of anterior chest
pain. The patient reported a productive cough with whitish material. The CT
scan (not shown) revealed emphysematous changes in the lung, possible
pericardial effusion, and localized paraesophageal fluid on the right side.
Over a few days, a diffuse neck swelling developed.
The patient's medical history was remarkable for multiple hospital
admissions because of recurrent pancreatitis. The first admission 30 months
earlier was associated with only peripancreatic inflammatory changes and no
pseudocyst formation. The second admission a few weeks later was associated
with pleural fluid on the left, consolidation of the left upper lung lobe, and
a pseudocyst measuring 6 x 3 x 4 cm located between the stomach
and the spleen as shown on CT. Smaller cystic changes were found in the lesser
sac. The patient was treated in the intensive care unit. Two weeks after the
second admission, CT-guided drainage of the cysts was performed; CT 3 weeks
later showed no peripancreatic cysts. The patient had undergone surgery for a
hernia 15 years earlier. His social history included drinking approximately
four alcoholic beverages per day, a 60-pack-year smoking history, and no risk
factors for HIV.
Physical examination revealed a cachectic man with a body weight of 60 kg,
normal temperature, and stable vital signs. Findings of pulmonary auscultation
and cardiac examination were normal. The abdominal examination revealed mild
mid epigastric tenderness. The neck swelling was not tender. No palpable
lymphadenopathy was seen. Flexible laryngoscopy revealed a pharyngeal lumen
narrowing caused by bulging of the lateral walls.
The following laboratory values at admission were abnormal: serum amylase
of 8627 U/L; a WBC of 16.5 x 103/µL, indicating
leukocytosis; and a hematocrit of 28.7%. CT of the neck and chest showed
diffuse multiloculate, low-density fluid collections in the retropharyngeal
space, prevertebral space, and right carotid space extending into the right
paratracheal space and slightly displacing the superior vena cava (Figs.
1A and
1B). No air bubbles were seen.
MR imaging 24 hr later confirmed the diffuse fluid collections in the deep
spaces of the neck connected with the mediastinum and upper abdomen (Figs.
1C,1D,1E).
MR imaging also showed a pericardial fluid collection.
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Fig. 1A. —50-year-old man with pancreatic pseudocysts in neck. Axial
contrast-enhanced CT scan at level of thyroid cartilage shows diffuse
low-density fluid collection (arrows), particularly in
retropharyngeal space, prevertebral space, and right carotid space.
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Fig. 1B. —50-year-old man with pancreatic pseudocysts in neck.
Contrast-enhanced CT scan at level of aortic arch shows low-density area in
right paratracheal space that slightly displaces superior vena cava. Anterior
part of lesion shows some enhancement. Paraesophageal fat planes are not
clear.
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Fig. 1C. —50-year-old man with pancreatic pseudocysts in neck. Axial
fat-suppressed T2-weighted turbo spin-echo MR image (TR/TE, 2400/110;
echo-train length, 18) in neck shows diffuse septate cystic areas.
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Fig. 1D. —50-year-old man with pancreatic pseudocysts in neck. Sagittal
T2-weighted turbo spin-echo MR image (2450/130; echo-train length, 19) in neck
shows prevertebral septate cystic areas from skull base to thoracic inlet.
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Fig. 1E. —50-year-old man with pancreatic pseudocysts in neck. Coronal
T2-weighted turbo spin-echo MR image (6000/140; echo-train length, 22) in
chest shows that cystic areas (arrows) extend throughout mediastinum
to abdominal cavity, where some pancreatic pseudocysts (arrowheads)
are obvious. Note also pericardial effusion.
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An immediate transoral fine-needle aspiration of the prevertebral fluid
lesions showed high levels of amylase (100500 U/L). No organisms were grown
from cultures. The patient was operated on immediately because of rupture of
the abdominal pseudocysts; and because of his poor general status, he was
admitted to the intensive care unit. Physical examination the next day showed
a significant reduction of the neck swelling. After 2 weeks in the intensive
care unit, the patient died as a result of sepsis.
Discussion
Pseudocysts, fistulas, and abscesses are common complications of acute and
recurrent pancreatitis [1]. The
term "pseudocyst" refers to a well-defined walled-off collection
of necrotic tissue, old blood, and secretions that originate from the pancreas
after pancreatitis [1]. These
secretions may remain within the pancreatic capsule, but more commonly they
become loculate in the lesser sac or extend along the retroperitoneum in any
direction. The pseudocysts may extend from the groin to the mediastinum
[2]. Extension of pancreatic
necrosis into the mediastinum, which is extremely rare, is possible via the
aorta or the esophageal hiatus, through the diaphragmatic crura, or through
erosion in the diaphragm
[2,3,4,5,6].
The radiologic descriptions of mediastinal pseudocysts, including their CT
and MR imaging findings, are limited
[3,
6]. Only one case has been
reported that describes CT findings in the neck
[7]. CT can reveal the cystic
nature of the lesion and its communication with an intraabdominal pseudocyst
[3]. MR imaging, because of its
multiplanar imaging capability, can show the entire intrathoracic location of
the pseudocyst [6]. The CT and
MR imaging findings in our patient were compatible with those described in the
literature.
To our knowledge, no MR imaging findings of pseudocyst extension into the
neck have been reported in the literature. The anatomic pathways between the
fascial planes of the neck and the mediastinum have been described by many
authors. According to Moncada et al.
[8], infections progressing to
the mediastinum follow three routes: the anterior cervical space, the
retropharyngeal space, and the carotid space. All these anatomic spaces were
involved in our patient (Fig.
1A,1B,1C,1D,1E).
Therefore, a retrograde mechanism of extension from the mediastinum to the
neck could be suggested. The diagnosis of our patient was established with the
aspiration of cyst fluid for amylase level, as reported by others
[4]. In addition, the decrease
in neck swelling after the operative abdominal pseudocyst drainage suggested a
connection with the anatomic spaces. Extension of the pseudocyst this far
could be explained by the cachectic nature of the patient
[7].
In conclusion, both CT and MR imaging are valuable in the evaluation of
deep neck processes. The multilevel capabilities of MR imaging contribute to
the anatomic evaluation of the extension of the pancreatic pseudocysts into
the neck and mediastinum and help guide the surgeon to perform a safe
transoral fine-needle aspiration.
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Introduction
Case Report
