Sugammadex in a patient with Sjogren's syndrome and polymyositis.

understood entity resulting from CSF leakage or from venous hypotension causing increased CSF absorption. It causes a range of symptoms from orthostatic headaches to coma. MRI and CT myelography are the investigations of choice in demonstrating CSF leaks as presumed sites of dural defects. CT myelography has traditionally been the first diagnostic tool, but this necessitates lumbar puncture for contrast injection and this is both invasive and of significant riskwith infra-tentorialherniation. MR myelography has been shown to have comparable detection rates in nerve root leaks and high cervical retrospinal CSF collections, and superior detection rates in spinal leaks. A diagnostic quandary arose in this patient who had serious contraindications to MRI and CT myelography. The presence of a PPM is widely recognized as a contraindication to MRI due to the risk of harmful arrhythmias and heating or displacement of the device or its leads. In a survey asking radiologists and cardiologists whether they would submit a patient to MRI with a PPM in situ, 97% radiologists responded that they would not, whereas 34% of cardiologists responded that they would under appropriate circumstances. There is now a substantial evidence base providing safety data on a large number of MRI studies with PPMs. The devices for which there is most evidence include those manufactured after 1998, in place for over 6 weeks and without epicardial or abandoned leads. – 7 The number of PPMs will continue to increase due to an ageing population and increasing indications. However, the number of patients with an expanding range of co-morbidities that will benefit from the diagnostic advantages offered by MRI will also multiply. MRI should only be considered when there is no lower-risk alternative to answer clinical questions essential to patient management. This case highlights the commonly overlooked pathology of SIH and raises awareness of the increasing evidence that PPMs are becoming relative rather than absolute contraindications to MRI.