Compressive lesions of the head and neck: Common and uncommon must-know entities

Abstract

There are many lesions that cause compression of nerves and vessels in the head and neck, and they can often be overlooked in the absence of adequate history or if not suspected by the radiologist. Many of these lesions require a high index of suspicion and optimal positioning for imaging. While a multimodality approach is critical in the evaluation of compressive lesions, an MRI utilizing high-resolution (heavily weighted) T2-weighted sequence is extremely useful as a starting point. In this review, we aim to discuss the radiological features of the common and uncommon compressive lesions of the head and neck which are broadly categorized into vascular, osseous, and miscellaneous etiologies.

Keywords: cervical rib; compressive lesions; glossopharyngeal neuralgia; hemifacial spasm; optic neuropathy; trigeminal neuralgia; trochlear nerve palsy.

Figure 1.

81-year-old female with long-standing sharp right face pain. Coronal high-resolution T2WI MRI (a) shows abutment of the right trigeminal nerve by a branch of the right superior cerebellar artery (red arrow). Axial high-resolution T2WI MRI (b) shows resultant volume loss of the nerve (yellow arrow); note normal bulk on the left (green arrow).

Figure 2.

60-year-old female with intermittent stabbing left throat pain. Axial T2-SPACE image through the brainstem demonstrates the V4 segment of the left vertebral artery (red arrow) contacting the left IX/X nerve complex (yellow arrow) near the root entry zone. Note the normal right side (green arrow).

Figure 3.

55-year-old female with right facial hemispasm and twitching of the right lip. Axial high resolution T2WI MRI (a) and Sagittal T2WI MRI (b) show abutment of the right facial nerve (yellow arrow) by a vessel of unclear origin (red arrow).

Figure 4.

58-year-old female with vertical diplopia and left trochlear nerve palsy. Coronal T2WI MRI (a) shows slight prominence of the left superior cavernous sinus at the expected location of the trochlear nerve (green arrow). Coronal T1 post-contrast image (b) shows ectasia of the left internal carotid artery (red arrow), presumed to be abutting the trochlear nerve (yellow arrow).

Figure 5.

75-year-old female with diplopia and right VI nerve palsy. Axial high-resolution T2WI shows dolichoectasia of the basilar artery (red arrow), coursing along the exit point at the level of right VI cranial nerve. Note the normal left VI cranial nerve (yellow arrow).

Figure 6.

Schematic representation medullary indentation by dolichoectatic vertebral artery. (a) 62-year-old female with ataxia and vertigo. Axial T2WI MRI (b) shows indentation and deformity of the left lateral aspect of the medulla (green arrow) by a dolichoectatic vertebral artery (red arrow). (c) 35-year-old female with persistent throbbing headaches. Axial T2WI MRI (b) shows mass effect on the anterolateral left medulla by a dolichoectatic vertebral artery (red arrow).

Figure 7.

54-year-old male with intermittent left Horner syndrome and left brachial plexopathy. Coronal CT neck image in the bone window (a) shows bilateral cervical ribs (yellow arrow pointing to the left). Sagittal image in the soft tissue window (b) shows the expected location of the left inferior cervical ganglion and brachial plexus (yellow circle), presumably compressed/stretched by the left cervical rib upon movement.

Figure 8.

68-year-old male with rotational syncope. Axial CTA of the neck shows symmetric vertebral arteries (green arrows) in the neutral position (a) and asymmetric severe narrowing of left vertebral artery (red arrow) when head is rotated to the right (b).

Figure 9.

68-year-old male with rotational syncope (same patient as Figure 8). Conventional angiogram demonstrates normal filling of the left vertebral artery in the neutral position (a) and confirms severe narrowing when the head is rotated towards the right (red arrow, b).

Figure 10.

A 57-year-old male (golfer) with multiple episodes of hemiparesis, tingling sensation and numbness in his left hand and face while playing golf. Axial CT angiogram of the neck (bone window) (a) and sagittal CT soft tissue of the neck (b) show compression of the right internal carotid artery (red arrow) by the right hyoid tubercle (yellow arrow and yellow circle).

Figure 11.

51-year-old female with intermittent left eye visual obscurations and visual loss. Coronal high-resolution T2WI of the brain shows herniation of the left rectus gyrus (green arrow) on to the left optic nerve (yellow arrow).