A middle aged patient had history of neck and occipital pain and presented to the neurologist who ordered an MRI cervical spine and brain. The report came as degenerative spine (Fig 1) and normal brain (Fig 2). the neurologist ordered physiotherapy and medications.

Patient had again transient LOC a month later.

An MRI brain was ordered which again was reported normal and patient was exhaustively investigated for various conditions, all of which were within normal limits.

A month and half later patient came to casualty with unconscious for 4 hours. An NCCT head was done which was reported as SAH.

A DSA was done which showed left ophthalmic ICA aneurysm which was promptly coiled.

Patient was declared dead two days later.

Now lets review the images again:

Fig 1: MR cervical spine, sagittal section, T1WI, showing the degenerative changes

Fig 2: Axial FLAIR image done on first visit, reported normal, shows the aneurysm very well

Fig3: MR brain done on 2nd visit very well shows the aneurysm on all planes and in all sequences

Fig 4: NCCT head, at admission on 3rd visit, shows subtle supratentorial brain parenchymal swelling and the ‘reversal sign’ suggestive of diffuse hypoxia with a ‘brain dead’ state probably already setting in

Fig 5: DSA images, pre and post –coiling, showing ophthalmic ICA aneurysm.

The images tell the entire story and also the sorry state of present medicine: both the radiologist and the neurologist had missed the lesion(s) repeatedly