PLACEMENT OF A FERROMAGNETIC INTRACEREBRAL ANEURYSM CLIP IN A MAGNETIC-FIELD WITH A FATAL OUTCOME

Magnetic resonance (MR) imaging may be contraindicated in patients wit h biomedical devices, among the most dangerous of which are intracrani al aneurysm clips, owing to the possibility of torque and dislodgment. A case is presented in which a patient with a reportedly nonferromagn etic clip was placed in a magnetic field. The patient developed an acu te intracerebral hemorrhage in the MR unit, with a fatal outcome. Imag ing studies strongly suggested a torqued clip as the cause. Autopsy re vealed a tom middle cerebral artery from clip movement, and the clip w as identified as a ferromagnetic type. This is the first reported case , to the authors' knowledge, of a fatal outcome due to an intracranial aneurysm clip placed in a magnetic field.