suspected necrotizing fasciitis. In two other patients. only unenhanced imaging was per- formed. The MR imaging results were correlated with the surgical.
Differentiation Fasciitis and Imaging OBJECTIVE.
Marius R. Schmid1 Thomas Kossmann2 Stefan DueweII1
This
in differentiating
study
fasciitis
AND
spin-echo fasciitis.
to evaluate
from
METHODS.
Tl-weighted necrotizing
formed. autopsy
was performed
necrotizing
MATERIALS enhanced suspected
of Necrotizing Cellulitis Using
Spin-echo
TI-weighted.
both
contrast
showed
with the surgical in five cases.
For
the diagnosis
fasciitis
fasciitis litis
was
imaging
thickening tissue
terized
fasciitis.
1 Institute
University
of Diagnostic
Zurich, Raemistr.
Radiology,
Hospital
100, CH-809i Zurich, Switzerland.
Address
correspondence
to S. Duewell.
2Division
of Trauma Surgery, University
CH-8091 Zurich, Switzerland.
by extensive and
by severe stages.
systemic clinical
rap-
charac-
and
fasciitis.
of necrosis
or
fascia
re-
I 1 cases
of necrotizing case
of cellu-
Contrast-enhanced
more
clearly
involvement.
T I-
than T2-weighted
of
toxicity
plane
litis
[ I,
of
and
MR
lacking
not
the therapeu-
resistance
need
diagnostic
to
patients
surgical tool
a
with
blunt cellu-
intervention.
should
the
provide
the dif-
ferentiation
between
ing fasciitis
before
surgery.
Additionally.
tool
make
it possible
to judge
should
necMR
imaging.
1131. Because
do
ideal
is of-
recognition
cial
MR imaging. its specificity.
Therefore.
findings
instrument
usually
muscle
fascial of clinical
necrosis
fascia
underlying
[31. Early
of deep
is a rare. infection
necrotizing
collections
and enhanceI I cases of
false-positive
involvement is revealed with because its sensitivity exceeds
a combination
fasciitis
tissue
cellulitis
and
necrotiz-
this the se-
verity of necrotizing fasciitis and to delineate the extension of the infectious process. Sta-
fasciitis difficult
the use of frozen-section
and [4-71.
cellulitis Although
only
may be cellulitis,
subcutaneous
particularly which in-
tissue,
treated in most cases with necrotizing fasciitis often tional
surgical
intervention.
Early
surgical
ddbridement
and
with
improved
fasciitis survival
have
can
antibiotics requires
quate
in necrotizing Hospital Zurich,
on
all
One
perwith
imaging
thickening. we fiund
identified
findings.
was
in I I cases,
necrotizing fasciitis may be difficult, and the clinical differentiation between necrotizing
volves after revision
be
contrast-
lesions.
the extent
be based
iiiaging
clinically
with fluid or superfIcial
of necrotizing
imaging
and areas
no additional
progressing
subcutaneous
spared
abscesses
to overestimate
idly
2J. In early
to
no deep fascial can be excluded. However,
ecrotizing
accompanied
thought
delineated
should
N
MR
the surgical
When
tends
regimen
with
was
did, but showed
CONCLUSION. rotizing fasciitis
Received June 24, 1997; accepted September 3, i997.
compared and
sequences
sequences
ten
six of cellulitis.
when
overstaged
weighted
tic
and
correctly
and
findings
vealed additional involvement of deep fasciae with fluid collections. ment after contrast administration. According to these criteria. necrotizing
of MR
in 15 patients with unenhanced imaging
when subcutaneous and when subcutaneous
enhancement.
value
T2-weighted.
were performed patients. only
The MR imaging results were correlated in one case, and with the clinical outcome Cellulitis was diagnosed on T2-weighted images
the diagnostic
cellulitis.
sequences In two other
RESULTS. was revealed
MR
and
ade-
associated with de-
and
the diagnosis
Lew
I 13)
demonstrated biopsy
of necrotizing
mediate the clock
histopathologic evaluation and is an invasive procedure.
MR
imaging
may
that provide
fasciitis
however,
ferentiate cellulitis
this
may
surgery;
fasciotomy
been
compared
be
alone, an addi-
menkovic
process
be the ideal
between necrotizing because MR imaging
requires
tool
before imaround to dif-
fasci itis and does a good
job of revealing contrast enhancement of soft tissues and is highly sensitive in the detec-
036i-803X/98/i703-615
layed surgical exploration 18-I 2]. At present, definitive diagnosis is made only at surgery when extensive undermining of the sur-
© American Roentgen Ray Society
rounding
imaging
AJR i998;i70:6i
5-620
AJR:170, March
1998
tissues
is discovered,
with
the fas-
tion
of
fluid is
collections. noninvasive.
Additionally. High
accuracy
MR of 615
Schmid
MR
imaging
tally
produced
Beltran
for the diagnosis cellulitis
of experimen-
has been
reported
by
et al. [14].
Gadolinium-based distribution volume
contrast agents in the extracellular
with a space
show an enhancement sues and bones. Animal
in inflamed and clinical
have demonstrated that in evaluating infectious
gadolinium is useful diseases of the mus-
culoskeletal crotic
system
tissue
tissue
[15,
differentiating
from inflamed 16]. Nevertheless,
ne-
or edematous it has not been
yet that the use of IV contrast
shown increases gard
by
soft tisstudies
the sensitivity
to the diagnosis
The
purpose
of MR study
the accuracy
of unenhanced
hanced
imaging
MR
rotizing defining
imaging
of infectious
of this
agents in re-
was
fasciitis the extent
and
12-weighted
msec) spin-echo tral
(3000-5000/100-1
sequences
selective
14
with fat saturation
suppression
pulse
(spec-
technique)
were
performed of all patients. In 15 patients, additional Il-weighted spin-echo sequences (300-540/1535 msec) with fat saturation after IV injection of 0.2 mM/kg of gadolinium tetraazacyclododecanetetraacetic
acid
(Dotarem:
Laboratoire
Guerbet,
Aul-
nay-sous-Bois. France) were acquired. In two patients with necrotizing fasciitis, the examinations had to be terminated before IV contrast injection because
massive
signs
of
systemic
condition
intervention.
toxicity
required
In general,
and
immediate
necand for process.
creased
averaging,
the examination
examinations
ened at the cost of suboptimal
time
was short-
Materials
and Methods
gists
Materials
MR imaging gust
1993
women [range.
examinations
to February
performed
1997
of
from Au-
17 patients
(eight
and nine men with a mean age of4l years 22-76 years]) with clinically suspected
necrotizing
fasciitis
were
reviewed
retrospectively.
The final diagnoses, proven surgically in I 1 cases and by autopsy in one, were necrotizing fasciitis in 1 1 patients and cellulitis in six patients. In seven patients, the infectious process involved only a single leg, in five patients only a single arm, and in one woman only the right shoulder. In four severe cases, besides the involvement of extremities, infectious ciae:
findings one
of
necrotizing
could these
also
be seen
patients
in pelvic
additionally
showed
fasciitis
of the abdominal
and
wall. Nine patients
had predisposing
factors
as small trauma.
skin
lesions,
Associated
surgery, diseases
injections, such
fas-
such
or blunt al-
cohol abuse, HIV infection, or renal insufficiency could be found in four patients with necrotizing fasciitis and in one patient with cellulitis. The patients underwent MR imaging examination within 2-7 days (mean, 3.3 days) after the onset of symptoms but less than 24 hr before surgery when necessary. One of 11 patients with necrotizing fasciitis died within 24 hr after the MR examination; and a second patient, a woman, survived after the amputation of her left calf. All patients with cellulitis survived. Only one patient with cellulitis underwent surgery because of a subcutaneous abscess.
MR imaging Advantage
was performed
system
tems, Milwaukee,
(General
on a 1.5-T Signa
Electric
Medical
Sys-
WI). The best fitting RF-coil arexpected area of involvement was used. Variation in matrix size and field of view for different infection sites ranged from 192 x 256 rangement
616
for
the
unaware
of the
surgical,
autopsy,
lections
within
the
subcutis
and
the
abscesses
were
intensity
identified
in areas
superficial
on T2-weighted
images
hancement on Ti -weighted ate meglumine injection and additional
with
high
signal
but with
no en-
images after gadoterin the center of the
enhancement
The
at the rim. The
results of the MR analysis were compared with the surgical findings in 1 1 cases, with autopsy in one case, and with the clinical outcome in five cases of cellulitis.
enhancement itself.
characteristics fasciitis
(n
of all cases 1 1; with
=
administration,
n
with
gadolinium
9) were
=
evalu-
ated. Generally, necrotizing fasciitis a high signal intensity on T2-weighted
showed and a
low
images
signal
intensity
on Tl-weighted
the subcutaneous cellulitis); contrast
tissue (comparable to enhancement of the sub-
of
cutaneous
tissue
volved
was
superficial
high
signal
intensity
and showed
contrast
small
in all cases.
deep
fasciae
abscesses
enhancement
after
in all cases
could
gad-
(Fig.
1).
fasciitis, (Fig.
be identified
increase
a
images
cases of necrotizing
massive
In-
had
on T2-weighted
administration
In six of nine The
found
and
in signal
2).
intensity
of
glumine fasciitis
led to the diagnosis of necrotizing (Fig. 3). The intramuscular signal inon T2-weighted
diffusely
in 10 of
sequences
I 1 cases
(Fig.
scribed intramuscular fluid sponding to intramuscular seen
in three
abscesses the abscess
wall
did not receive crete, ment
diffuse could
2A).
contrast (Fig.
Circum-
collections abscesses
(Fig.
patients
showed
increased lA).
correwere
Two
of these
enhancement
2B);
the
gadolinium
of
third
patient
diglumine.
A dis-
intramuscular contrast enhancebe seen in seven of nine cases
with necrotizing fasciitis (Fig. IB). No alterations of the signal intensity in the bone marrow could
be detected
one with previous
a hairy cell osteosynthesis
femoral
except
in two patients,
leukemia and one after of a fracture of the
diaphysis.
In all cases
of
necrotizing
fasciitis,
of 42 deep fasciae showed ment on T2-weighted MR autopsy
findings
a total
signs of involveimages. Surgical
could
prove
only
34
involved deep fasciae, all of them seen on T2-weighted MR images. Six of these eight
Results Eleven cases of six cases
of necrotizing
of cellulitis
fled. MR imaging of
signal
diglumine
and
ity
with contrast
and of the muscle
necrotizing
tensity
fascia could be seen on T2-weighted images and deeper structures were normal. Necrotizing fasciitis was diagnosed in all cases in which, in addition to the subcutaneous changes, involvement of the deep fasciae was visible, which was defined as thickening of the fascia, high signal intensity on 12-weighted images, and contrast enhancement. Necrosis or
100%,
accuracy rotizing
of
were
therefore for
94%
A single
fasciitis
and five
correcfly
identi-
showed
a specificity
fascitis.
a sensitiv-
of 86%,
the detection
and
old woman
fasciae
that
deep
fasciae
not involved an
increase
of nec-
The
was
cellulitis
case ofcellulitis
as necrotizing fasciitis in a 29-yearwho had blunt trauma to her right
overstaged
showed fluid on T2-weighted at surgery
after signal
high
of the subcutaneous
muscle,
one
intensity
imaging
unknown
1 day and one 3 days
examination. These to the interpreters
The MR examination thickening
ofthe
before
MR
injections were of the imaging.
of this patient showed superficial and deep fascia
a of
tion
was
of all cases
signal
with
intensity
fat in all patients.
superficial
increase
weighted
a signal
of the
tissue on 12-weighted images to high contrast enhancement
She received two intramuscular inof corticosteroids in her right deltoid
of the
showed
injection.
characteristics
showed
subcutaneous and a moderate ening
collections along scans but were
also
IV contrast
jections
shoulder.
Examination Technique
were
by two radiolo-
or clinical findings. Cellulitis was diagnosed when thickening of the subcutaneous tissues and contrast enhancement with or without fluid col-
process
thoracic
as leukemia,
who
were analyzed
muscle,
of the fascia
deep fascia on the T2-weighted scans of the patients who did not receive gadolinium di-
image quality.
Data Analysis
All MR images
the deltoid
olinium
were optimized to minimize the overall scan time. Therefore, using smaller matrix sizes and de-
and contrast-en-
from cellulitis of the infectious
saturation
therapeutic
to evaluate
for differentiating
to 256 x 256 and from 26 x l9cmto4Ox40cm, respectively. Il-weighted spin-echo sequences (TR rangelrE range, 300-540/8-21 msec) without fat
their poor physical
processes.
et al.
images recognized
on
after
fascia T2-weighted
contrast in four
Thick-
with
signal and
Ti-
administracases,
case also showed a large subcutaneous scess (Fig. 4). Except for one patient,
and
one
aball pa-
AJR:170, March
1998
MR
Imaging
of Necrotizing
Fasciitis
and
Cellulitis
Fig. 1.-Necrotizing fasciitis of right calf in 34-year-old man. A, T2-weighted fat-saturated spin-echo MR image shows signal enhancement of subcutaneous tissue (arrows) and fascia between muscle (arrowheads). Note increased signal intensity in medial part of soleus muscle. B, Enhanced Ti-weighted fat-saturated spin-echo MR image shows signal enhancement ofsubcutis (white arrows) and deepfasciae in A, especially along lateral only limited enhancement
tients
with
of deep
cellulitis
fasciae
normalities
between
soleus
no involvement
showed
and
were
part offascia
muscles.
No osseous
and gastrocnemius
ing fasciitis ab-
found.
could
trast-enhanced criteria,
tis were
Discussion tients
lulitis
MR
imaging
in our study
of all 17 pa-
examinations
showed
signs
ofcellulitis
in-
neous
ing
hanced
According judged
on 12-weighted
TI-weighted
to
and contrast images
our
previous
the infectious
process
en-
fascial
Note muscular
involvement
on 12-weighted
and
11-weighted
images. of necrotizing
of the
false-positive
of 100%.
accuracy
of 94%
fasciitis.
(Fig.
5).
to the ability
definition,
we
lections
to be a necrotiz-
if deep
arrows).
all I I cases
fascial involvement. sitivity
(black
Following
collections
This
Overall, a specificity sensitivity
of MR imaging
along
of
for the detection high
the deep
are characterized
of deep
we noticed 86%,
a senand
to detect
fascial
an
of necrotizis mainly
sheaths. by high
in medial
correspond
F171 and edema
planes
to foul
these
on fluid
perifascial
fluid
fasciae images.
I I 81. even
when mine
acquired injection.
soon after gadolinium diglushowed an enhancement in
nearly
the same
areas
tensity on these areas
12-weighted correspond
than
rather
fluid col-
major
damage
in-
of the fascial
of the involved T I -weighted
Contrast-enhanced
tissue
signal
and soleus
images. At surgery.
due
These
muscles
(arrowheads) is less prominent than part of soleus muscle, which shows
and thickening
T2-weighted collections
fascii-
staging
edema
tensity
con-
identified correctly, but one case of celwas overstaged as necrotizing fasciitis
because
cluding thickening of the subcutaneous tissue and increase of signal intensity of the subcutatissue
only
be identified
these
The
muscles
gastrocnemius
work
must
increased
with
increased
to highly
extravasation
Fig. 2.-Necrotizing muscular
abscess
tissue,
capillary
resulting of the
in-
Because to necrotic
vascularized
of the neighboring
be considered,
signal
sequences. at surgery
in early contrast
netand agent
fasciitis with within right bi-
ceps muscle in 40-year-old woman. A, T2-weighted fat-saturated fast spin-echo MR image shows thickening of subcutaneous tissue with fluid collections along superficial fascia (small arrows) and along deep fascia
between biceps and triceps muscles (large arrow). (arrowhead) and
Note edema
abscess within bi-
ceps muscle. B, Enhanced Ti-weighted fat-saturated spin-echo MR image shows clear delineation of abscess wall. Note contrast enhancement of superficial (small arrows) (large arrow) fascia.
AJR:170, March
1998
and
deep
617
Schmid
et al.
Fig. 3.-Necrotizing fasciitis in 57.year-old man who died 24 hr after MR imaging. A, Ti-weighted spin-echo MR image shows bilateral hypointense thickening of deep fascia of latissimus dorsi muscles (arrowheads). B, Fluid collections, histologically verified as necrosis, can be seen on both sides of both latissimus dorsi muscles (arrowheads) on fat-saturated echo MR image. pleural effusion.
Note involvement
(Fig. 5). At relatively
few
of superficial
locations
( 1 2 locations
in seven patients).
an abscesslike
the necrotic
with rim enhancement
contrast
tissue
administration
could
fascia
delineation
be
of right serratus
lections. of
after
The
infectious fasciae
signal
By comparing
MR
imaging
with
quences
gical findings, we found that the extent of infection revealed by MR imaging was usually overestimated. Several nonnecrotic deep fasciae showed slight to moderate signal increase on T2-weighted images. Of the 42
muscular
surgery
typical
or autopsy
as inflammatory
fluid
col-
infectious
This
rare
618
signal
of
and a diffuse
(Fig.
in
se-
seven
of
2). This
correpatients as in-
[3].
is
the
contrast
studies clinical
be detected
could
which
is comparable
16,
[ 15, history
of contrast
administration,
usto the
19]. But
of
the
enhancement we
noted
by
patients
after that
the
early extravasation necrotic areas (Fig. of the aggressiveness
of the IV contrast agent in 5) seems to be a parameter of the process, whereas
abscess
shown
formation,
The those
by
the
after IV contrast
enhancement indicates
relatively necrosis
other
the pattern
with
Iv
intra-
lesions
agents,
of
T2-weighted fast spinfascia of right arm, and
brachial
additional
contrast
comparing
was less severe
intramuscular
fasciitis
ing
results
on 12-weighted
increase
of subcutaneous
No
the a slight
fasciae and therefore (Fig. 1). Only three necrosis, represented
of necrotizing
Fig. 4.-38-year’old man with cellulitis of left forearm. A, T2-weighted fat-saturated spin-echo MR image shows massive thickening B, Enhanced Ti-weighted spin-echo MR image delineates large subcutaneous
is non-
showed
enhancement
abscesses
occurrence
involvement
necrosis.
increase
contrast
additional
neighboring
muscles
intramuscular
tramuscular
explanation
fasciae
in 10 of I I cases
nine cases.
fasciae with increased signal intensity on T2weighted images, only 34 were verified by
likely of
than that of the sponds to edema had
(arrow),
surrounding intensity
the sur-
muscle
most
edema with
The
identified
(Fig. 2).
anterior
a less
aggressive
results
of our study
of Saiag
et al. [20],
of subcutaneous tissue with large fluid collection within abscess with hypointense center and rim enhancement
subcutaneous (arrows).
typical
rim
administration,
process
(Fig.
2).
are comparable
to
who
26
examined
fat (arrows).
AJR:170,
March
1998
MR
Imaging
of Necrotizing
Fasciitis
and
Cellulitis
Fig. 5-32-year-old man with necrotizing fasciitis of left leg. A, Enhanced Ti-weighted spin-echo MR image shows thickening
and contrast enhancement of subcutaneous tissue (as seen in cases of cellulitis) (white arrows); additionally, thickening and contrast enhancement involve deep fascia between vastus lateralis muscle and biceps femoris muscle (black arrow). No abscess formation is seen. B, T2-weighted fast spin-echo MR image shows corresponding fluid collections within deep fascia (arrow) that were surgically verified as necrotic fascia.
patients
with
severe
acute
tions, but only three signs of necrotizing
soft-tissue
patients fasciitis
infec-
in his series had on MR images.
All of these three cases were confirmed gery. Hopkins et al. I 191 also reported sensitivity detection
(89lOO%)
MR imaging
for
of soft-tissue
infections,
of 46% was low. They of osteomyelitis. pyarthrosis.
and myositis
(total. n
and cellulitis
their
compared abscesses, 22) with
=
I2
Using lyzed
MR imaging. Rahmouni et al. [6] ana36 cases of acute soft-tissue infections. which
MR
had
They
images
fascial results, when could
are
collections.
they
diagnosed
fluid collections be detected.
pected
processes.
fascial
necrosis
that
12-weighted
for
However, only
fasciae
they
injected
in cases
with
for
the
detection
Conventional
detailed
methods
of necrotizing
radiography
information,
thickening. eign bodies
gas
such
formation,
of soft-tissue
radiography
is more
until
the
necrotizing
well advanced. siderable gas
with the development in the subcutaneous
AJR:i70,
1998
March
necrotizing
such
non-
deep
if our
study
is limited
specificity.
Many
tissue
entities
findings
if diagnosis
is
MR imaging tic
findings
we have
disthe
high
of thickening
its
content
from results
and
the
and this study
the immediate
in necrotic
adniinishelps to
seems
to inof gad-
extravasation
tissue
In
is a marker
(1w the
of the infection.
cellulitis.
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spe-
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3. Gozal
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immediately
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has a fatal out-
sensitivity
such
biopsy. should be pertniied. MR imaging can help to (md
aggressiveness
of the most
from
made
Our
of necrotit-
presence
examinations.
abscesses, that
I. Weinbren
history.
to
fasciitis.
of
disorders,
disease.
is not
the
further
necrotizing
water
fasciitis
exclude
mi-
MR
in every case If MR imag-
MR imaging appears to be the niethxl of choice to differentiate necrotizing fasciitis from
is probably
or neoplastic
differentiation
has
sis of necrotizing
lower
phlebe-
and
necrotizing
dicate
olinium
fluid.
because
can be diagnosed
and the clinical
of contissue in
and
Nevertheless,
[25-27j.
clinical
Because
accu-
diseases.
in an increased
not
fasciitis,
delineate
[6, 20].
cellulitis
other
rheumatic
and lymphedema
these
those
Therefre.
ideal location for these biopsies. The tration of IV gadolinium digluminc
collec-
their
does
ing
sheaths.
be perfIrmed early necrotizing fasciitis.
frozen-section those cases,
as high of
method
ing
al-
suspected.
fascial
imaging
difficult, it is important and reliable diagnosis.
howspecific
be
tool for diagnosing
this
soft
come
and
show that MR
result
cific
forgas sensi-
process
because
as myositis.
may
been
191;
no
fasciitis
CT
fascial
of suspected
can
studies
between
in detecting
should
or sonogra-
and CT do not have
necrotizing
cussed
can
imaging
for differentiation
deep
aging
foreign
fluid
on CT
fasciitis MR
along
de-
and fascial and foreign
massive
seen
Otherbe
collections
[22-241.
of
fasciae with
suboptimal
soft-tissue possible
tive than by physical examination ever. plain radiography shows abnormality
phy.
fasciitis,
fas-
gives as
and
[2 1 1. Detection
conventional
have
wooden
fluid
sonography
In cases
along
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