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Benson JC, Trejo-Lopez JA, Cormier JL, Parney IF, Mark IT, Madhavan AA, Kotsenas AL, Rydberg CH, Luetmer PH, Eckel LJ, Johnson DR. Radiology-pathology correlation: Giant tumefactive perivascular spaces. Neuroradiol J 2024:19714009241247459. [PMID: 38613202 DOI: 10.1177/19714009241247459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2024] Open
Abstract
Dilated perivascular spaces (PVSs) are common and easily recognized on imaging. However, rarer giant tumefactive PVSs (GTPVSs) can have unusual multilocular cystic configurations, and are often confused for other pathologic entities, including neoplasms, cystic infarctions, and neuroepithelial cysts. Because GTPVSs are scarcely encountered and even more infrequently operated upon, many radiologists are unaware of the imaging and pathologic features of these lesions. Here, a case of a resected GTPVS is presented, highlighting both its radiologic and histologic characteristics, and discussing how such lesions can be differentiated from their closest mimickers on imaging.
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Affiliation(s)
- John C Benson
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Jason L Cormier
- Department of Neurosurgery, Acadiana Neurosurgery, Lafayette, LA, USA
| | - Ian F Parney
- Department of Neurosurgery, Mayo Clinic, Rochester, LA, USA
| | - Ian T Mark
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Amy L Kotsenas
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
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Mark IT, Van Gompel J, Bancos I, Nagelschneider AA, Johnson DR, Bathla G, Madhavan AA, Weber NM, Yu L. Back to the Future: Dynamic Contrast-Enhanced Photon-Counting Detector CT for the Detection of Pituitary Adenoma in Cushing Disease. AJNR Am J Neuroradiol 2024:ajnr.A8171. [PMID: 38290737 DOI: 10.3174/ajnr.a8171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 01/15/2024] [Indexed: 02/01/2024]
Abstract
Historically, MR imaging has been unable to detect a pituitary adenoma in up to one-half of patients with Cushing disease. This issue is problematic because the standard-of-care treatment is surgical resection, and its success is correlated with finding the tumor on imaging. Photon-counting detector CT is a recent advancement that has multiple benefits over conventional energy-integrating detector CT. We present the use of dynamic contrast-enhanced imaging using photon-counting detector CT for the detection of pituitary adenomas in patients with Cushing disease.
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Affiliation(s)
- Ian T Mark
- From the Department of Radiology (I.T.M. A.A.N., D.R.J., G.B., A.A.M., N.M.W., L.Y.), Mayo Clinic, Rochester, Minnesota
| | - Jamie Van Gompel
- Department of Neurosurgery (J.V.G.), Mayo Clinic, Rochester, Minnesota
| | - Irina Bancos
- Department of Endocrinology (I.B.), Mayo Clinic, Rochester, Minnesota
| | - Alex A Nagelschneider
- From the Department of Radiology (I.T.M. A.A.N., D.R.J., G.B., A.A.M., N.M.W., L.Y.), Mayo Clinic, Rochester, Minnesota
| | - Derek R Johnson
- From the Department of Radiology (I.T.M. A.A.N., D.R.J., G.B., A.A.M., N.M.W., L.Y.), Mayo Clinic, Rochester, Minnesota
| | - Girish Bathla
- From the Department of Radiology (I.T.M. A.A.N., D.R.J., G.B., A.A.M., N.M.W., L.Y.), Mayo Clinic, Rochester, Minnesota
| | - Ajay A Madhavan
- From the Department of Radiology (I.T.M. A.A.N., D.R.J., G.B., A.A.M., N.M.W., L.Y.), Mayo Clinic, Rochester, Minnesota
| | - Nikkole M Weber
- From the Department of Radiology (I.T.M. A.A.N., D.R.J., G.B., A.A.M., N.M.W., L.Y.), Mayo Clinic, Rochester, Minnesota
| | - Lifeng Yu
- From the Department of Radiology (I.T.M. A.A.N., D.R.J., G.B., A.A.M., N.M.W., L.Y.), Mayo Clinic, Rochester, Minnesota
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3
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Faghani S, Moassefi M, Madhavan AA, Mark IT, Verdoorn JT, Erickson BJ, Benson JC. Identifying Patients with CSF-Venous Fistula Using Brain MRI: A Deep Learning Approach. AJNR Am J Neuroradiol 2024; 45:439-443. [PMID: 38423747 DOI: 10.3174/ajnr.a8173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 12/12/2023] [Indexed: 03/02/2024]
Abstract
BACKGROUND AND PURPOSE Spontaneous intracranial hypotension is an increasingly recognized condition. Spontaneous intracranial hypotension is caused by a CSF leak, which is commonly related to a CSF-venous fistula. In patients with spontaneous intracranial hypotension, multiple intracranial abnormalities can be observed on brain MR imaging, including dural enhancement, "brain sag," and pituitary engorgement. This study seeks to create a deep learning model for the accurate diagnosis of CSF-venous fistulas via brain MR imaging. MATERIALS AND METHODS A review of patients with clinically suspected spontaneous intracranial hypotension who underwent digital subtraction myelogram imaging preceded by brain MR imaging was performed. The patients were categorized as having a definite CSF-venous fistula, no fistula, or indeterminate findings on a digital subtraction myelogram. The data set was split into 5 folds at the patient level and stratified by label. A 5-fold cross-validation was then used to evaluate the reliability of the model. The predictive value of the model to identify patients with a CSF leak was assessed by using the area under the receiver operating characteristic curve for each validation fold. RESULTS There were 129 patients were included in this study. The median age was 54 years, and 66 (51.2%) had a CSF-venous fistula. In discriminating between positive and negative cases for CSF-venous fistulas, the classifier demonstrated an average area under the receiver operating characteristic curve of 0.8668 with a standard deviation of 0.0254 across the folds. CONCLUSIONS This study developed a deep learning model that can predict the presence of a spinal CSF-venous fistula based on brain MR imaging in patients with suspected spontaneous intracranial hypotension. However, further model refinement and external validation are necessary before clinical adoption. This research highlights the substantial potential of deep learning in diagnosing CSF-venous fistulas by using brain MR imaging.
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Affiliation(s)
- Shahriar Faghani
- From the Radiology Informatics Lab, Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Mana Moassefi
- From the Radiology Informatics Lab, Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | | | - Ian T Mark
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | | | - Bradley J Erickson
- From the Radiology Informatics Lab, Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - John C Benson
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
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4
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Benson JC, Mark IT, Madhavan AA, Johnson-Tesch B, Diehn FE, Carr CM, Kim DK, Brinjikji W, Verdoorn JT. Intracranial findings in spontaneous intracranial hypotension: Does the severity of abnormalities correspond with certainty and/or multifocality of cerebrospinal fluid leaks? Neuroradiol J 2024:19714009241242645. [PMID: 38525966 DOI: 10.1177/19714009241242645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024] Open
Abstract
BACKGROUND AND PURPOSE Spontaneous intracranial hypotension (SIH) is caused by spinal cerebrospinal fluid (CSF) leaks. This study assessed whether the certainty and/or multifocality of CSF leaks is associated with the severity of intracranial sequelae of SIH. MATERIALS AND METHODS A retrospective review was completed of patients with suspected SIH that underwent digital subtraction myelogram (DSM) preceded by brain MRI. DSMs were evaluated for the presence or absence of a CSF leak, categorized both as positive/negative/indeterminate and single versus multifocal. Brain MRIs were assessed for intracranial sequelae of SIH based on two probabilistic scoring systems (Dobrocky and Mayo methods). For each system, both an absolute "numerical" score (based on tabulation of findings) and "categorized" score (classification of probability) were tabulated. RESULTS 174 patients were included; 113 (64.9%) were female, average age 52.0 ± 14.3 years. One or more definite leaks were noted in 76 (43.7%) patients; an indeterminate leak was noted in 22 (12.6%) patients. 16 (16.3%) had multiple leaks. There was no significant difference in the severity of intracranial findings between patients with a single versus multiple leaks (p values ranged from .36 to .70 using categorized scores and 0.22-0.99 for numerical scores). Definite leaks were more likely to have both higher categorized intracranial scores (Mayo p = .0008, Dobrocky p = .006) and numerical scores (p = .0002 for Mayo and p = .006 for Dobrocky). CONCLUSIONS Certainty of a CSF leak on diagnostic imaging is associated with severity of intracranial sequelae of SIH, with definite leaks having significantly more intracranial findings than indeterminate leaks. Multifocal leaks do not cause greater intracranial abnormalities.
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Affiliation(s)
| | - Ian T Mark
- Department of Radiology, Mayo Clinic, USA
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Madhavan AA, Bathla G, Benson JC, Diehn FE, Nagelschneider AA, Lehman VT. High yield clinical applications for photon counting CT in neurovascular imaging. Br J Radiol 2024:tqae058. [PMID: 38460543 DOI: 10.1093/bjr/tqae058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 02/05/2024] [Accepted: 03/07/2024] [Indexed: 03/11/2024] Open
Abstract
Photon-counting CT uses a novel x-ray detection mechanism that confers many advantages over that used in traditional energy integrating CT. As photon-counting CT becomes more available, it is important to thoroughly understand its benefits and highest yield areas for improvements in diagnosis of various diseases. Based on our early experience, we have identified several areas of neurovascular imaging in which photon-counting CT shows promise. Here, we describe the benefits in diagnosing arterial and venous diseases in the head, neck, and spine. Specifically, we focus on applications in head and neck CT angiography, spinal CT angiography, and CT myelography for detection of CSF-venous fistulas. Each of these applications highlights the technological advantages of PCCT in neurovascular imaging. Further understanding of these applications will not only benefit institutions incorporating PCCT into their practices but will also help guide future directions for implementation of PCCT for diagnosing other pathologies in neuroimaging.
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Affiliation(s)
- Ajay A Madhavan
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905
| | - Girish Bathla
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905
| | - John C Benson
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905
| | - Felix E Diehn
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905
| | - Alex A Nagelschneider
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905
| | - Vance T Lehman
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905
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Ajmera P, Agarwal AK, Mehta PM, Benson JC, Madhavan AA, Diehn FE, Soni N, Bathla G. Cauda equina neuroendocrine tumors: A single institutional imaging review of cases over two decades. Neuroradiol J 2024; 37:84-91. [PMID: 37933451 PMCID: PMC10863566 DOI: 10.1177/19714009231212359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023] Open
Abstract
Cauda Equina Neuroendocrine Tumors (CE-NET), previously referred to as paragangliomas are a rare subset of spinal tumors, with limited data on imaging. Herein, we present a retrospective review of clinical and imaging findings of CE-NETs in ten patients who were evaluated at our institution over the past two decades. All patients had well-defined intradural lesions in the lumbar spine which demonstrated slow growth. A review of imaging findings revealed the presence of an eccentric vascular pedicle along the dorsal aspect of the tumor in 8 of the 10 patients (eccentric vessel sign), a distinctive finding that has not previously been reported with this tumor and may help improve the accuracy of imaging-based diagnosis. In all cases, a gross-total resection was performed, with resolution of symptoms in most of the cases.
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Affiliation(s)
- Pranav Ajmera
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Amit K Agarwal
- Department of Radiology, Mayo Clinic, Jacksonville, FL, USA
| | - Parv M Mehta
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - John C Benson
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Felix E Diehn
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Neetu Soni
- Department of Radiology, Mayo Clinic, Jacksonville, FL, USA
| | - Girish Bathla
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
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7
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Madhavan AA, Liebo GB, Baffour F, Diehn FE, Maus TP, Murthy NS, Rhodes NG, Tiegs-Heiden CA. A review of epidural and non-epidural contrast flow patterns during fluoroscopic and CT-guided epidural steroid injections. Interv Neuroradiol 2024:15910199231221857. [PMID: 38179603 DOI: 10.1177/15910199231221857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024] Open
Abstract
Epidural steroid injections are commonly performed using fluoroscopic or CT guidance. With both modalities, the injection of contrast material is necessary before steroid administration to ensure adequate epidural flow and exclude non-epidural flow. While fluoroscopic guidance is conventional, CT is utilized at some centers and can be particularly helpful in the setting of challenging or postoperative anatomy. It is important for proceduralists to be adept at evaluating contrast media flow patterns under both modalities. The goal of this review article is to describe and provide examples of epidural and non-epidural flow patterns on both conventional fluoroscopy and CT. Specific non-epidural patterns discussed include intrathecal flow, intradural/subdural flow, vascular uptake, flow into the retrodural space of Okada, inadvertent facet joint flow, and intradiscal flow.
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Affiliation(s)
- Ajay A Madhavan
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Greta B Liebo
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Francis Baffour
- Division of Musculoskeletal Radiology, Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Felix E Diehn
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Timothy P Maus
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Naveen S Murthy
- Division of Musculoskeletal Radiology, Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Nicholas G Rhodes
- Division of Musculoskeletal Radiology, Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Christin A Tiegs-Heiden
- Division of Musculoskeletal Radiology, Department of Radiology, Mayo Clinic, Rochester, MN, USA
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8
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Huynh TJ, Parizadeh D, Ahmed AK, Gandia CT, Davison HC, Murray JV, Mark IT, Madhavan AA, Shlapak D, Rozen TD, Brinjikji W, Vibhute P, Gupta V, Brewer K, Fermo O. Lateral Decubitus Dynamic CT Myelography with Real-Time Bolus Tracking (dCTM-BT) for Evaluation of CSF-Venous Fistulas: Diagnostic Yield Stratified by Brain Imaging Findings. AJNR Am J Neuroradiol 2023; 45:105-112. [PMID: 38164531 PMCID: PMC10756575 DOI: 10.3174/ajnr.a8082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 10/29/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND AND PURPOSE CSF-venous fistulas (CVFs) associated with spontaneous intracranial hypotension (SIH) may have a transient appearance, relative to contrast arrival, which may influence the diagnostic performance of lateral decubitus CT myelography (CTM). We developed a dynamic CTM protocol using real-time bolus-tracking (dCTM-BT) to improve the temporal resolution and standardize the timing of CTM acquisitions post-intrathecal contrast administration. The purpose of our study was to evaluate the feasibility of the dCTM-BT technique and evaluate its diagnostic yield for CVF detection, stratified by brain MRI SIH findings. MATERIALS AND METHODS Patients with suspected SIH without extradural fluid collection on spine MRI who underwent dCTM-BT were retrospectively reviewed. CT bolus monitoring was performed at the upper thoracic level. Following the visualization of dense intrathecal contrast, at least 3 CTM acquisitions of the spine were obtained and reviewed by 2 neuroradiologists. The Bern SIH score was calculated on the brain MRI. The diagnostic yield for CVF detection was evaluated, stratified by Bern score categories and a receiver operating characteristic (ROC) analysis. RESULTS Out of 48 patients, 23 (48%) had a CVF on dCTM-BT, located at T1-5 (n = 4), T6-12 (n = 18), L1 (n = 1), with 70% on the right. CVF was identified in 22/22 (100%) of patients who had a high Bern score, 1/7 (14%) of those who had an intermediate score, and 0/19 (0%) of those who had a low score. The area under the ROC curve was 0.99 (95% CI, 0.98-1.00). The optimal cutoff was a Bern score of ≥5 (96% sensitivity, 100% specificity). CONCLUSIONS dCTM-BT is feasible and has excellent diagnostic performance for CVF identification/localization. The Bern score is strongly associated with CVF detection and may help inform who will benefit from dCTM-BT.
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Affiliation(s)
- Thien J Huynh
- From the Department of Radiology (T.J.H., D.P., A.K.A., C.T.G., H.C.D., J.V.M., P.V., V.G., K.B.), Mayo Clinic, Jacksonville, Florida
- Department of Neurosurgery (T.J.H.), Mayo Clinic, Jacksonville, Florida
| | - Donna Parizadeh
- From the Department of Radiology (T.J.H., D.P., A.K.A., C.T.G., H.C.D., J.V.M., P.V., V.G., K.B.), Mayo Clinic, Jacksonville, Florida
| | - Ahmed K Ahmed
- From the Department of Radiology (T.J.H., D.P., A.K.A., C.T.G., H.C.D., J.V.M., P.V., V.G., K.B.), Mayo Clinic, Jacksonville, Florida
| | - Christopher T Gandia
- From the Department of Radiology (T.J.H., D.P., A.K.A., C.T.G., H.C.D., J.V.M., P.V., V.G., K.B.), Mayo Clinic, Jacksonville, Florida
| | - Hal C Davison
- From the Department of Radiology (T.J.H., D.P., A.K.A., C.T.G., H.C.D., J.V.M., P.V., V.G., K.B.), Mayo Clinic, Jacksonville, Florida
| | - John V Murray
- From the Department of Radiology (T.J.H., D.P., A.K.A., C.T.G., H.C.D., J.V.M., P.V., V.G., K.B.), Mayo Clinic, Jacksonville, Florida
| | - Ian T Mark
- Department of Radiology (I.T.M., A.A.M., D.S., W.B.), Mayo Clinic, Rochester, Minnesota
| | - Ajay A Madhavan
- Department of Radiology (I.T.M., A.A.M., D.S., W.B.), Mayo Clinic, Rochester, Minnesota
| | - Darya Shlapak
- Department of Radiology (I.T.M., A.A.M., D.S., W.B.), Mayo Clinic, Rochester, Minnesota
| | - Todd D Rozen
- Department of Neurology (T.D.R., O.F.), Mayo Clinic, Jacksonville, Florida
| | - Waleed Brinjikji
- Department of Radiology (I.T.M., A.A.M., D.S., W.B.), Mayo Clinic, Rochester, Minnesota
| | - Prasanna Vibhute
- From the Department of Radiology (T.J.H., D.P., A.K.A., C.T.G., H.C.D., J.V.M., P.V., V.G., K.B.), Mayo Clinic, Jacksonville, Florida
| | - Vivek Gupta
- From the Department of Radiology (T.J.H., D.P., A.K.A., C.T.G., H.C.D., J.V.M., P.V., V.G., K.B.), Mayo Clinic, Jacksonville, Florida
| | - Kacie Brewer
- From the Department of Radiology (T.J.H., D.P., A.K.A., C.T.G., H.C.D., J.V.M., P.V., V.G., K.B.), Mayo Clinic, Jacksonville, Florida
| | - Olga Fermo
- Department of Neurology (T.D.R., O.F.), Mayo Clinic, Jacksonville, Florida
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Madhavan AA, Cutsforth-Gregory JK, Brinjikji W, Benson JC, Diehn FE, Mark IT, Verdoorn JT, Zhou Z, Yu L. Application of a Denoising High-Resolution Deep Convolutional Neural Network to Improve Conspicuity of CSF-Venous Fistulas on Photon-Counting CT Myelography. AJNR Am J Neuroradiol 2023; 45:96-99. [PMID: 38164538 PMCID: PMC10756582 DOI: 10.3174/ajnr.a8097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 10/30/2023] [Indexed: 01/03/2024]
Abstract
Photon-counting detector CT myelography is a recently described technique that has several advantages for the detection of CSF-venous fistulas, one of which is improved spatial resolution. To maximally leverage the high spatial resolution of photon-counting detector CT, a sharp kernel and a thin section reconstruction are needed. Sharp kernels and thin slices often result in increased noise, degrading image quality. Here, we describe a novel deep-learning-based algorithm used to denoise photon-counting detector CT myelographic images, allowing the sharpest and thinnest quantitative reconstruction available on the scanner to be used to enhance diagnostic image quality. Currently, the algorithm requires 4-6 hours to create diagnostic, denoised images. This algorithm has the potential to increase the sensitivity of photon-counting detector CT myelography for detecting CSF-venous fistulas, and the technique may be valuable for institutions attempting to optimize photon-counting detector CT myelography imaging protocols.
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Affiliation(s)
- Ajay A Madhavan
- From the Department of Radiology (A.A.M., W.B., J.C.B., F.E.D., I.T.M., J.T.V., Z.Z., L.Y.), Mayo Clinic, Rochester, Minnesota
| | | | - Waleed Brinjikji
- From the Department of Radiology (A.A.M., W.B., J.C.B., F.E.D., I.T.M., J.T.V., Z.Z., L.Y.), Mayo Clinic, Rochester, Minnesota
| | - John C Benson
- From the Department of Radiology (A.A.M., W.B., J.C.B., F.E.D., I.T.M., J.T.V., Z.Z., L.Y.), Mayo Clinic, Rochester, Minnesota
| | - Felix E Diehn
- From the Department of Radiology (A.A.M., W.B., J.C.B., F.E.D., I.T.M., J.T.V., Z.Z., L.Y.), Mayo Clinic, Rochester, Minnesota
| | - Ian T Mark
- From the Department of Radiology (A.A.M., W.B., J.C.B., F.E.D., I.T.M., J.T.V., Z.Z., L.Y.), Mayo Clinic, Rochester, Minnesota
| | - Jared T Verdoorn
- From the Department of Radiology (A.A.M., W.B., J.C.B., F.E.D., I.T.M., J.T.V., Z.Z., L.Y.), Mayo Clinic, Rochester, Minnesota
| | - Zhongxing Zhou
- From the Department of Radiology (A.A.M., W.B., J.C.B., F.E.D., I.T.M., J.T.V., Z.Z., L.Y.), Mayo Clinic, Rochester, Minnesota
| | - Lifeng Yu
- From the Department of Radiology (A.A.M., W.B., J.C.B., F.E.D., I.T.M., J.T.V., Z.Z., L.Y.), Mayo Clinic, Rochester, Minnesota
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10
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Mark IT, Madhavan AA, Delone DR, Oien MP, Messina SA. Direct pseudomeningocele contrast injection for spinal CSF leak localization. Neuroradiol J 2023:19714009231224413. [PMID: 38146822 DOI: 10.1177/19714009231224413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2023] Open
Abstract
CT myelography has been traditionally used to evaluate post-operative paraspinal fluid collections to discern CSF leaking into a pseudomeningocele versus a contained seroma. Rather than performing a lumbar puncture and injecting intrathecal contrast for myelography, we present the first report of direct contrast injection into a post-operative paraspinal pseudomeningocele for CSF leak confirmation and localization. This is a simple procedure that has several advantages over a conventional CT myelogram for the evaluation of post-operative paraspinal fluid collections.
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11
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Madhavan AA, Cutsforth-Gregory JK, Brinjikji W, Bathla G, Benson JC, Diehn FE, Eckel LJ, Mark IT, Morris PP, Payne MA, Verdoorn JT, Weber NM, Yu L, Baffour F, Fletcher JG, McCollough CH. Diagnostic Performance of Decubitus Photon-Counting Detector CT Myelography for the Detection of CSF-Venous Fistulas. AJNR Am J Neuroradiol 2023; 44:1445-1450. [PMID: 37945523 PMCID: PMC10714843 DOI: 10.3174/ajnr.a8040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 09/24/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND AND PURPOSE CSF-venous fistulas are a common cause of spontaneous intracranial hypotension. Lateral decubitus digital subtraction myelography and CT myelography are the diagnostic imaging standards to identify these fistulas. Photon-counting CT myelography has technological advantages that might improve CSF-venous fistula detection, though no large studies have yet assessed its diagnostic performance. We sought to determine the diagnostic yield of photon-counting detector CT myelography for detection of CSF-venous fistulas in patients with spontaneous intracranial hypotension. MATERIALS AND METHODS We retrospectively searched our database for all decubitus photon-counting detector CT myelograms performed at our institution since the introduction of the technique in our practice. Per our institutional workflow, all patients had prior contrast-enhanced brain MR imaging and spine MR imaging showing no extradural CSF. Two neuroradiologists reviewed preprocedural brain MRIs, assessing previously described findings of intracranial hypotension (Bern score). Additionally, 2 different neuroradiologists assessed each myelogram for a definitive or equivocal CSF-venous fistula. The yield of photon-counting detector CT myelography was calculated and stratified by the Bern score using low-, intermediate-, and high-probability tiers. RESULTS Fifty-seven consecutive photon-counting detector CT myelograms in 57 patients were included. A single CSF-venous fistula was definitively present in 38/57 patients. After we stratified by the Bern score, a definitive fistula was seen in 56.0%, 73.3%, and 76.5% of patients with low-, intermediate-, and high-probability brain MR imaging, respectively. CONCLUSIONS Decubitus photon-counting detector CT myelography has an excellent diagnostic performance for the detection of CSF-venous fistulas. The yield for patients with intermediate- and high-probability Bern scores is at least as high as previously reported yields of decubitus digital subtraction myelography and CT myelography using energy-integrating detector scanners. The yield for patients with low-probability Bern scores appears to be greater compared with other modalities. Due to the retrospective nature of this study, future prospective work will be needed to compare the sensitivity of photon-counting detector CT myelography with other modalities.
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Affiliation(s)
- Ajay A Madhavan
- From the Department of Radiology (A.A.M., W.B., G.B., J.C.B., F.E.D., L.J.E., I.T.M., P.P.M., J.T.V., N.M.W., L.Y., F.B., J.G.F., C.H.M.), Mayo Clinic, Rochester, Minnesota
| | | | - Waleed Brinjikji
- From the Department of Radiology (A.A.M., W.B., G.B., J.C.B., F.E.D., L.J.E., I.T.M., P.P.M., J.T.V., N.M.W., L.Y., F.B., J.G.F., C.H.M.), Mayo Clinic, Rochester, Minnesota
| | - Girish Bathla
- From the Department of Radiology (A.A.M., W.B., G.B., J.C.B., F.E.D., L.J.E., I.T.M., P.P.M., J.T.V., N.M.W., L.Y., F.B., J.G.F., C.H.M.), Mayo Clinic, Rochester, Minnesota
| | - John C Benson
- From the Department of Radiology (A.A.M., W.B., G.B., J.C.B., F.E.D., L.J.E., I.T.M., P.P.M., J.T.V., N.M.W., L.Y., F.B., J.G.F., C.H.M.), Mayo Clinic, Rochester, Minnesota
| | - Felix E Diehn
- From the Department of Radiology (A.A.M., W.B., G.B., J.C.B., F.E.D., L.J.E., I.T.M., P.P.M., J.T.V., N.M.W., L.Y., F.B., J.G.F., C.H.M.), Mayo Clinic, Rochester, Minnesota
| | - Laurence J Eckel
- From the Department of Radiology (A.A.M., W.B., G.B., J.C.B., F.E.D., L.J.E., I.T.M., P.P.M., J.T.V., N.M.W., L.Y., F.B., J.G.F., C.H.M.), Mayo Clinic, Rochester, Minnesota
| | - Ian T Mark
- From the Department of Radiology (A.A.M., W.B., G.B., J.C.B., F.E.D., L.J.E., I.T.M., P.P.M., J.T.V., N.M.W., L.Y., F.B., J.G.F., C.H.M.), Mayo Clinic, Rochester, Minnesota
| | - Pearse P Morris
- From the Department of Radiology (A.A.M., W.B., G.B., J.C.B., F.E.D., L.J.E., I.T.M., P.P.M., J.T.V., N.M.W., L.Y., F.B., J.G.F., C.H.M.), Mayo Clinic, Rochester, Minnesota
| | - Melissa A Payne
- Department of Neurology (J.K.C.-G., M.A.P.), Mayo Clinic, Rochester, Minnesota
| | - Jared T Verdoorn
- From the Department of Radiology (A.A.M., W.B., G.B., J.C.B., F.E.D., L.J.E., I.T.M., P.P.M., J.T.V., N.M.W., L.Y., F.B., J.G.F., C.H.M.), Mayo Clinic, Rochester, Minnesota
| | - Nikkole M Weber
- From the Department of Radiology (A.A.M., W.B., G.B., J.C.B., F.E.D., L.J.E., I.T.M., P.P.M., J.T.V., N.M.W., L.Y., F.B., J.G.F., C.H.M.), Mayo Clinic, Rochester, Minnesota
| | - Lifeng Yu
- From the Department of Radiology (A.A.M., W.B., G.B., J.C.B., F.E.D., L.J.E., I.T.M., P.P.M., J.T.V., N.M.W., L.Y., F.B., J.G.F., C.H.M.), Mayo Clinic, Rochester, Minnesota
| | - Francis Baffour
- From the Department of Radiology (A.A.M., W.B., G.B., J.C.B., F.E.D., L.J.E., I.T.M., P.P.M., J.T.V., N.M.W., L.Y., F.B., J.G.F., C.H.M.), Mayo Clinic, Rochester, Minnesota
| | - Joel G Fletcher
- From the Department of Radiology (A.A.M., W.B., G.B., J.C.B., F.E.D., L.J.E., I.T.M., P.P.M., J.T.V., N.M.W., L.Y., F.B., J.G.F., C.H.M.), Mayo Clinic, Rochester, Minnesota
| | - Cynthia H McCollough
- From the Department of Radiology (A.A.M., W.B., G.B., J.C.B., F.E.D., L.J.E., I.T.M., P.P.M., J.T.V., N.M.W., L.Y., F.B., J.G.F., C.H.M.), Mayo Clinic, Rochester, Minnesota
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12
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Carabenciov ID, Madhavan AA, Cutsforth-Gregory JK. B-Cell Lymphoma Presenting With Marked Intracranial Pachymeningitis. Mayo Clin Proc 2023; 98:1888-1889. [PMID: 38044004 DOI: 10.1016/j.mayocp.2023.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 06/20/2023] [Accepted: 06/23/2023] [Indexed: 12/05/2023]
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13
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Benson JC, Madhavan AA, Mark IT, Cutsforth-Gregory JK, Brinjikji W, Verdoorn JT. Likelihood of Discovering a CSF Leak Based on Intracranial MRI Findings in Patients without a Spinal Longitudinal Extradural Collection: A New Probabilistic Scoring System. AJNR Am J Neuroradiol 2023; 44:1339-1344. [PMID: 37884301 PMCID: PMC10631522 DOI: 10.3174/ajnr.a8030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/14/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND AND PURPOSE The likelihood of discovering a CSF leak can be determined by assessing intracranial abnormalities. However, the Dobrocky scoring system, which is used to determine this likelihood, did not incorporate patients with CSF-venous fistulas. This study sought to create a new probabilistic scoring system applicable to patients without a spinal longitudinal extradural collection. MATERIALS AND METHODS A retrospective review was completed of patients with suspected spontaneous intracranial hypotension who underwent brain MR imaging followed by digital subtraction myelography with same-day CT myelography. Patients with and without leaks found on digital subtraction myelography were included. MRIs were assessed for numerous reported stigmata of spontaneous intracranial hypotension and were compared between cohorts. RESULTS One hundred seventy-four patients were included; 113 (64.9%) were women (average age, 52.0 [SD, 14.3] years). A CSF leak was found in 98 (56.3%) patients, nearly all of which (93.9%) were CSF-venous fistulas. Diffuse dural enhancement, internal auditory canals dural enhancement, non-Chiari cerebellar descent, pituitary engorgement, brain sag, dural venous sinus engorgement, and decreased suprasellar cistern size were associated with a CSF leak. A probabilistic scoring system was made in which a single point value was assigned to each of those findings: 0-2 considered low probability and ≥3 considered intermediate-to-high probability of a CSF leak. CONCLUSIONS This study offers a new probabilistic scoring system for evaluating the likelihood of discovering a CSF leak on the basis of intracranial MR imaging findings, though the new system is not superior to that of the Dobrocky method for predicting the presence of CSF leaks.
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Affiliation(s)
- John C Benson
- From the Department of Radiology (J.C.B., A.A.M., I.T.M., W.B., J.T.V.), Mayo Clinic, Rochester, Minnesota
| | - Ajay A Madhavan
- From the Department of Radiology (J.C.B., A.A.M., I.T.M., W.B., J.T.V.), Mayo Clinic, Rochester, Minnesota
| | - Ian T Mark
- From the Department of Radiology (J.C.B., A.A.M., I.T.M., W.B., J.T.V.), Mayo Clinic, Rochester, Minnesota
| | | | - Waleed Brinjikji
- From the Department of Radiology (J.C.B., A.A.M., I.T.M., W.B., J.T.V.), Mayo Clinic, Rochester, Minnesota
| | - Jared T Verdoorn
- From the Department of Radiology (J.C.B., A.A.M., I.T.M., W.B., J.T.V.), Mayo Clinic, Rochester, Minnesota
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14
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Shlapak DP, Mark IT, Kim DK, Benson JC, Diehn FE, Kissoon NR, Liebo GB, Madhavan AA, Morris JM, Morris PP, Oien MP, Verdoorn JT, Carr CM. Incremental diagnostic yield and clinical outcomes of lateral decubitus CT myelogram immediately following negative lateral decubitus digital subtraction myelogram. Neuroradiol J 2023; 36:593-600. [PMID: 37128777 PMCID: PMC10569200 DOI: 10.1177/19714009231173110] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023] Open
Abstract
INTRODUCTION Spontaneous intracranial hypotension (SIH) caused by a spinal cerebrospinal fluid (CSF) leak classically presents with orthostatic headache. Digital subtraction myelography (DSM) has a well-established diagnostic yield in the absence of extradural spinal collection. At our institution, DSM is followed by lateral decubitus CT myelogram (LDCTM) in the same decubitus position to increase diagnostic yield of the combined study. We evaluated the incremental diagnostic yield of LDCTM following negative DSM and reviewed patient outcomes. METHODS Retrospective review of consecutive DSMs with subsequent LDCTM from April 2019 to March 2021 was performed. Combined reports were reviewed, and studies with positive DSMs were excluded. Of the exams with negative DSM, only studies with LDCTM reports identifying potential leak site were included. Interventions and follow-up clinical notes were reviewed to assess symptoms improvement following treatment. RESULTS Of the 83 patients with negative DSMs, 11 (13.2%) had positive leak findings on LDCTMs, and 21 (25.3%) were equivocal. Of 11 positive LDCTMs, 6 leaks were nerve sheath tears (NSTs) and 5 were CSF-venous fistulas (CVFs). 10/11 (90.9%) had intervention and follow-up, with 9/10 (90%) having positive clinical outcome. Of the 21 equivocal LDCTM patients (19 CVFs and 2 NSTs), 15 (71.4%) had interventions and follow-up, with 3/15 (20.0%) with positive clinical outcomes. CONCLUSION LDCTM following negative DSM has an incremental diagnostic yield up to 38.6%, with up to 14.5% of positive patient outcomes following treatment. LDCTM should be considered after DSM to maximize diagnostic yield of the combined exam.
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Affiliation(s)
| | - Ian T Mark
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Dong Kun Kim
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - John C Benson
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Felix E Diehn
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Narayan R Kissoon
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | - Greta B Liebo
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Michael P Oien
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Carrie M Carr
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
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15
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Mark IT, Madhavan AA, Benson JC, Verdoorn JT, Yu L. Updated ultrafast dynamic computed tomography myelography technique for cerebrospinal fluid leaks. Interv Neuroradiol 2023:15910199231193463. [PMID: 37606552 DOI: 10.1177/15910199231193463] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023] Open
Abstract
We present an updated ultrafast dynamic computed tomography myelography technique that can be used for the localization of spontaneous spinal cerebrospinal fluid leaks in the setting of spontaneous intracranial hypotension. This has over twice the temporal resolution of previously described techniques at the same radiation dose output.
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Affiliation(s)
- Ian T Mark
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - John C Benson
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Lifeng Yu
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
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16
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Welby JP, Madhavan AA, Campeau NG, Eckel LJ, Silvera VM, Guerin JB. Dorsoventral splitting of the infundibulum in a child with pituitary hypoplasia. Radiol Case Rep 2023; 18:2754-2757. [PMID: 37334326 PMCID: PMC10275733 DOI: 10.1016/j.radcr.2023.05.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 05/01/2023] [Accepted: 05/13/2023] [Indexed: 06/20/2023] Open
Abstract
Pituitary development arises from ectodermal tissue creating Rathke's pouch and ultimately the adenohypophysis anteriorly whereas neuroectodermal tissue arising from the diencephalon creates the neurohypophysis posteriorly. Alterations in pituitary development can lead to hormonal dysregulation and dysfunction. Following clinical suspicion of pituitary endocrinopathy, MRI plays a vital role in identifying and characterizing underlying structural abnormalities of the pituitary gland, as well as any associated extrapituitary findings. Here we report a case of an 18-month-old female presenting with short stature and growth hormone deficiency. MRI was notable for a shallow sella turcica, a hypoplastic adenohypophysis, thin pituitary stalk, and ectopic neurohypophysis. Interestingly, the pituitary stalk was noted to split dorsoventrally with a split pituitary bright spot and T1 hypointense lobe hypothesized to represent separation of the posterior pituitary lobes.
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17
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Madhavan AA, Yu L, Brinjikji W, Cutsforth-Gregory JK, Schwartz FR, Mark IT, Benson JC, Amrhein TJ. Utility of Photon-Counting Detector CT Myelography for the Detection of CSF-Venous Fistulas. AJNR Am J Neuroradiol 2023; 44:740-744. [PMID: 37202116 PMCID: PMC10249691 DOI: 10.3174/ajnr.a7887] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 04/26/2023] [Indexed: 05/20/2023]
Abstract
CSF-venous fistulas are an increasingly recognized type of CSF leak that can be particularly challenging to detect, even with recently improved imaging techniques. Currently, most institutions use decubitus digital subtraction myelography or dynamic CT myelography to localize CSF-venous fistulas. Photon-counting detector CT is a relatively recent advancement that has many theoretical benefits, including excellent spatial resolution, high temporal resolution, and spectral imaging capabilities. We describe 6 cases of CSF-venous fistulas detected on decubitus photon-counting detector CT myelography. In 5 of these cases, the CSF-venous fistula was previously occult on decubitus digital subtraction myelography or decubitus dynamic CT myelography using an energy-integrating detector system. All 6 cases exemplify the potential benefits of photon-counting detector CT myelography in identifying CSF-venous fistulas. We suggest that further implementation of this imaging technique will likely be valuable to improve the detection of fistulas that might otherwise be missed with currently used techniques.
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Affiliation(s)
- A A Madhavan
- From the Division of Neuroradiology (A.A.M., L.Y., W.B., I.T.M., J.C.B.)
| | - L Yu
- From the Division of Neuroradiology (A.A.M., L.Y., W.B., I.T.M., J.C.B.)
| | - W Brinjikji
- From the Division of Neuroradiology (A.A.M., L.Y., W.B., I.T.M., J.C.B.)
| | - J K Cutsforth-Gregory
- Department of Radiology and Department of Neurology (J.K.C.-G.), Mayo Clinic, Rochester, Minnesota
| | - F R Schwartz
- Division of Neuroradiology (F.R.S., T.J.A.), Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - I T Mark
- From the Division of Neuroradiology (A.A.M., L.Y., W.B., I.T.M., J.C.B.)
| | - J C Benson
- From the Division of Neuroradiology (A.A.M., L.Y., W.B., I.T.M., J.C.B.)
| | - T J Amrhein
- Division of Neuroradiology (F.R.S., T.J.A.), Department of Radiology, Duke University Medical Center, Durham, North Carolina
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18
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Wagle S, Benson JC, Madhavan AA, Carr CM, Garza I, Diehn FE, Kim DK. The clue is in the kidneys: greater renal contrast medium accumulation on ipsilateral side down CT myelogram after lateral decubitus digital subtraction myelogram as a predictor of laterality of cerebrospinal fluid leak. Clin Radiol 2023:S0009-9260(23)00173-3. [PMID: 37225571 DOI: 10.1016/j.crad.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 03/31/2023] [Accepted: 04/23/2023] [Indexed: 05/26/2023]
Abstract
AIM To assess the potential correlation of the laterality of a cerebrospinal fluid (CSF)-venous fistula with the laterality of decubitus computed tomography (CT) myelogram (post decubitus digital subtraction myelogram) based on which side demonstrated more renal contrast medium excretion. MATERIALS AND METHODS Patients with CSF-venous fistulas diagnosed at lateral decubitus digital subtraction myelograms were reviewed retrospectively. Patients who did not have CT myelogram following one or both left and right lateral decubitus digital subtraction myelograms were excluded. Two neuroradiologists independently interpreted the CT myelogram for the presence or absence of renal contrast, and whether subjectively more renal contrast medium was visualised on the left or right lateral decubitus CT myelogram. RESULTS Renal contrast medium was seen in lateral decubitus CT myelograms in 28 of 30 (93.3%) patients with CSF-venous fistulas. Having more renal contrast medium in right lateral decubitus CT myelogram was 73.9% sensitive and 71.4% specific for the diagnosis of a right-sided CSF-venous fistula, whereas having more renal contrast medium in the left lateral decubitus CT myelogram was 71.4% sensitive and 82.6% specific for a left-sided CSF-venous fistula (p=0.02). CONCLUSION When the CSF-venous fistula lies on the dependent side of a decubitus CT myelogram performed after decubitus digital subtraction myelogram, relatively more renal contrast medium is visualised compared to when the fistula lies on the non-dependent side.
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Affiliation(s)
- S Wagle
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - J C Benson
- Department of Radiology, Mayo Clinic, Rochester, MN, USA.
| | - A A Madhavan
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - C M Carr
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - I Garza
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - F E Diehn
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - D K Kim
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
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19
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Siminski CP, Carr CM, Kallmes DF, Oien MP, Atkinson JLD, Benson JC, Diehn FE, Kim DK, Liebo GB, Lehman VT, Madhavan AA, Mark IT, Morris PP, Shlapak DP, Verdoorn JT, Morris JM. Fluoroscopy- and CT-Guided Gold Fiducial Marker Placement for Intraoperative Localization during Spinal Surgery: Review of 179 Cases at a Single Institution-Technique and Safety Profile. AJNR Am J Neuroradiol 2023; 44:618-622. [PMID: 37080723 PMCID: PMC10171395 DOI: 10.3174/ajnr.a7854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 03/16/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND AND PURPOSE Wrong-level spinal surgery, especially in the thoracic spine, remains a challenge for a variety of reasons related to visualization, such as osteopenia, large body habitus, severe kyphosis, radiographic misinterpretation, or anatomic variation. Preoperative fiducial marker placement performed in a dedicated imaging suite has been proposed to facilitate identification of thoracic spine vertebral levels. In this current study, we report our experience using image-guided percutaneous gold fiducial marker placement to enhance the accuracy and safety of thoracic spinal surgical procedures. MATERIALS AND METHODS A retrospective review was performed of all fluoroscopy- or CT-guided gold fiducial markers placed at our institution between January 3, 2019, and March 16, 2022. A chart review of 179 patients was performed detailing the procedural approach and clinical information. In addition, the method of gold fiducial marker placement (fluoroscopy/CT), procedure duration, spinal level of the gold fiducial marker, radiation dose, fluoroscopy time, surgery date, and complications (including whether wrong-level surgery occurred) were recorded. RESULTS A total of 179 patients (104 female) underwent gold fiducial marker placement. The mean age was 57 years (range, 12-96 years). Fiducial marker placement was performed by 13 different neuroradiologists. All placements were technically successful without complications. All 179 (100%) operations were performed at the correct level. Most fiducial markers (143) were placed with fluoroscopy with the most common location at T6-T8. The most common location for placement in CT was at T3 and T4. CONCLUSIONS All operations guided with gold fiducial markers were performed at the correct level. There were no complications of fiducial marker placement.
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Affiliation(s)
- C P Siminski
- From the Mayo Clinic Alix School of Medicine (C.P.S.)
| | - C M Carr
- Department of Radiology (C.M.C., D.F.K., M.P.O., F.E.D., D.K.K., G.B.L., V.T.L., A.A.M., I.T.M., P.P.M., D.P.S., J.T.V., J.M.M.), Mayo Clinic, Rochester, Minnesota
| | - D F Kallmes
- Department of Radiology (C.M.C., D.F.K., M.P.O., F.E.D., D.K.K., G.B.L., V.T.L., A.A.M., I.T.M., P.P.M., D.P.S., J.T.V., J.M.M.), Mayo Clinic, Rochester, Minnesota
| | - M P Oien
- Department of Radiology (C.M.C., D.F.K., M.P.O., F.E.D., D.K.K., G.B.L., V.T.L., A.A.M., I.T.M., P.P.M., D.P.S., J.T.V., J.M.M.), Mayo Clinic, Rochester, Minnesota
| | - J L D Atkinson
- Department of Neuroradiology (J.L.D.A., J.C.B.), Mayo Clinic, Rochester, Minnesota
| | - J C Benson
- Department of Neuroradiology (J.L.D.A., J.C.B.), Mayo Clinic, Rochester, Minnesota
| | - F E Diehn
- Department of Radiology (C.M.C., D.F.K., M.P.O., F.E.D., D.K.K., G.B.L., V.T.L., A.A.M., I.T.M., P.P.M., D.P.S., J.T.V., J.M.M.), Mayo Clinic, Rochester, Minnesota
| | - D K Kim
- Department of Radiology (C.M.C., D.F.K., M.P.O., F.E.D., D.K.K., G.B.L., V.T.L., A.A.M., I.T.M., P.P.M., D.P.S., J.T.V., J.M.M.), Mayo Clinic, Rochester, Minnesota
| | - G B Liebo
- Department of Radiology (C.M.C., D.F.K., M.P.O., F.E.D., D.K.K., G.B.L., V.T.L., A.A.M., I.T.M., P.P.M., D.P.S., J.T.V., J.M.M.), Mayo Clinic, Rochester, Minnesota
| | - V T Lehman
- Department of Radiology (C.M.C., D.F.K., M.P.O., F.E.D., D.K.K., G.B.L., V.T.L., A.A.M., I.T.M., P.P.M., D.P.S., J.T.V., J.M.M.), Mayo Clinic, Rochester, Minnesota
| | - A A Madhavan
- Department of Radiology (C.M.C., D.F.K., M.P.O., F.E.D., D.K.K., G.B.L., V.T.L., A.A.M., I.T.M., P.P.M., D.P.S., J.T.V., J.M.M.), Mayo Clinic, Rochester, Minnesota
| | - I T Mark
- Department of Radiology (C.M.C., D.F.K., M.P.O., F.E.D., D.K.K., G.B.L., V.T.L., A.A.M., I.T.M., P.P.M., D.P.S., J.T.V., J.M.M.), Mayo Clinic, Rochester, Minnesota
| | - P P Morris
- Department of Radiology (C.M.C., D.F.K., M.P.O., F.E.D., D.K.K., G.B.L., V.T.L., A.A.M., I.T.M., P.P.M., D.P.S., J.T.V., J.M.M.), Mayo Clinic, Rochester, Minnesota
| | - D P Shlapak
- Department of Radiology (C.M.C., D.F.K., M.P.O., F.E.D., D.K.K., G.B.L., V.T.L., A.A.M., I.T.M., P.P.M., D.P.S., J.T.V., J.M.M.), Mayo Clinic, Rochester, Minnesota
| | - J T Verdoorn
- Department of Radiology (C.M.C., D.F.K., M.P.O., F.E.D., D.K.K., G.B.L., V.T.L., A.A.M., I.T.M., P.P.M., D.P.S., J.T.V., J.M.M.), Mayo Clinic, Rochester, Minnesota
| | - J M Morris
- Department of Radiology (C.M.C., D.F.K., M.P.O., F.E.D., D.K.K., G.B.L., V.T.L., A.A.M., I.T.M., P.P.M., D.P.S., J.T.V., J.M.M.), Mayo Clinic, Rochester, Minnesota
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20
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Pradeep A, Madhavan AA, Brinjikji W, Cutsforth-Gregory JK. Incidence of spontaneous intracranial hypotension in Olmsted County, Minnesota: 2019-2021. Interv Neuroradiol 2023:15910199231165429. [PMID: 36945844 DOI: 10.1177/15910199231165429] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND As the myriad clinical and radiographic presentations of spontaneous intracranial hypotension are increasingly recognized, disease prevalence appears to rise. True incidence data remain insufficient. We sought to calculate the incidence of spontaneous intracranial hypotension among the residents of Olmsted County, Minnesota. METHODS Our institution is a quaternary care center for spontaneous intracranial hypotension evaluation and provides primary neurologic care for local residents. All patients who were evaluated at our institution from 2019 to 2021 for spontaneous intracranial hypotension were reviewed, and cases of spontaneous intracranial hypotension with advanced imaging work-up using digital subtraction myelography or dynamic computed tomography myelography were identified. Patients who were residents of Olmsted County were identified. RESULTS Fourteen patients with spontaneous intracranial hypotension were identified in Olmsted County during the study period, all of whom were adults and underwent our institution's standard spontaneous intracranial hypotension work-up. In Olmsted County, the incidence of spontaneous intracranial hypotension was 3.8 per 100,000 adult population, including 3.2 per 100,000 adult females and 2.5 per 100,000 adult males. Seven of 14 patients (50%) had a cerebrospinal fluid-venous fistula. CONCLUSION This study uniquely presents the incidence rate of spontaneous intracranial hypotension in the general population of Olmsted County, Minnesota. Spontaneous intracranial hypotension is more common in women than men and has an overall incidence roughly equivalent to that of aneurysmal subarachnoid hemorrhage in Olmsted County, a widely known neurologic condition. Approximately half the cases of spontaneous intracranial hypotension are due to cerebrospinal fluid-venous fistulas, which generally require specialty expertise for diagnosis and treatment.
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Affiliation(s)
- Aishwarya Pradeep
- Mayo Clinic Alix School of Medicine, 6915Mayo Clinic, Rochester, MN, USA
| | - Ajay A Madhavan
- Division of Neuroradiology, Department of Radiology, 6915Mayo Clinic, Rochester, MN, USA
| | - Waleed Brinjikji
- Division of Neuroradiology, Department of Radiology, 6915Mayo Clinic, Rochester, MN, USA
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21
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Madhavan AA, Cutsforth-Gregory JK, Benson JC, Brinjikji W, Mark IT, Verdoorn JT. Conebeam CT as an Adjunct to Digital Subtraction Myelography for Detection of CSF-Venous Fistulas. AJNR Am J Neuroradiol 2023; 44:347-350. [PMID: 36759140 PMCID: PMC10187817 DOI: 10.3174/ajnr.a7794] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 01/13/2023] [Indexed: 02/11/2023]
Abstract
Lateral decubitus digital subtraction myelography is an effective technique for precisely localizing CSF-venous fistulas, a common cause of spontaneous intracranial hypotension. However, despite an optimal imaging technique, digital subtraction myelography fails to identify some CSF-venous fistulas for a variety of reasons. Here, we describe a technique involving conebeam CT performed during intrathecal contrast injection as an adjunct to digital subtraction myelography, allowing identification of some otherwise-missed CSF-venous fistulas.
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Affiliation(s)
- A A Madhavan
- From the Division of Neuroradiology (A.A.M., J.C.B., W.B., I.T.M., J.T.V.)
| | - J K Cutsforth-Gregory
- Department of Radiology and Department of Neurology (J.K.C.-G.), Mayo Clinic, Rochester, Minnesota
| | - J C Benson
- From the Division of Neuroradiology (A.A.M., J.C.B., W.B., I.T.M., J.T.V.)
| | - W Brinjikji
- From the Division of Neuroradiology (A.A.M., J.C.B., W.B., I.T.M., J.T.V.)
| | - I T Mark
- From the Division of Neuroradiology (A.A.M., J.C.B., W.B., I.T.M., J.T.V.)
| | - J T Verdoorn
- From the Division of Neuroradiology (A.A.M., J.C.B., W.B., I.T.M., J.T.V.)
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22
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Liou H, Diehn FE, Lehman VT, Murthy NS, Carr CM, Madhavan AA, Benson JC, Oien MP, Kim DK. Safety Profile and Technical Success Rate of CT-guided Atlanto-axial Lateral Articulation Injections. Pain Med 2023:7059536. [PMID: 36852864 DOI: 10.1093/pm/pnad029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/27/2022] [Accepted: 01/24/2023] [Indexed: 03/01/2023]
Abstract
OBJECTIVES To describe the technique, safety profile, and outcome of CT-guided atlanto-axial lateral articulation injections performed at our institution. METHODS Consecutive cases of all CT-guided atlanto-axial injections performed from January 2017 to April 2022 at our institution were searched in the electronic medical records. Patient charts were reviewed for demographics, characterization of pain, potential altered anatomy, pain level before and immediately following the procedure, procedure technique, complications, and follow-up outcomes, if available. RESULTS 45 injections in 40 different patients were included. The average age was 67.4 years and 28 (70%) were female. Of the 45 injections, 43 (96%) were technically successful. The average change in pain score (0-10) from immediately before to immediately after the injection was -3.36 (SD = 2.87, range=-8∼+3). Of all injections, 14 (31%) had a post-procedural pain score of zero. In two (4%) cases, patients reported an increase in pain score immediately after the injection. In three (7%) cases, transient non-vertebral artery vascular uptake of contrast was documented during the procedure, which could be cleared with needle repositioning. There were no complications. CONCLUSION CT-guided atlanto-axial lateral articulation injection is a safe procedure with a high technical success rate. It allows for direct visualization of vital structures and provides an alternative option to the traditional fluoroscopic guidance, especially in cases of prior technically unsuccessful fluoroscopically-guided injection or altered anatomy.
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Affiliation(s)
- Harris Liou
- Mayo Clinic Alix School of Medicine, Scottsdale, AZ, 85259
| | - Felix E Diehn
- Department of Radiology, Mayo Clinic, Rochester, MN, 55902
| | - Vance T Lehman
- Department of Radiology, Mayo Clinic, Rochester, MN, 55902
| | | | - Carrie M Carr
- Department of Radiology, Mayo Clinic, Rochester, MN, 55902
| | | | - John C Benson
- Department of Radiology, Mayo Clinic, Rochester, MN, 55902
| | - Michael P Oien
- Department of Radiology, Mayo Clinic, Rochester, MN, 55902
| | - Dong Kun Kim
- Department of Radiology, Mayo Clinic, Rochester, MN, 55902
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23
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Farnsworth PJ, Madhavan AA, Verdoorn JT, Shlapak DP, Johnson DR, Cutsforth-Gregory JK, Brinjikji W, Lehman VT. Spontaneous intracranial hypotension: updates from diagnosis to treatment. Neuroradiology 2023; 65:233-243. [PMID: 36336758 DOI: 10.1007/s00234-022-03079-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 10/26/2022] [Indexed: 11/09/2022]
Abstract
Spontaneous intracranial hypotension (SIH) is caused by spinal cerebrospinal fluid (CSF) leaks, which result in continued loss of CSF volume and multiple debilitating clinical manifestations. The estimated annual incidence of SIH is 5/100,000. Diagnostic methods have evolved in recent years due to improved understanding of pathophysiology and implementation of advanced myelographic techniques. Here, we synthesize recent updates and contextualize them in an algorithm for diagnosis and treatment of SIH, highlighting basic principles and points of practice variability or continued debate. This discussion includes finer points of SIH diagnosis, CSF leak classification systems, less common types and variants of CSF leaks, brain MRI Bern scoring, potential SIH complications, key technical considerations, and positioning strategies for different types of dynamic myelography. The roles of conservative measures, non-targeted or targeted blood patches, surgery, and recently developed endovascular techniques are presented.
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Affiliation(s)
- Paul J Farnsworth
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
| | - Ajay A Madhavan
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Jared T Verdoorn
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Darya P Shlapak
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Derek R Johnson
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.,Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | | | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.,Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | - Vance T Lehman
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
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24
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Nayab A, Malik MH, Madhavan AA, Glockner J, Collins DA, Wenger DE. Incidental diagnosis of presacral ganglioneuroma in a patient with hematuria. Radiol Case Rep 2023; 18:1324-1328. [PMID: 36704366 PMCID: PMC9870923 DOI: 10.1016/j.radcr.2022.11.084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 11/26/2022] [Accepted: 11/29/2022] [Indexed: 01/20/2023] Open
Abstract
Ganglioneuromas are benign neuroblastic tumors seen most in pediatric population. The most common locations are mediastinal, retroperitoneal and adrenal regions. Ganglioneuromas rarely occur in presacral space. We present one such case of an incidentally diagnosed presacral ganglioneuroma in an asymptomatic 71-year-old male who initially presented with hematuria.
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Affiliation(s)
- Asra Nayab
- Corresponding author at: Mayo Clinic, Department of Radiology, 200 1st St SW Rochester MN 55905.
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25
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Benson JC, Madhavan AA, Cutsforth-Gregory JK, Johnson DR, Carr CM. The Monro-Kellie Doctrine: A Review and Call for Revision. AJNR Am J Neuroradiol 2023; 44:2-6. [PMID: 36456084 PMCID: PMC9835920 DOI: 10.3174/ajnr.a7721] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 10/05/2022] [Indexed: 12/05/2022]
Abstract
The Monro-Kellie doctrine is a well-accepted principle of intracranial hemodynamics. It has undergone few consequential revisions since it was established. Its principle is straightforward: The combined volume of neuronal tissue, blood, and CSF is constant. To maintain homeostatic intracranial pressure, any increase or decrease in one of these elements leads to a reciprocal and opposite change in the others. The Monro-Kellie doctrine assumes a rigid, unadaptable calvaria. Recent studies have disproven this assumption. The skull expands and grows in response to pathologic changes in intracranial pressure. In this review, we outline what is known about calvarial changes in the setting of pressure dysregulation and suggest a revision to the Monro-Kellie doctrine that includes an adaptable skull as a fourth component.
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Affiliation(s)
- J C Benson
- From the Departments of Radiology (J.C.B., A.A.M., D.R.J., C.M.C.)
| | - A A Madhavan
- From the Departments of Radiology (J.C.B., A.A.M., D.R.J., C.M.C.)
| | | | - D R Johnson
- From the Departments of Radiology (J.C.B., A.A.M., D.R.J., C.M.C.)
| | - C M Carr
- From the Departments of Radiology (J.C.B., A.A.M., D.R.J., C.M.C.)
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26
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Mark IT, Morris PP, Brinjikji W, Madhavan AA, Cutsforth-Gregory JK, Verdoorn JT. Sacral CSF-Venous Fistulas and Potential Imaging Techniques. AJNR Am J Neuroradiol 2022; 43:1824-1826. [PMID: 36328406 DOI: 10.3174/ajnr.a7699] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 10/05/2022] [Indexed: 11/06/2022]
Abstract
This is the first study to describe CSF-venous fistulas involving the sacrum, a location that may be underrecognized on the basis of current imaging techniques. We describe a delayed decubitus flat CT myelogram technique that may be useful to identify sacral CSF-venous fistulas.
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Affiliation(s)
- I T Mark
- From the Departments of Radiology (I.T.M., P.P.M., W.B., A.A.M., J.T.V.)
| | - P P Morris
- From the Departments of Radiology (I.T.M., P.P.M., W.B., A.A.M., J.T.V.)
| | - W Brinjikji
- From the Departments of Radiology (I.T.M., P.P.M., W.B., A.A.M., J.T.V.)
| | - A A Madhavan
- From the Departments of Radiology (I.T.M., P.P.M., W.B., A.A.M., J.T.V.)
| | | | - J T Verdoorn
- From the Departments of Radiology (I.T.M., P.P.M., W.B., A.A.M., J.T.V.)
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27
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Cogswell PM, Murphy MC, Madhavan AA, Bhatti MT, Cutsforth-Gregory JK, Senjem ML, Huston J, Chen JJ. Features of Idiopathic Intracranial Hypertension on MRI With MR Elastography: Prospective Comparison With Control Individuals and Assessment of Postintervention Changes. AJR Am J Roentgenol 2022; 219:940-951. [PMID: 35822642 PMCID: PMC10481645 DOI: 10.2214/ajr.22.27904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND. Understanding of dynamic changes of MRI findings in response to intracranial pressure (ICP) changes in idiopathic intracranial hypertension (IIH) is limited. Brain stiffness, as assessed by MR elastography (MRE), may reflect changes in ICP. OBJECTIVE. The purpose of this study was to compare pituitary height, ventricular size, and brain stiffness between patients with IIH and control individuals and to evaluate for changes in these findings in patients with IIH after interventions to reduce ICP. METHODS. This prospective study included 30 patients (28 women, two men; median age, 29.9 years) with IIH and papilledema and 21 control individuals (21 women, 0 men; median age, 29.1 years), recruited from January 2017 to July 2019. All participants underwent 3-T brain MRI with MRE; patients with IIH underwent additional MRI examinations with MRE after acute intervention (lumbar puncture with normal closing pressure; n = 11) and/or chronic intervention (medical management or venous sinus stenting with resolution or substantial reduction in papilledema; n = 12). Pituitary height was measured on sagittal MP-RAGE images. Ventricular volumes were estimated using unified segmentation, and postintervention changes were assessed by tensor-based morphometry. Stiffness pattern score and regional stiffness values were estimated from MRE. RESULTS. In patients with IIH, median pituitary height was smaller than in control individuals (3.1 vs 4.9 mm, p < .001) and was increased after chronic (4.0 mm, p = .05), but not acute (2.3 mm, p = .50), intervention. Ventricular volume was not different between patients with IIH and control individuals (p = .33) and did not change after acute (p = .83) or chronic (p = .97) intervention. In patients with IIH, median stiffness pattern score was greater than in control individuals (0.25 vs 0.15, p < .001) and decreased after chronic (0.23, p = .11) but not acute (0.25, p = .49) intervention. Median occipital lobe stiffness was 3.08 kPa in patients with IIH versus 2.94 kPa in control individuals (p = .07) and did not change after acute (3.24 kPa, p = .73) or chronic (3.10 kPa, p = .83) intervention. CONCLUSION. IIH is associated with a small pituitary and increased brain stiffness pattern score; both findings may respond to chronic interventions to lower ICP. CLINICAL IMPACT. The "partially empty sella" sign and brain stiffness pattern score may serve as dynamic markers of ICP in IIH.
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Affiliation(s)
- Petrice M Cogswell
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Matthew C Murphy
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Ajay A Madhavan
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - M Tariq Bhatti
- Department of Neurology, Mayo Clinic, Rochester, MN
- Department of Ophthalmology, Mayo Clinic, Rochester, MN
| | | | - Matthew L Senjem
- Department of Information Technology, Mayo Clinic, Rochester, MN
| | - John Huston
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - John J Chen
- Department of Neurology, Mayo Clinic, Rochester, MN
- Department of Ophthalmology, Mayo Clinic, Rochester, MN
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28
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Madhavan AA, Benson JC, Cutsforth-Gregory JK, Atkinson JD, Carr CM. Co-existing fast CSF leaks and CSF-venous fistulas on dynamic CT myelography. Radiol Case Rep 2022; 17:2968-2971. [PMID: 35755098 PMCID: PMC9218289 DOI: 10.1016/j.radcr.2022.05.053] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 05/21/2022] [Indexed: 11/21/2022] Open
Abstract
Spontaneous intracranial hypotension can be caused by spinal dural tears or CSF-venous fistulas. It is rare for patients to have more than one type of leak at any given time. Here, we illustrate 3 examples of dural tears that co-existed with CSF-venous fistulas, with both being seen on dynamic CT myelography. To our knowledge, coexistent CSF-venous fistulas and dural tears have not been previously illustrated on dynamic CT myelography, even though this is one of the most commonly used modalities to work-up patients with CSF leaks. We discuss the clinical importance of the rare co-occurrence of these leaks with regard to diagnosis and treatment, as well as implications for understanding and classifying CSF leaks.
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29
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Carr CM, Benson JC, DeLone DR, Diehn FE, Kim DK, Ma D, Nagelschneider AA, Madhavan AA, Johnson DR. Manifestations of radiation toxicity in the head, neck, and spine: An image-based review. Neuroradiol J 2022; 35:427-436. [PMID: 35499087 PMCID: PMC9437506 DOI: 10.1177/19714009221096824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND AND PURPOSE Radiation therapy is an important component of treatment in patients with malignancies of the head, neck, and spine. However, radiation to these regions has well-known potential side effects, many of which can be encountered on imaging. In this manuscript, we review selected radiographic manifestations of therapeutic radiation to the head, neck, and spine that may be encountered in the practice of radiology. METHODS We conducted an extensive literature review of known complications of radiation therapy in the head, neck, and spine. We excluded intracranial and pulmonary radiation effects from our search. We selected complications that had salient, recognizable imaging findings. We searched our imaging database for illustrative examples of these complications. RESULTS Based on our initial literature search and imaging database review, we selected cases of radiation-induced tumors, radiation tissue necrosis (osteoradionecrosis and soft tissue necrosis), carotid stenosis and blowout secondary to radiation, enlarging thyroglossal duct cysts, radiation myelopathy, and radiation-induced vertebral compression fractures. CONCLUSIONS We describe the clinical and imaging features of selected sequelae of radiation therapy to the head, neck, and spine, with a focus on those with characteristic imaging findings that can be instrumental in helping to make the diagnosis. Knowledge of these entities and their imaging findings is crucial for accurate diagnosis. Not only do radiologists play a key role in early detection of these entities, but many of these entities can be misinterpreted if one is not familiar with them.
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Affiliation(s)
- Carrie M Carr
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - John C Benson
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - David R DeLone
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Felix E Diehn
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Dong K Kim
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Daniel Ma
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
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30
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Madhavan AA, Cutsforth-Gregory JK, Oushy SH, Borg N, Brinjikji W. Combined CSF-venous Fistula and middle meningeal artery embolization for treatment of spontaneous intracranial hypotension. Interv Neuroradiol 2022:15910199221109044. [PMID: 35712963 DOI: 10.1177/15910199221109044] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Transvenous Onyx embolization was recently described as an effective treatment of spontaneous intracranial hypotension caused by CSF-venous fistulas. Patients with CSF-venous fistulas can present with a wide spectrum of clinical and imaging findings, sometimes including spontaneous subdural hematomas, subdural hygromas, or a combination of both. Here, we describe four patients with spontaneous intracranial hypotension complicated by subdural fluid collections caused by CSF-venous fistulas. The patients were treated with transvenous Onyx embolization of their CSF-venous fistulas and transarterial particle embolization of the bilateral middle meningeal arteries, with both procedures performed in a single treatment session. All four patients had clinical improvement and decreased size or resolution of their subdural fluid collections. Based on our findings, we believe that middle meningeal embolization could be a useful adjunct to CSF-venous fistula embolization. A case-control study comparing patients who did or did not undergo middle meningeal embolization will be necessary to validate this supposition.
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Affiliation(s)
- Ajay A Madhavan
- Division of Neuroradiology, Department of Radiology, 6915Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | | | - Soliman H Oushy
- Department of Neurosurgery, 6915Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Nicholas Borg
- Department of Neurosurgery, 6915Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
| | - Waleed Brinjikji
- Division of Neuroradiology, Department of Radiology, 6915Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
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31
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Madhavan AA, Verdoorn JT, Shlapak DP, Pope MC, Benson JC, Diehn FE, Liebo GB, Lehman VT, Kim DK, Oien MP, Cutsforth-Gregory JK, Carr CM. Lateral decubitus dynamic CT myelography for fast cerebrospinal fluid leak localization. Neuroradiology 2022; 64:1897-1903. [PMID: 35614322 DOI: 10.1007/s00234-022-02985-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 05/18/2022] [Indexed: 11/29/2022]
Abstract
Dynamic CT myelography is used to precisely localize fast spinal CSF leaks. The procedure is most commonly performed in the prone position, which successfully localizes most fast ventral leaks. We have recently encountered a small subset of patients in whom prone dynamic CT myelography is unsuccessful in localizing leaks. We sought to determine the added value of lateral decubitus dynamic CT myelography, which is occasionally attempted in our practice, in localizing the leak after failed prone dynamic CT myelography. We retrospectively identified 6 patients who underwent lateral decubitus dynamic CT myelography, which was performed in each case because their prone dynamic CT myelogram was unrevealing. Two neuroradiologists independently reviewed preprocedural spine MRI and all dynamic CT myelograms for each patient. Lateral decubitus positioning allowed for precise leak localization in all 6 patients. Five of six patients were noted to have dorsal and/or lateral epidural fluid collections on spine MRI. One patient had a single prominent diverticulum on spine MRI (larger than 6 mm), whereas the others had no prominent diverticula. Our study suggests that institutions performing dynamic CT myelography to localize fast leaks should consider a lateral decubitus study if performing the study in the prone position is unrevealing. Furthermore, the presence of dorsal and/or lateral epidural fluid collections on spine MRI may suggest that a lateral decubitus study is of higher yield and could be considered initially.
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Affiliation(s)
- Ajay A Madhavan
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
| | - Jared T Verdoorn
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Darya P Shlapak
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Matt C Pope
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - John C Benson
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Felix E Diehn
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Greta B Liebo
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Vance T Lehman
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Dong Kun Kim
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Michael P Oien
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | | | - Carrie M Carr
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
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Tiegs-Heiden CA, Madhavan AA, Diehn FE, Lehman VT, Murthy NS. Injection into the Space of Okada during Transforaminal Epidural Steroid Injections. Pain Med 2022; 23:1066-1074. [PMID: 35021225 DOI: 10.1093/pm/pnac008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 12/21/2021] [Accepted: 12/25/2021] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Ensuring medication delivery to the epidural space is crucial for effective transforaminal epidural steroid injections, done by injecting a small amount of contrast at final needle position. The purpose of this study is to illustrate the appearance of contrast flow in the retrodural retroligamentous space of Okada during CT- and fluoroscopically-guided cervical and lumbar transforaminal epidural steroid injections. DESIGN This retrospective study will utilize a series of cases to demonstrate contrast within the space of Okada during epidural transforaminal steroid injections. SETTING Tertiary medical center. SUBJECTS Study subjects are adult patients who underwent transforaminal epidural steroid injection at our institution. METHODS Cases were identified utilizing a search engine of existing radiology reports at our institution. Epidural steroid injection procedural reports were searched for the terms "Okada" and "retrodural space." Images from the procedure were reviewed by the authors, all proceduralists with dedicated training in spinal injections, to confirm the presence of contrast within the space of Okada. RESULTS This case series illustrates six examples of contrast injection into the retrodural space of Okada during cervical and lumbar transforaminal epidural steroid injections. CONCLUSIONS Contrast uptake in the retrodural space of Okada may be seen during transforaminal epidural injections. Although relatively uncommon, this is likely underrecognized. It is extremely important that providers who perform transforaminal epidural steroid injections be familiar with this non-epidural contrast flow pattern so that they can adjust needle positioning in order to deliver steroid to the epidural space.
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Majed M, Madhavan AA, Pittock SJ, Dubey D. "Hot Cross Bun" Sign in a Patient With Kelch-like Protein 11 Rhombencephalitis. Mayo Clin Proc 2022; 97:122-123. [PMID: 34996544 DOI: 10.1016/j.mayocp.2021.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 11/15/2021] [Indexed: 10/19/2022]
Affiliation(s)
| | | | - Sean J Pittock
- Department of Neurology; Department of Laboratory Medicine and Pathology
| | - Divyanshu Dubey
- Department of Neurology; Department of Laboratory Medicine and Pathology
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Madhavan AA, Wood CP, Aksamit AJ, Schwartz KM, Atkinson JL, Kumar N. Superficial siderosis associated with an iatrogenic posterior fossa dural leak identified on CT cisternography. Neuroradiol J 2021; 35:403-407. [PMID: 34477007 DOI: 10.1177/19714009211042875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Superficial siderosis refers to hemosiderin deposition along the pial surface of the brain and spinal cord. It results from chronic and repetitive low-grade bleeding into the subarachnoid space. Dural tears are a common cause of superficial siderosis. Although such tears typically occur in the spine, dural tears can also occur in the posterior fossa. In many cases, posterior fossa dural tears are iatrogenic, and patients may present with neuroimaging evidence of postoperative pseudomeningoceles. We present a case of superficial siderosis caused by a persistent posterior fossa dural leak. The patient presented with superficial siderosis 30 years after a Chiari I malformation repair. A pinhole-sized dural tear was identified preoperatively using computed tomography cisternography. The dural defect was successfully repaired. An additional small tear that was not seen on imaging was also identified at surgery and successfully repaired.
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Madhavan AA, Carr CM, Benson JC, Brinjikji W, Diehn FE, Kim DK, Lehman VT, Liebo GB, Morris PP, Shlapak DP, Verdoorn JT, Morris JM. Diagnostic Yield of Intrathecal Gadolinium MR Myelography for CSF Leak Localization. Clin Neuroradiol 2021; 32:537-545. [PMID: 34292360 DOI: 10.1007/s00062-021-01060-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 06/23/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Intrathecal gadolinium magnetic resonance (MR) myelography can be used to localize various types of spinal cerebrospinal fluid (CSF) leaks; however, its diagnostic yield is not well known. We sought to determine the diagnostic yield of MR myelography in patients with spontaneous intracranial hypotension. METHODS A retrospective review was performed on all patients who had undergone intrathecal gadolinium MR myelography at our institution from 2002 to 2020 for suspected spinal CSF leak. The MR myelography images were reviewed for the presence or absence of a spinal CSF leak site. Images were also evaluated for the presence an extradural fluid collection. RESULTS A total of 97 patients were included in the final cohort. The average age was 52.6 years; 67.0% were female, 4 patients underwent 2 examinations each, yielding a total of 101 MR myelograms. The source of a spinal CSF leak was localized in 14 patients. The diagnostic yield for CSF leak localization on intrathecal gadolinium MR myelography was 14/101 (13.9%) per GdM examination and 14/97 (14.4%) per patient. Among the subset of patients without extradural fluid collections, the yield was 15.7% per examination. All detected leaks were either CSF-venous fistulas or distal nerve root sleeve tears. CONCLUSION Intrathecal gadolinium MR myelography is capable of localizing CSF-venous fistulas and distal nerve root sleeve tears; however, our data show that it has a limited diagnostic yield. We suggest that other modalities may be a better first step before attempting intrathecal gadolinium MR myelography.
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Affiliation(s)
- Ajay A Madhavan
- Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA.
| | - Carrie M Carr
- Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA
| | - John C Benson
- Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA
| | - Felix E Diehn
- Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA
| | - Dong Kun Kim
- Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA
| | - Vance T Lehman
- Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA
| | - Greta B Liebo
- Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA
| | - Pearse P Morris
- Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA
| | - Darya P Shlapak
- Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA
| | - Jared T Verdoorn
- Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA
| | - Jonathan M Morris
- Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA
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Madhavan AA, Eckel LJ, Carr CM, Diehn FE, Lehman VT. Subdural spinal metastases detected on CT myelography: A case report and brief review. Radiol Case Rep 2021; 16:1499-1503. [PMID: 33981371 PMCID: PMC8082046 DOI: 10.1016/j.radcr.2021.03.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/12/2021] [Accepted: 03/13/2021] [Indexed: 11/26/2022] Open
Abstract
Spinal metastases are most commonly osseous and may extend to the epidural space. Less commonly, spinal metastases can be subdural, leptomeningeal, or intramedullary. Among these, subdural metastases are the most rare, with few reported cases. While these lesions are now almost exclusively detected on MRI, they can rarely be apparent on other modalities. It is important to recognize subdural metastases on any modality, because they have a significant impact on patient prognosis and treatment. We report a case of renal cell carcinoma in a 68-year-old male initially presenting with subdural metastases detected on CT myelography, with subsequent confirmation by MRI. The case illustrates, to our knowledge, the first example of subdural metastatic disease seen on CT myelography.
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Carr CM, Benson JC, DeLone DR, Diehn FE, Kim DK, Merrell KW, Nagelschneider AA, Madhavan AA, Johnson DR. Intracranial long-term complications of radiation therapy: an image-based review. Neuroradiology 2021; 63:471-482. [PMID: 33392738 DOI: 10.1007/s00234-020-02621-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 12/08/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Radiation therapy is commonly utilized in the majority of solid cancers and many hematologic malignancies and other disorders. While it has an undeniably major role in improving cancer survival, radiation therapy has long been recognized to have various negative effects, ranging from mild to severe. In this manuscript, we review several intracranial manifestations of therapeutic radiation, with particular attention to those that may be encountered by radiologists. METHODS We conducted an extensive literature review of known complications of intracranial radiation therapy. Based on this review, we selected complications that had salient, recognizable imaging findings. We searched our imaging database for illustrative examples of these complications, focusing only on patients who had a history of intracranial radiation therapy. We then selected cases that best exemplified expected imaging findings in these entities. RESULTS Based on our initial literature search and imaging database review, we selected cases of radiation-induced meningioma, radiation-induced glioma, cavernous malformation, enlarging perivascular spaces, leukoencephalopathy, stroke-like migraine after radiation therapy, Moyamoya syndrome, radiation necrosis, radiation-induced labyrinthitis, optic neuropathy, and retinopathy. Although retinopathy is not typically apparent on imaging, it has been included given its clinical overlap with optic neuropathy. CONCLUSIONS We describe the clinical and imaging features of selected sequelae of intracranial radiation therapy, with a focus on those most relevant to practicing radiologists. Knowledge of these complications and their imaging findings is important, because radiologists play a key role in early detection of these entities.
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Affiliation(s)
- Carrie M Carr
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - John C Benson
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - David R DeLone
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Felix E Diehn
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Dong Kun Kim
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | | | - Alex A Nagelschneider
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Ajay A Madhavan
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Derek R Johnson
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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Madhavan AA, Rinaldo L, Arce K, Brinjikji W. Hypervascular mucoepidermoid caricinoma of the palate. Stomatologija 2021; 23:22-25. [PMID: 34528904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Salivary mucoepidermoid carcinoma is the most common malignant salivary gland tumor. Low or intermediate grade tumors are slow-growing and can be mistaken for benign lesions on both physical exam and imaging studies. We present a case of hypervascular mucoepidermoid carcinoma of the hard palate that was initially thought to represent a benign vascular lesion. To our knowledge, only two prior cases of hypervascular mucoepidermoid carcinoma have been previously reported. This is the first case showing the MRI features of this tumor and its temporal evolution on CT over several years. Our patient ultimately underwent angiographic tumor embolization so that her lesion could be safely biopsied without significant bleeding risk. We present this as a potential diagnostic pitfall and explain how the treatment for hypervascular mucoepidermoid carcinoma varies compared to conventional tumors.
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Affiliation(s)
- Ajay A Madhavan
- Department of Radiology, Mayo 200 First St SW, Rochester, MN 55905, USA.
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McKeon A, Shelly S, Zivelonghi C, Basal E, Dubey D, Flanagan E, Madhavan AA, Mariotto S, Toledano M, Tracy JA, Zekeridou A, Pittock SJ. Neuronal intermediate filament IgGs in CSF: Autoimmune Axonopathy Biomarkers. Ann Clin Transl Neurol 2020; 8:425-439. [PMID: 33369283 PMCID: PMC7886032 DOI: 10.1002/acn3.51284] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 10/26/2020] [Accepted: 12/06/2020] [Indexed: 12/03/2022] Open
Abstract
Objectives To describe CSF‐defined neuronal intermediate filament (NIF) autoimmunity. Methods NIF‐IgG CSF‐positive patients (41, 0.03% of 118599 tested, 1996–2019) were included (serum was neither sensitive nor specific). Criteria‐based patient NIF‐IgG staining of brain and myenteric NIFs was detected by indirect immunofluorescence assay (IFA); NIF‐specificity was confirmed by cell‐based assays (CBAs, alpha internexin, neurofilament light [NF‐L]), heavy‐[NF‐H] chain). Results Sixty‐one percent of 41 patients were men, median age, 61 years (range, 21–88). Syndromes were encephalopathy predominant (23), cerebellar ataxia predominant (11), or myeloradiculoneuropathies (7). MRI abnormalities (T2 hyperintensities of brain, spinal cord white matter tracts. and peripheral nerve axons) and neurophysiologic testing (EEG, EMG, evoked potentials) co‐localized with clinical neurological phenotypes (multifocal in 29%). Thirty patients (73%) had ≥ 1 immunological perturbation: cancer (paraneoplastic), 22; systemic infection (parainfectious [including ehrlichosis, 3] or HIV), 7; checkpoint‐inhibitor cancer immunotherapy, 4; other, 5. Cancers were as follows: neuroendocrine‐lineage carcinomas, 12 (small cell, 6; Merkel cell, 5; pancreatic, 1 [11/12 had NF‐L‐IgG detected, versus 8/29 others, P = 0.0005]) and other, 11. Onset was predominantly subacute (92%) and accompanied by inflammatory CSF (75%), and immunotherapy response (77%). In contrast, CSF controls (15684 total) demonstrated NIF‐IgG negativity (100% of test validation controls), and low frequencies of autoimmune diagnoses (20% of consecutively referred clinical specimens) and neuroendocrine‐lineage carcinoma diagnosis (3.1% vs. 30% of NIF cases), P < 0.0001. Median NF‐L protein concentration was higher in 8 NF‐L‐IgG‐positive patients (median, 6718 ng/L) than 16 controls. Interpretation Neurological autoimmunity, defined by CSF‐detected NIF‐IgGs, represents a continuum of treatable axonopathies, sometimes paraneoplastic or parainfectious.
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Affiliation(s)
- Andrew McKeon
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Shahar Shelly
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Cecilia Zivelonghi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.,Neurology Unit, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Eati Basal
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Divyanshu Dubey
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Eoin Flanagan
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ajay A Madhavan
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sara Mariotto
- Neurology Unit, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Michel Toledano
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Anastasia Zekeridou
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sean J Pittock
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
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Madhavan AA, McDonald RJ, Diehn FE, Carr CM, Verdoorn JT. Giant torus mandibularis causing submandibular duct obstruction and sialadenitis. Neuroradiol J 2020; 34:249-252. [PMID: 33307982 DOI: 10.1177/1971400920978431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Torus mandibularis is a benign osseous overgrowth arising from the lingual surface of the mandible. It is a common, incidental finding on imaging due to its relatively high prevalence. In the majority of cases, mandibular tori are asymptomatic. We report a novel presentation of a giant torus mandibularis causing bilateral obstruction of the submandibular ducts and consequent sialadenitis. Our patient presented with progressive pain centered in the floor of his mouth and had bilateral submandibular glandular enlargement on exam. Computed tomography showed a giant right torus mandibularis, which was causing obstruction and dilation of the bilateral submandibular ducts. Although conservative management was attempted, he ultimately underwent surgical resection of his torus with symptomatic improvement. This patient highlights a novel complication of torus mandibularis and illustrates successful treatment. Though not previously described, this complication may be underreported and should be considered in the appropriate clinical setting.
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Affiliation(s)
| | | | | | | | - Jared T Verdoorn
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, USA
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Affiliation(s)
- Ajay A Madhavan
- From the Departments of Radiology (A.A.M., C.M.C.), Hematology and Oncology (H.A.), and Neurology (N.P.S., E.N.), Mayo Clinic, Rochester, MN
| | - Carrie M Carr
- From the Departments of Radiology (A.A.M., C.M.C.), Hematology and Oncology (H.A.), and Neurology (N.P.S., E.N.), Mayo Clinic, Rochester, MN
| | - Hassan Alkhateeb
- From the Departments of Radiology (A.A.M., C.M.C.), Hematology and Oncology (H.A.), and Neurology (N.P.S., E.N.), Mayo Clinic, Rochester, MN
| | - Nathan P Staff
- From the Departments of Radiology (A.A.M., C.M.C.), Hematology and Oncology (H.A.), and Neurology (N.P.S., E.N.), Mayo Clinic, Rochester, MN
| | - Elie Naddaf
- From the Departments of Radiology (A.A.M., C.M.C.), Hematology and Oncology (H.A.), and Neurology (N.P.S., E.N.), Mayo Clinic, Rochester, MN.
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Madhavan AA, Carr CM, Morris PP, Flanagan EP, Kotsenas AL, Hunt CH, Eckel LJ, Lindell EP, Diehn FE. Imaging Review of Paraneoplastic Neurologic Syndromes. AJNR Am J Neuroradiol 2020; 41:2176-2187. [PMID: 33093137 DOI: 10.3174/ajnr.a6815] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 06/29/2020] [Indexed: 12/19/2022]
Abstract
Paraneoplastic syndromes are systemic reactions to neoplasms mediated by immunologic or hormonal mechanisms. The most well-recognized paraneoplastic neurologic syndrome, both clinically and on imaging, is limbic encephalitis. However, numerous additional clinically described syndromes affect the brain, spinal cord, and peripheral nerves. Many of these syndromes can have imaging findings that, though less well described, are important in making the correct diagnosis. Moreover, imaging in these syndromes frequently mimics more common pathology, which can be a diagnostic challenge for radiologists. Our goal is to review the imaging findings of paraneoplastic neurologic syndromes, including less well-known entities and atypical presentations of common entities. Specifically, we discuss limbic encephalitis, paraneoplastic cerebellar degeneration, paraneoplastic brain stem encephalitis, cranial neuropathy, myelitis, and polyneuropathy. We also demonstrate common diagnostic pitfalls that can be encountered when imaging these patients.
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Affiliation(s)
- A A Madhavan
- From the Division of Neuroradiology, Department of Radiology (A.A.M., C.M.C., P.P.M., A.L.K., C.H.H., L.J.E., E.P.L., F.E.D.)
| | - C M Carr
- From the Division of Neuroradiology, Department of Radiology (A.A.M., C.M.C., P.P.M., A.L.K., C.H.H., L.J.E., E.P.L., F.E.D.)
| | - P P Morris
- From the Division of Neuroradiology, Department of Radiology (A.A.M., C.M.C., P.P.M., A.L.K., C.H.H., L.J.E., E.P.L., F.E.D.)
| | - E P Flanagan
- Department of Neurology (E.P.F.), Mayo Clinic, Rochester, Minnesota
| | - A L Kotsenas
- From the Division of Neuroradiology, Department of Radiology (A.A.M., C.M.C., P.P.M., A.L.K., C.H.H., L.J.E., E.P.L., F.E.D.)
| | - C H Hunt
- From the Division of Neuroradiology, Department of Radiology (A.A.M., C.M.C., P.P.M., A.L.K., C.H.H., L.J.E., E.P.L., F.E.D.)
| | - L J Eckel
- From the Division of Neuroradiology, Department of Radiology (A.A.M., C.M.C., P.P.M., A.L.K., C.H.H., L.J.E., E.P.L., F.E.D.)
| | - E P Lindell
- From the Division of Neuroradiology, Department of Radiology (A.A.M., C.M.C., P.P.M., A.L.K., C.H.H., L.J.E., E.P.L., F.E.D.)
| | - F E Diehn
- From the Division of Neuroradiology, Department of Radiology (A.A.M., C.M.C., P.P.M., A.L.K., C.H.H., L.J.E., E.P.L., F.E.D.)
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Abstract
Tolosa–Hunt syndrome is characterized by unilateral retro-orbital headaches and cranial nerve palsies, usually involving cranial nerves III–VI. It is rare for other cranial nerves to be involved, although this has previously been reported. We report a 19-year-old woman presenting with typical features of Tolosa–Hunt syndrome but ultimately developing bilateral facial nerve palsies and enhancement of both facial nerves on magnetic resonance imaging. The patient presented with unilateral retro-orbital headaches and palsies of cranial nerves III–VI. She was diagnosed with Tolosa–Hunt syndrome but was non-compliant with her corticosteroid treatment due to side effects. She returned with progressive left followed by right facial nerve palsy. Her corresponding follow-up magnetic resonance imaging scans showed sequential enhancement of the left and right facial nerves. She ultimately had clinical improvement with IV methylprednisolone. To our knowledge, Tolosa–Hunt syndrome associated with bilateral facial nerve palsy and corroborative facial nerve enhancement on magnetic resonance imaging has not previously been described. Moreover, our patient’s clinical course is instructive, as it demonstrates that this atypical presentation of Tolosa–Hunt syndrome can indeed respond to corticosteroid treatment and should not be mistaken for other entities such as Bell’s palsy.
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Madhavan AA, Diehn FE, Rykken JB, Wald JT, Wood CP, Schwartz KM, Kaufmann TJ, Hunt CH, Kim DK, Eckel LJ. The Central Dot Sign : A Specific Post-gadolinium Enhancement Feature of Intramedullary Spinal Cord Metastases. Clin Neuroradiol 2020; 31:383-390. [PMID: 32382876 DOI: 10.1007/s00062-020-00909-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 04/17/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE Peripheral enhancement characteristics on magnetic resonance imaging (MRI), namely the rim and flame signs, are specific for intramedullary spinal cord metastases (ISCM) compared to primary cord masses. The study compared the frequency of a novel finding-the central dot sign-in ISCMs versus primary intramedullary masses. METHODS In this study 45 patients with 64 ISCMs and 64 control patients with 64 primary intramedullary cord masses were investigated and 2 radiologists blinded to lesion type independently evaluated MR images for the presence of a central dot sign: a punctate focus of enhancement in/near the center of an enhancing intramedullary mass. The frequency of this sign in the two patient groups was compared. RESULTS A total of 63 enhancing ISCMs in 44 patients and 54 enhancing primary cord masses in 54 patients were included. The central dot sign was identified in 6% (4/63) of enhancing ISCMs in 9% (4/44) of patients and in none (0/54) of the enhancing primary cord masses (p = 0.038, per patient). The specificity for diagnosing ISCMs among spinal cord masses was 100%. The central dot sign was present in the axial plane only in two ISCMs and in the axial and sagittal planes in two ISCMs. The two ISCMs harboring the central dot sign also demonstrated both the previously described rim and flame signs, and two also demonstrated the rim sign alone. CONCLUSION The central dot sign is not sensitive but highly specific for ISCMs compared to primary spinal cord masses. The rim and/or flame signs may or may not be concurrently present in ISCMs.
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Affiliation(s)
- Ajay A Madhavan
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA.
| | - Felix E Diehn
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA
| | - Jeffrey B Rykken
- Division of Neuroradiology, Department of Radiology, University of Minnesota, 420 Delaware St SE, MN 55455, Minneapolis, USA
| | - John T Wald
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA
| | - Chris P Wood
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA
| | - Kara M Schwartz
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA
| | - Timothy J Kaufmann
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA
| | - Christopher H Hunt
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA
| | - Dong Kun Kim
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA
| | - Laurence J Eckel
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, 200 First St SW, MN 55905, Rochester, USA
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Madhavan AA, Guerin JB, Eckel LJ, Lehman VT, Carr CM. Dorsal cauda equina nerve root enhancement on magnetic resonance imaging due to ANNA-1-associated paraneoplastic polyneuropathy. Neuroradiol J 2020; 33:443-447. [PMID: 32290766 DOI: 10.1177/1971400920919689] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
A 69-year-old female presented with subacute onset ascending weakness and paraesthesias. She was initially diagnosed with Guillain-Barré syndrome (GBS) based on her clinical presentation and cerebrospinal fluid (CSF) analysis showing albuminocytological dissociation. However, she was later found to have anti-neuronal nuclear antibody 1 (ANNA-1/anti-Hu)-positive CSF and was subsequently diagnosed with small-cell lung cancer. Her neurological symptoms were ultimately attributed to ANNA-1/anti-Hu-associated paraneoplastic polyneuropathy. During the course of her evaluation, she had magnetic resonance imaging findings of dorsal predominant cauda equina nerve root enhancement, which has not been previously described. The only previously reported case of cauda equina enhancement due to ANNA-1-associated polyneuropathy described ventral predominant findings. The distinction between ventral and dorsal enhancement is important, since it suggests that different patterns of nerve root involvement may be associated with this paraneoplastic syndrome. Therefore, ANNA-1-associated paraneoplastic inflammatory polyneuropathy can be considered in the differential diagnosis of cauda equina nerve root enhancement with ventral and/or dorsal predominance. This can potentially be helpful in differentiating ANNA-1 polyneuropathy from GBS, which classically has ventral predominant enhancement.
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Affiliation(s)
- Ajay A Madhavan
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, USA
| | - Julie B Guerin
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, USA
| | - Laurence J Eckel
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, USA
| | - Vance T Lehman
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, USA
| | - Carrie M Carr
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, USA
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Madhavan AA, Kim DK, Brinjikji W, Atkinson J, Carr CM. Diagnosis of a Cerebrospinal Fluid–Venous Fistula Associated with a Venous Malformation Using Digital Subtraction and Computed Tomography Myelography. World Neurosurg 2020; 135:262-266. [DOI: 10.1016/j.wneu.2019.12.075] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 12/11/2019] [Accepted: 12/12/2019] [Indexed: 10/25/2022]
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Madhavan AA, Summerfield D, Hunt CH, Kim DK, Krecke KN, Raghunathan A, Benson JC. Polyclonal lymphocytic infiltrate with arachnoiditis resulting from intrathecal stem cell transplantation. Neuroradiol J 2020; 33:174-178. [PMID: 32013747 DOI: 10.1177/1971400920902451] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Stem cell treatment outside of studied and approved medical indications can have unforeseen adverse consequences. Here, we present a 74-year-old male that underwent such therapy. The patient presented to our institution with progressive lower extremity weakness and urinary incontinence. He had previously undergone intrathecal stem cell therapy in Moscow, Russia for weakness and fatigue. Magnetic resonance imaging of his thoracic and lumbar spine showed marked enlargement of the cauda equina nerve roots and abnormal mass-like soft tissue involving the thoracolumbar thecal sac. Surgical biopsy of the intrathecal soft tissue showed polyclonal lymphocytic and glial cell proliferation. The patient's symptoms did not improve with medical treatment or radiation, and he is currently under observation after multidisciplinary evaluation. Our patient's experience illustrates one of the potential risks of "stem cell tourism" and exemplifies the imaging and histopathologic features of this rare entity. We also compare our patient's treatment with other similar examples of stem cell treatments in our institution and others. These have had a wide spectrum of results. In some instances, intrathecal stem cells have caused abnormal imaging findings without any associated patient symptoms. In extreme examples, however, stem cell treatments have resulted in central nervous system neoplasms. Our patient's lesion is quite unique, with only one similar lesion having been previously published.
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Affiliation(s)
- Ajay A Madhavan
- Mayo Clinic, Department of Radiology, Division of Neuroradiology, Rochester, MN USA
| | - Dan Summerfield
- Mayo Clinic, Department of Laboratory Medicine and Pathology, Rochester, MN USA
| | - Christopher H Hunt
- Mayo Clinic, Department of Radiology, Division of Neuroradiology, Rochester, MN USA
| | - Dong K Kim
- Mayo Clinic, Department of Radiology, Division of Neuroradiology, Rochester, MN USA
| | - Karl N Krecke
- Mayo Clinic, Department of Radiology, Division of Neuroradiology, Rochester, MN USA
| | - Aditya Raghunathan
- Mayo Clinic, Department of Laboratory Medicine and Pathology, Rochester, MN USA
| | - John C Benson
- Mayo Clinic, Department of Radiology, Division of Neuroradiology, Rochester, MN USA
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Madhavan AA, Carr CM, Carlson ML, Lane JI. Imaging Findings Related to the Valsalva Maneuver in Head and Neck Radiology. AJNR Am J Neuroradiol 2019; 40:1987-1993. [PMID: 31727744 DOI: 10.3174/ajnr.a6309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 09/23/2019] [Indexed: 11/07/2022]
Abstract
Forced exhalation against a closed glottis, known as the Valsalva maneuver, is an important clinical diagnostic and therapeutic tool due to its physiologic effects. Several unique conditions and anatomic changes can occur with repetitive or acute changes in pressure from the Valsalva maneuver. We will discuss and review various pertinent head and neck imaging cases with findings resulting from induced pressure gradients, including the Valsalva maneuver. Additionally, we will demonstrate the diagnostic utility of the Valsalva maneuver in head and neck radiology.
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Affiliation(s)
- A A Madhavan
- From the Departments of Radiology (A.A.M., C.M.C., J.I.L.)
| | - C M Carr
- From the Departments of Radiology (A.A.M., C.M.C., J.I.L.)
| | - M L Carlson
- Otolaryngology-Head and Neck Surgery (M.L.C.), Mayo Clinic School of Medicine, Rochester, Minnesota
| | - J I Lane
- From the Departments of Radiology (A.A.M., C.M.C., J.I.L.)
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Gundelach JH, Madhavan AA, Wettstein PJ, Bram RJ. The anticancer drug Dp44mT inhibits T‐cell activation and CD25 through a copper‐dependent mechanism. FASEB J 2012; 27:782-92. [DOI: 10.1096/fj.12-215756] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Justin H. Gundelach
- Department of Pediatric and Adolescent MedicineCollege of Medicine, Mayo ClinicRochesterMinnesotaUSA
- Department of Biochemistry and Molecular BiologyCollege of Medicine, Mayo ClinicRochesterMinnesotaUSA
| | - Ajay A. Madhavan
- Department of Pediatric and Adolescent MedicineCollege of Medicine, Mayo ClinicRochesterMinnesotaUSA
| | - Peter J. Wettstein
- Department of ImmunologyCollege of Medicine, Mayo ClinicRochesterMinnesotaUSA
- Department of SurgeryCollege of Medicine, Mayo ClinicRochesterMinnesotaUSA
| | - Richard J. Bram
- Department of Pediatric and Adolescent MedicineCollege of Medicine, Mayo ClinicRochesterMinnesotaUSA
- Department of ImmunologyCollege of Medicine, Mayo ClinicRochesterMinnesotaUSA
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