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Houk JL, Morrison S, Peskoe S, Amrhein TJ, Kranz PG. Validity of the Bern Score as a Surrogate Marker of Clinical Severity in Patients with Spontaneous Intracranial Hypotension. AJNR Am J Neuroradiol 2023; 44:1096-1100. [PMID: 37562827 PMCID: PMC10494944 DOI: 10.3174/ajnr.a7962] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 07/06/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND AND PURPOSE The Bern score is a quantitative scale characterizing brain MR imaging changes in spontaneous intracranial hypotension. Higher scores are associated with more abnormalities on brain MR imaging, raising the question of whether the score can serve as a measure of disease severity. However, the relationship between clinical symptom severity and the Bern score has not been evaluated. Our purpose was to assess correlations between Bern scores and clinical headache severity in spontaneous intracranial hypotension. MATERIALS AND METHODS This study was a single-center, retrospective cohort of patients satisfying the International Classification of Headache Disorders-3 criteria for spontaneous intracranial hypotension. Fifty-seven patients who completed a pretreatment headache severity questionnaire (Headache Impact Test-6) and had pretreatment brain MR imaging evidence of spontaneous intracranial hypotension were included. Pearson correlation coefficients (ρ) for the Headache Impact Test-6 and Bern scores were calculated. Receiver operating characteristic curves were used to assess the ability of Bern scores to discriminate among categories of headache severity. RESULTS We found low correlations between clinical headache severity and Bern scores (ρ = 0.139; 95% CI, -0.127-0.385). Subgroup analyses examining the timing of brain MR imaging, symptom duration, and prior epidural blood patch showed negligible-to-weak correlations in all subgroups. Receiver operating characteristic analysis found that the Bern score poorly discriminated subjects with greater headache severity from those with lower severity. CONCLUSIONS Pretreatment Bern scores show a low correlation with headache severity in patients with spontaneous intracranial hypotension. This finding suggests that brain imaging findings as reflected by Bern scores may not reliably reflect clinical severity and should not replace clinical metrics for outcome assessment.
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Affiliation(s)
- J L Houk
- From the Department of Radiology (J.L.H., T.J.A., P.G.K.), Duke University Medical Center, Durham, North Carolina
| | - S Morrison
- Department of Biostatistics and Bioinformatics (S.M., S.P.), Duke University School of Medicine, Durham, North Carolina
| | - S Peskoe
- Department of Biostatistics and Bioinformatics (S.M., S.P.), Duke University School of Medicine, Durham, North Carolina
| | - T J Amrhein
- From the Department of Radiology (J.L.H., T.J.A., P.G.K.), Duke University Medical Center, Durham, North Carolina
| | - P G Kranz
- From the Department of Radiology (J.L.H., T.J.A., P.G.K.), Duke University Medical Center, Durham, North Carolina
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Kranz PG, Malinzak MD, Gray L, Willhite J, Amrhein TJ. Resisted Inspiration Improves Visualization of CSF-Venous Fistulas in Spontaneous Intracranial Hypotension. AJNR Am J Neuroradiol 2023; 44:994-998. [PMID: 37414450 PMCID: PMC10411851 DOI: 10.3174/ajnr.a7927] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 06/07/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND AND PURPOSE CSF-venous fistulas are an important cause of spontaneous intracranial hypotension but are challenging to detect. A newly described technique known as resisted inspiration has been found to augment the CSF-venous pressure gradient and was hypothesized to be of potential use in CSF-venous fistula detection but has not yet been investigated in patients with spontaneous intracranial hypotension. The purpose of this investigation was to determine whether resisted inspiration results in improved visibility of CSF-venous fistulas on CT myelography in patients with spontaneous intracranial hypotension. MATERIALS AND METHODS A retrospective cohort of patients underwent CT myelography from November 2022 to January 2023. Patients with an observed or suspected CSF-venous fistula identified during CT myelography using standard maximum suspended inspiration were immediately rescanned using resisted inspiration and the Valsalva maneuver. The visibility of the CSF-venous fistula among these 3 respiratory phases was compared, and changes in venous drainage patterns between phases were assessed. RESULTS Eight patients with confirmed CSF-venous fistulas who underwent CT myelography using the 3-phase respiratory protocol were included. Visibility of the CSF-venous fistula was greatest during resisted inspiration in 5/8 (63%) of cases. Visibility was optimal with the Valsalva maneuver and maximum suspended inspiration in 1 case each, and it was equivalent in all respiratory phases in 1 case. In 2/8 (25%) cases, the pattern of venous drainage shifted between respiratory phases. CONCLUSIONS In patients with spontaneous intracranial hypotension, resisted inspiration improved visualization of CSF-venous fistulas in most, but not all, cases. Further investigation is needed to determine the impact of this technique on the overall diagnostic yield of myelography in this condition.
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Affiliation(s)
- P G Kranz
- From the Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - M D Malinzak
- From the Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - L Gray
- From the Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - J Willhite
- From the Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - T J Amrhein
- From the Department of Radiology, Duke University Medical Center, Durham, North Carolina
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Amrhein TJ, Williams JW, Gray L, Malinzak MD, Cantrell S, Deline CR, Carr CM, Kim DK, Goldstein KM, Kranz PG. Efficacy of Epidural Blood Patching or Surgery in Spontaneous Intracranial Hypotension: A Systematic Review and Evidence Map. AJNR Am J Neuroradiol 2023; 44:730-739. [PMID: 37202114 PMCID: PMC10249694 DOI: 10.3174/ajnr.a7880] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 04/21/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Spontaneous intracranial hypotension is an important cause of treatable secondary headaches. Evidence on the efficacy of epidural blood patching and surgery for spontaneous intracranial hypotension has not been synthesized. PURPOSE Our aim was to identify evidence clusters and knowledge gaps in the efficacy of treatments for spontaneous intracranial hypotension to prioritize future research. DATA SOURCES We searched published English language articles on MEDLINE (Ovid), the Web of Science (Clarivate), and EMBASE (Elsevier) from inception until October 29, 2021. STUDY SELECTION We reviewed experimental, observational, and systematic review studies assessing the efficacy of epidural blood patching or surgery in spontaneous intracranial hypotension. DATA ANALYSIS One author performed data extraction, and a second verified it. Disagreements were resolved by consensus or adjudicated by a third author. DATA SYNTHESIS One hundred thirty-nine studies were included (median, 14 participants; range, 3-298 participants). Most articles were published in the past decade. Most assessed epidural blood patching outcomes. No studies met level 1 evidence. Most were retrospective cohort or case series (92.1%, n = 128). A few compared the efficacy of different treatments (10.8%, n = 15). Most used objective methods for the diagnosis of spontaneous intracranial hypotension (62.3%, n = 86); however, 37.7% (n = 52) did not clearly meet the International Classification of Headache Disorders-3 criteria. CSF leak type was unclear in 77.7% (n = 108). Nearly all reported patient symptoms using unvalidated measures (84.9%, n = 118). Outcomes were rarely collected at uniform prespecified time points. LIMITATIONS The investigation did not include transvenous embolization of CSF-to-venous fistulas. CONCLUSIONS Evidence gaps demonstrate a need for prospective study designs, clinical trials, and comparative studies. We recommend using the International Classification of Headache Disorders-3 diagnostic criteria, explicit reporting of CSF leak subtype, inclusion of key procedural details, and using objective validated outcome measures collected at uniform time points.
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Affiliation(s)
- T J Amrhein
- From the Department of Radiology (T.J.A., L.G., M.D.M., P.G.K.), Duke University Medical Center, Durham, North Carolina
| | - J W Williams
- Division of General Internal Medicine (J.W.W., K.M.G.)
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (J.W.W., K.M.G.), Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - L Gray
- From the Department of Radiology (T.J.A., L.G., M.D.M., P.G.K.), Duke University Medical Center, Durham, North Carolina
| | - M D Malinzak
- From the Department of Radiology (T.J.A., L.G., M.D.M., P.G.K.), Duke University Medical Center, Durham, North Carolina
| | - S Cantrell
- Duke University Medical Center Library (S.C.), Duke University School of Medicine, Durham, North Carolina
| | - C R Deline
- Spinal CSF Leak Foundation (C.R.D.), Spokane, Washington
| | - C M Carr
- Department of Radiology (C.M.C., D.K.K.), Mayo Clinic, Rochester, Minnesota
| | - D K Kim
- Department of Radiology (C.M.C., D.K.K.), Mayo Clinic, Rochester, Minnesota
| | - K M Goldstein
- Division of General Internal Medicine (J.W.W., K.M.G.)
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (J.W.W., K.M.G.), Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - P G Kranz
- From the Department of Radiology (T.J.A., L.G., M.D.M., P.G.K.), Duke University Medical Center, Durham, North Carolina
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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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Amrhein TJ, Gray L, Malinzak MD, Kranz PG. Respiratory Phase Affects the Conspicuity of CSF-Venous Fistulas in Spontaneous Intracranial Hypotension. AJNR Am J Neuroradiol 2020; 41:1754-1756. [PMID: 32675336 DOI: 10.3174/ajnr.a6663] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 05/05/2020] [Indexed: 01/03/2023]
Abstract
Spinal CSF-venous fistulas are a cause of spontaneous intracranial hypotension that can be difficult to detect on imaging. We describe how the respiratory phase affects the visibility of CSF-venous fistulas during myelography.
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Affiliation(s)
- T J Amrhein
- From the Department of Radiology, Duke University Medical Center, Durham, North Carolina.
| | - L Gray
- From the Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - M D Malinzak
- From the Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - P G Kranz
- From the Department of Radiology, Duke University Medical Center, Durham, North Carolina
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Kranz PG, Gray L, Amrhein TJ. Decubitus CT Myelography for Detecting Subtle CSF Leaks in Spontaneous Intracranial Hypotension. AJNR Am J Neuroradiol 2019; 40:754-756. [PMID: 30819772 DOI: 10.3174/ajnr.a5995] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 12/22/2018] [Indexed: 11/07/2022]
Abstract
Spontaneous intracranial hypotension is caused by spinal CSF leaks, but the site of the leak is not always detected on spinal imaging. We report on the additional value of decubitus positioning during CT myelography in enhancing the detection of subtle leaks.
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Affiliation(s)
- P G Kranz
- From the Department of Radiology, Duke University Medical Center, Durham, North Carolina.
| | - L Gray
- From the Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - T J Amrhein
- From the Department of Radiology, Duke University Medical Center, Durham, North Carolina
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Kranz PG, Joshi AB, Roy LA, Choudhury KR, Amrhein TJ. Inadvertent Intrafacet Injection during Lumbar Interlaminar Epidural Steroid Injection: A Comparison of CT Fluoroscopic and Conventional Fluoroscopic Guidance. AJNR Am J Neuroradiol 2016; 38:398-402. [PMID: 28059710 DOI: 10.3174/ajnr.a5000] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 09/02/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Inadvertent intrafacet injection can occur during interlaminar epidural steroid injection, resulting in a false-positive loss of resistance and nontarget injection of medication. The purpose of this investigation was to compare the observed rates of this phenomenon during lumbar interlaminar epidural steroid injection performed by using conventional fluoroscopic and CT fluoroscopic guidance. MATERIALS AND METHODS We retrospectively reviewed 349 lumbar interlaminar epidural steroid injections performed by using conventional fluoroscopy or CT fluoroscopic guidance to determine the observed rates of inadvertent intrafacet injection with each technique. Cases of inadvertent intrafacet injection were classified as either recognized or unrecognized by the proceduralist at the time of the procedure. Multivariate logistic regression was used to determine the independent effect of imaging guidance technique, age, and sex. RESULTS The rate of inadvertent intrafacet injection was observed to be 7.5% in the CT fluoroscopic group and 0.75% in the conventional fluoroscopy group. All 16 cases identified from CT fluoroscopic procedures were recognized during the procedure; the single case identified from conventional fluoroscopy procedures was not recognized prospectively. The type of imaging guidance showed a statistically significant effect on the detection of the phenomenon (OR for conventional fluoroscopy versus CT fluoroscopy = 0.10, P = .03) that was independent of differences in age or sex. CONCLUSIONS Inadvertent intrafacet injection is identified during CT fluoroscopic-guided interlaminar epidural steroid injection at a rate that is 10-fold greater than the same procedure performed under conventional fluoroscopy guidance.
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Affiliation(s)
- P G Kranz
- From the Departments of Radiology (P.G.K., K.R.C., T.J.A.)
| | | | - L A Roy
- Anesthesiology (L.A.R.), Duke University Medical Center, Durham, North Carolina
| | - K R Choudhury
- From the Departments of Radiology (P.G.K., K.R.C., T.J.A.)
| | - T J Amrhein
- From the Departments of Radiology (P.G.K., K.R.C., T.J.A.)
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Amrhein TJ, Befera NT, Gray L, Kranz PG. CT Fluoroscopy-Guided Blood Patching of Ventral CSF Leaks by Direct Needle Placement in the Ventral Epidural Space Using a Transforaminal Approach. AJNR Am J Neuroradiol 2016; 37:1951-1956. [PMID: 27390315 DOI: 10.3174/ajnr.a4842] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 04/22/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Epidural blood patch treatment of spontaneous intracranial hypotension arising from ventral CSF leaks can be difficult secondary to challenges in achieving ventral spread of patching material. The purpose of this study was to determine the technical success rates and safety profile of direct needle placement into the ventral epidural space via a posterior transforaminal approach. MATERIALS AND METHODS We retrospectively reviewed consecutive CT fluoroscopy-guided epidural blood patches from June 2013 through July 2015. Cases were included if a posterior transforaminal approach was taken to place the needle directly in the ventral epidural space. Rates of technical success (defined as contrast in the spinal canal ventral epidural space) and optimal epidurogram (defined as contrast spreading into or beyond the middle third of the spinal canal ventral epidural space) were determined. Factors influencing these rates were assessed. All complications, inadvertent intravascular injections, and intrathecal punctures were recorded. RESULTS A total of 72 ventral epidural blood patches were identified; immediate technical success was achieved in 95.8% and an optimal epidurogram in 47.2%. Needle position within the spinal canal ventral epidural space was associated with obtaining an optimal epidurogram (P = .005). Inadvertent intravascular injection was identified in 29.3% of cases, but all were venous. There were no inadvertent intrathecal punctures or complications. CONCLUSIONS Direct needle placement in the ventral epidural space via a transforaminal approach for treatment of ventral CSF leaks has an excellent technical success rate and safety profile. This technique can be considered as a treatment option in selected patients with ventral CSF leaks for whom traditional techniques are unsuccessful.
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Affiliation(s)
- T J Amrhein
- From the Department of Radiology, Duke University Medical Center, Durham, North Carolina.
| | - N T Befera
- From the Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - L Gray
- From the Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - P G Kranz
- From the Department of Radiology, Duke University Medical Center, Durham, North Carolina
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Kranz PG, Tanpitukpongse TP, Choudhury KR, Amrhein TJ, Gray L. Imaging Signs in Spontaneous Intracranial Hypotension: Prevalence and Relationship to CSF Pressure. AJNR Am J Neuroradiol 2016; 37:1374-1378. [PMID: 26869465 PMCID: PMC7960347 DOI: 10.3174/ajnr.a4689] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [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: 10/19/2015] [Accepted: 11/27/2015] [Indexed: 08/10/2023]
Abstract
BACKGROUND AND PURPOSE Patients with spontaneous intracranial hypotension often exhibit low CSF pressure and changes on brain MR imaging and/or evidence of CSF leak on myelography. We investigated whether individual imaging signs of spontaneous intracranial hypotension correlate with measured CSF pressure and how frequently these 2 markers of spontaneous intracranial hypotension were concordant. MATERIALS AND METHODS We performed a retrospective, cross-sectional study of 99 subjects with spontaneous intracranial hypotension. Prevalence of brain and myelographic imaging signs of spontaneous intracranial hypotension was recorded. CSF pressure among subjects with or without individual imaging signs was compared by using a 2-tailed t test and ANOVA. Concordance between low CSF pressure (≤6 cm H2O) and imaging was defined as the presence of the sign in a subject with low CSF pressure or absence of the sign when pressure was not low. RESULTS Dural enhancement, brain sagging, and venous distension sign were present in 83%, 61%, and 75% of subjects, respectively, and myelographic evidence of CSF leak was seen in 55%. Marginal correlations between CSF pressure and brain sagging (P = .046) and the venous distension sign (P = .047) were found. Dural enhancement and myelographic evidence of leak were not significantly correlated with CSF pressure. Rates of concordance between imaging signs and low CSF pressure were generally low, ranging from 39% to 55%. CONCLUSIONS Brain and myelographic signs of spontaneous intracranial hypotension correlate poorly with CSF pressure. These findings reinforce the need to base the diagnosis of spontaneous intracranial hypotension on multiple diagnostic criteria and suggest the presence of patient-specific variables that influence CSF pressure in these individuals.
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Affiliation(s)
- P G Kranz
- From the Department of Radiology, Duke University Medical Center, Durham, North Carolina.
| | - T P Tanpitukpongse
- From the Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - K R Choudhury
- From the Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - T J Amrhein
- From the Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - L Gray
- From the Department of Radiology, Duke University Medical Center, Durham, North Carolina
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Kranz PG, Amrhein TJ, Schievink WI, Karikari IO, Gray L. The "Hyperdense Paraspinal Vein" Sign: A Marker of CSF-Venous Fistula. AJNR Am J Neuroradiol 2016; 37:1379-81. [PMID: 26869470 DOI: 10.3174/ajnr.a4682] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 12/04/2015] [Indexed: 11/07/2022]
Abstract
CSF-venous fistula is a recently reported cause of spontaneous intracranial hypotension that may occur in the absence of myelographic evidence of CSF leak. Information about this entity is currently very limited, but it is of potential importance given the large percentage of cases of spontaneous intracranial hypotension associated with negative myelography findings. We report 3 additional cases of CSF-venous fistula and describe the "hyperdense paraspinal vein" sign, which may aid in its detection.
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Affiliation(s)
- P G Kranz
- From the Departments of Radiology (P.G.K., T.J.A., L.G.)
| | - T J Amrhein
- From the Departments of Radiology (P.G.K., T.J.A., L.G.)
| | - W I Schievink
- Department of Neurosurgery (W.I.S.), Cedars-Sinai Medical Center, Los Angeles, California
| | - I O Karikari
- Neurosurgery (I.O.K.), Duke University Medical Center, Durham, North Carolina
| | - L Gray
- From the Departments of Radiology (P.G.K., T.J.A., L.G.)
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Kranz PG, Amrhein TJ, Gray L. Incidence of Inadvertent Intravascular Injection during CT Fluoroscopy-Guided Epidural Steroid Injections. AJNR Am J Neuroradiol 2015; 36:1000-7. [PMID: 25614475 DOI: 10.3174/ajnr.a4219] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [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: 09/05/2014] [Accepted: 10/21/2014] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Inadvertent intravascular injection during epidural steroid injection can result in complications and has been investigated previously with conventional fluoroscopy, but not CT fluoroscopy. The purpose of this study was to determine the incidence of intravascular injections recognized during CT fluoroscopy-guided epidural steroid injection. MATERIALS AND METHODS We retrospectively reviewed 575 consecutive CT fluoroscopy-guided epidural steroid injections. Procedures were assessed to determine the incidence of intravascular injection. Cases positive for intravascular injection were classified on the basis of anatomic location, distance from the needle tip, washout pattern, and presence of combined epidural and vascular injection. Cases were also graded as either venous or arterial by using a 5-point scale. RESULTS Intravascular injection was observed in 26% of cervical transforaminal epidural steroid injections (7/27), 9% of cervical interlaminar epidural steroid injections (4/47), 8% of lumbar transforaminal epidural steroid injections (22/275), and 2% of lumbar interlaminar epidural steroid injections (4/222). Vessels were most commonly identified close to the needle, but in 30% of cases, they were visualized in the anterior paraspinal soft tissues remote from the needle. Washout was most commonly delayed (86%), though rapid washout occurred in 14% of cases. Simultaneous epidural and vascular injections occurred in 32% of cases. Most visualized vessels were venous, but 2 cases were classified as probably arterial. CONCLUSIONS Intravascular injections can be detected with CT fluoroscopy. The incidence in our study was similar to that in previous reports using conventional fluoroscopy. Technical factors such as the "double-tap" on CT fluoroscopy following contrast injection, assessment for discordance between injected and visualized contrast volume, and maintenance of an appropriate FOV facilitate the detection of such events.
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Affiliation(s)
- P G Kranz
- From the Department of Radiology, Duke University Medical Center, Durham, North Carolina.
| | - T J Amrhein
- From the Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - L Gray
- From the Department of Radiology, Duke University Medical Center, Durham, North Carolina
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Amrhein TJ, Paxton BE, Lungren MP, Befera NT, Collins HR, Yurko C, Eastwood JD, Kilani RK. Physician self-referral and imaging use appropriateness: negative cervical spine MRI frequency as an assessment metric. AJNR Am J Neuroradiol 2014; 35:2248-53. [PMID: 25104287 DOI: 10.3174/ajnr.a4076] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Imaging self-referral is increasingly cited as a contributor to diagnostic imaging overuse. The purpose of this study was to determine whether ownership of MR imaging equipment by ordering physicians influences the frequency of negative cervical spine MR imaging findings. MATERIALS AND METHODS A retrospective review was performed of 500 consecutive cervical spine MRIs ordered by 2 separate referring-physician groups serving the same geographic community. The first group owned the scanners used and received technical fees for their use, while the second group did not. Final reports were reviewed, and for each group, the percentage of negative study findings and the frequency of abnormalities were calculated. The number of concomitant shoulder MRIs was recorded. RESULTS Five hundred MRIs meeting inclusion criteria were reviewed (250 with financial interest, 250 with no financial interest). Three hundred fifty-two had negative findings (190 with financial interest, 162 with no financial interest); there were 17.3% more scans with negative findings in the financial interest group (P = .006). Among scans with positive findings, there was no significant difference in the mean number of lesions per scan, controlled for age (1.90 with financial interest, 2.19 with no financial interest; P = .23). Patients in the financial interest group were more likely to undergo concomitant shoulder MR imaging (24 with financial interest, 11 with no financial interest; P = .02). CONCLUSIONS Cervical spine MRIs referred by physicians with a financial interest in the imaging equipment used were significantly more likely to have negative findings. There was otherwise a highly similar distribution and severity of disease between the 2 patient samples. Patients in the financial interest group were more likely to undergo concomitant shoulder MR imaging.
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Affiliation(s)
- T J Amrhein
- From the Department of Radiology (T.J.A., B.E.P., N.T.B., C.Y., J.D.E., R.K.K.), Duke University Medical Center, Durham, North Carolina
| | - B E Paxton
- From the Department of Radiology (T.J.A., B.E.P., N.T.B., C.Y., J.D.E., R.K.K.), Duke University Medical Center, Durham, North Carolina
| | - M P Lungren
- Department of Radiology (M.P.L.), Stanford University School of Medicine, Stanford, California
| | - N T Befera
- From the Department of Radiology (T.J.A., B.E.P., N.T.B., C.Y., J.D.E., R.K.K.), Duke University Medical Center, Durham, North Carolina
| | - H R Collins
- Center for Biomedical Imaging (H.R.C.), Medical University of South Carolina, Charleston, South Carolina
| | - C Yurko
- From the Department of Radiology (T.J.A., B.E.P., N.T.B., C.Y., J.D.E., R.K.K.), Duke University Medical Center, Durham, North Carolina
| | - J D Eastwood
- From the Department of Radiology (T.J.A., B.E.P., N.T.B., C.Y., J.D.E., R.K.K.), Duke University Medical Center, Durham, North Carolina
| | - R K Kilani
- From the Department of Radiology (T.J.A., B.E.P., N.T.B., C.Y., J.D.E., R.K.K.), Duke University Medical Center, Durham, North Carolina
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13
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Kranz PG, Amrhein TJ, Gray L. Rebound intracranial hypertension: a complication of epidural blood patching for intracranial hypotension. AJNR Am J Neuroradiol 2014; 35:1237-40. [PMID: 24407273 PMCID: PMC7965157 DOI: 10.3174/ajnr.a3841] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [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: 10/14/2013] [Accepted: 11/10/2013] [Indexed: 11/07/2022]
Abstract
Rebound intracranial hypertension is a complication of epidural blood patching for treatment of intracranial hypotension characterized by increased intracranial pressure, resulting in potentially severe headache, nausea, and vomiting. Because the symptoms of rebound intracranial hypertension may bear some similarity to those of intracranial hypotension and literature reports of rebound intracranial hypertension are limited, it may be mistaken for refractory intracranial hypotension, leading to inappropriate management. This clinical report of 9 patients with confirmed rebound intracranial hypertension reviews the clinical characteristics of patients with this condition, emphasizing factors that can be helpful in discriminating rebound intracranial hypertension from refractory spontaneous intracranial hypotension, and discusses treatment.
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Affiliation(s)
- P G Kranz
- From the Department of Radiology (P.G.K., L.G.), Duke University Medical Center, Durham, North Carolina
| | - T J Amrhein
- Department Radiology and Radiological Science (T.J.A.), Medical University of South Carolina, Charleston, South Carolina
| | - L Gray
- From the Department of Radiology (P.G.K., L.G.), Duke University Medical Center, Durham, North Carolina
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