Headache response after CT-guided fibrin glue occlusion of CSF-venous fistulas.

OBJECTIVE: To assess headache response and patient perception of improvement after computed tomography (CT)-guided fibrin glue occlusion of cerebrospinal fluid-venous fistulas (CVFs) in a large sample size and with a long clinical follow-up. BACKGROUND: CVFs are an increasingly identified type of spinal leak in patients with spontaneous intracranial hypotension (SIH), and CT-guided fibrin glue occlusion has been introduced as a treatment option in a prior small series. METHODS: Retrospective case series review of medical records from a single institution was performed for all patients with CVFs that were treated with CT-guided fibrin glue occlusion between August 2018 and April 2022 in an outpatient or inpatient setting. Pre- and posttreatment Headache Impact Tests (HIT-6) were administered to patients, and a change in scores was evaluated. In some patients, pretreatment HIT-6 tests were not obtained prior to the fibrin glue procedure, and the patient was asked to fill out the pretreatment test based on personal recall of their symptoms prior to treatment. Patients completed a Patient Global Impression of Change (PGIC) scale after treatment. Pre- and posttreatment brain imaging was compared using Bern SIH scores. RESULTS: Thirty-five patients (19 females, 16 males; mean age 60 years) with CVFs treated with CT-guided fibrin glue occlusion met the inclusion criteria. Mean pretreatment and posttreatment HIT-6 scores were 64.7 ± 10.2 and 43.4 ± 9.9 (p < 0.001), respectively. The posttreatment HIT-6 questionnaires were completed on average 10.3 months after treatment, and 20 patients filled out the pretreatment HIT-6 form after their treatment. The mean PGIC score was 6.1 ± 1.3. Mean pretreatment and posttreatment Bern SIH scores were 5.9 ± 2.5 and 1.5 ± 1.5 (p < 0.001), respectively. CONCLUSIONS: We report a large series of patients who underwent CT-guided fibrin glue occlusion of CVFs. We showed that headache scores decreased after treatment, and the majority of patients had high PGIC scores. Posttreatment brain MRIs also showed improved Bern SIH scores.

Spontaneous Intracranial Hypotension in the Critical Patient.

Spontaneous intracranial hypotension typically manifests with orthostatic headaches and is caused by spinal dural tears, ruptured meningeal diverticula, or CSF-venous fistulas. While most patients are diagnosed and treated in the outpatient setting, some patients will occasionally present in the emergent ICU setting due to subdural hematomas, coma, or downward brain herniation. In this review paper, we will discuss the diagnostic and treatment steps that intensivists can undertake to coordinate a team approach to successfully manage these patients. A brief general overview of spontaneous intracranial hypotension will also be discussed.

CT-guided Fibrin Glue Occlusion of Cerebrospinal Fluid-Venous Fistulas.

Background Cerebrospinal fluid-venous fistulas (CVFs) are one of the less common etiologic causes of spontaneous intracranial hypotension. CVFs are most commonly treated with open surgical ligation and have reportedly not responded well to percutaneous treatments. Purpose To study treatment outcomes of CT-guided fibrin glue occlusion for CVFs. Materials and Methods Retrospective review of medical records from two institutions was performed for all patients with CVFs who underwent CT-guided percutaneous fibrin glue occlusion from March to October 2020. CVFs were assessed for resolution or persistence at posttreatment decubitus CT myelography (CTM). Pre- and posttreatment brain MRI scans were reviewed for principal signs of spontaneous intracranial hypotension. Clinical symptoms were documented before and immediately after therapy, and the current symptoms to date after fibrin glue occlusion were documented. Results CT-guided fibrin glue occlusion was performed in 13 patients (mean age, 62 years ± 14 [standard deviation]; eight women) with CVFs. Ten of 10 patients who underwent final posttreatment decubitus CTM examinations showed CVF resolution. All 13 patients showed improvement on posttreatment brain MRI scans. All 13 patients are currently asymptomatic, although three patients were asymptomatic before fibrin glue occlusion. Conclusion CT-guided fibrin glue occlusion is an effective treatment for patients with cerebrospinal fluid-venous fistulas (CVFs). Direct fibrin glue administration within the CVF may be one of the key factors for success. Further studies are needed to determine the long-term efficacy of this treatment. © RSNA, 2021.

Neonatal Magnetic Resonance Imaging Without Sedation Correlates With Injury Severity in Brachial Plexus Birth Palsy.

PURPOSE: Which infants with brachial plexus birth palsy (BPBP) should undergo microsurgical plexus reconstruction remains controversial. The current gold standard for the decision for plexus reconstruction is serial clinical examinations, but this approach obviates the possibility of early surgical treatment. We hypothesize that a new technique using 3-dimensional volumetric proton density magnetic resonance imaging (MRI) without sedation can evaluate the severity of BPBP injury earlier than serial clinical examinations. METHODS: Infants were prospectively enrolled prior to 12 weeks of age and imaged using 3 Tesla MRI without sedation. Clinical scores were collected at all visits. The imaging findings were graded based on the number of injured levels and the severity of each injury, and a radiological score was calculated. All infants were followed at least until the decision for surgery was made based on clinical examination. RESULTS: Nine infants completed the MRI scan and clinical follow-up. The average Toronto score at presentation was 4.4 out of 10 (range, 0-8.2); the average Active Movement Scale score was 50 out of 105 (range, 0-86). Four infants required surgery: 2 because of a flail limb and Horner syndrome and 2 owing to failure to recover antigravity elbow flexion by age 6 months. Radiological scores ranged from 0 to 18 out of a maximum score of 25. The average radiological score for those infants who required surgery was 12 (range, 6.5-18), whereas the average score for infants who did not require surgery was 3.5 (range, 0-8). CONCLUSIONS: Three-dimensional proton density MRI can evaluate spinal nerve roots in infants without the need for radiation, contrast agents, or sedation. These data suggest that MRI can help determine the severity of injury earlier than clinical examination in infants with BPBP, although further study of a larger sample of infants with varying severity of disease is necessary. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Clinical scoring system may improve yield of head CT of non-trauma emergency department patients.

The positive rate of head CT in non-trauma patients presenting to the emergency department (ED) is low. Currently, indications for imaging are based on the individual experience of the treating physician, which contributes to overutilization and variability in imaging utilization. The goals of this study are to ascertain the predictors of positive head CT in non-trauma patients and demonstrate feasibility of a clinical scoring algorithm to improve yield. We retrospectively reviewed 500 consecutive ED non-trauma patients evaluated with non-contrast head CT after presenting with headache, altered mentation, syncope, dizziness, or focal neurologic deficit. Medical records were assessed for clinical risk factors: focal neurologic deficit, altered mental status, nausea/vomiting, known malignancy, coagulopathy, and age. Data was analyzed using logistic regression and receiver operator characteristic (ROC) curves and three derived algorithms. Positive CTs were found in 51 of 500 patients (10.2 %). Only two clinical factors were significant: focal neurologic deficit (adjusted odds ratio (OR) 20.7; 95 % confidence interval (CI) 9.4-45.7) and age >55 (adjusted OR 3.08; CI 1.44-6.56). Area under the ROC curve for all three algorithms was 0.73-0.83. In proposed algorithm C, only patients with focal neurologic deficit (major risk factor) or ≥2 of the five minor risk factors (altered mental status, nausea/vomiting, known malignancy, coagulopathy, and age) would undergo CT imaging. This may reduce utilization by 34 % with only a small decrease in sensitivity (98 %). Our simple scoring algorithm utilizing multiple clinical risk factors could help to predict the non-trauma patients who will benefit from CT imaging, resulting in reduced radiation exposure without sacrificing sensitivity.

Factors Predictive of Treatment Success in CT-Guided Fibrin Occlusion of CSF-Venous Fistulas: A Multicenter Retrospective Cross-Sectional Study.

BACKGROUND AND PURPOSE: CSF-to-venous fistulas contribute to spontaneous intracranial hypotension. CT-guided fibrin occlusion has been described as a minimally invasive treatment strategy; however, its reproducibility across different institutions remains unclear. This multi-institution study evaluated the clinical and radiologic outcomes of CT-guided fibrin occlusion, hypothesizing a correlation among cure rates, fibrin injectate spread, and drainage patterns. MATERIALS AND METHODS: A retrospective evaluation was conducted on CT-guided fibrin glue treatment in patients with CSF-to-venous fistulas from 6 US and UK institutions from 2020 to 2023. Patient information, procedural characteristics, and injectate spread and drainage patterns were examined. Clinical improvement assessed through medical records served as the primary outcome. RESULTS: Of 119 patients at a mean follow-up of 5.0 months, fibrin occlusion resulted in complete clinical improvement in 59.7%, partial improvement in 34.5%, and no improvement in 5.9% of patients. Complications were reported in 4% of cases. Significant associations were observed between clinical improvement and concordant injectate spread with the fistula drainage pattern (P = .0089) and pretreatment symptom duration (P < .001). No associations were found between clinical improvement and cyst puncture, intravascular extension, rebound headache, body mass index, age, or number of treatment attempts. CONCLUSIONS: Fibrin occlusion performed across various institutions shows cure when associated with injectate spread matching the CVF drainage pattern and shorter pretreatment symptom duration, emphasizing the importance of accurate injectate placement and early intervention.

Developing a Spinal CSF Leak Program in a Multihospital Network.

OBJECTIVE: Spontaneous spinal cerebrospinal fluid (CSF) leaks are rare and challenging to diagnose and treat. Patients may present to a variety of physicians, and many patients are often referred to a specialized center with a dedicated spinal CSF leak program and expertise in this condition. To our knowledge, there are no reported publications on how to create such a program. CONCLUSION: In this article, we describe the specific steps we took to develop a spinal CSF leak program, which we have implemented over a multihospital network.

Non-Sedated Rapid Volumetric Proton Density MRI Predicts Neonatal Brachial Plexus Birth Palsy Functional Outcome.

BACKGROUND AND PURPOSE: The current prognostic biomarker of functional outcome in brachial plexus birth palsy is serial clinical examination throughout the first 6 months of age. This can delay surgical treatment and prolong parental anxiety in neonates who will recover spontaneously. A potentially superior biomarker is a volumetric proton density MRI performed at clinical presentation and within the first 12 weeks of life, providing a high spatial and contrast resolution examination in 4 minutes. METHODS: Nine neonates ranging in age from 4 to 9 weeks who presented with brachial plexus birth palsy were enrolled. All subjects underwent non-sedated 3 Tesla MRI with Cube Proton Density MRI sequence at the same time as their initial clinical visit. Serial clinical examinations were conducted at routine 4 week intervals and the functional performance scores were recorded. MRI findings were divided into pre-ganglionic and post-ganglionic injuries and a radiological scoring system (Shriners Radiological Score) was developed for this study. RESULTS: Proton Density MRI was able to differentiate between pre-ganglionic and post-ganglionic injuries. Radiological scores (Shriners Radiological Score) correlated better with functional performance at 6 months of age (P = .022) than the initial clinical examinations (Active Movement Scale P = .213 and Toronto P = .320). CONCLUSIONS: Rapid non-sedated volumetric Cube Proton Density MRI protocol performed at initial clinical presentation can accurately grade severity of brachial plexus birth palsy injury and predict functional performance at 6 months of age.

Earlier and more specific detection of persistent neck disease with diffusion-weighted MRI versus subsequent PET/CT after definitive chemoradiation for oropharyngeal squamous cell carcinoma.

BACKGROUND: The purpose of this study was to test if diffusion-weighted imaging (DWI) identified persistent neck disease after chemoradiotherapy (CRT) for oropharyngeal cancer earlier and as accurately as subsequent positron emission tomography (PET)/CT. METHODS: We performed a review of patients with oropharyngeal cancer treated with definitive CRT who underwent DWI and PET/CT at a median of 8 and 14 weeks posttreatment. Imaging characteristics were correlated with pathologically proven neck failure. RESULTS: Forty-one patients and 58 hemi-necks were analyzed. With a median follow-up of 120 weeks, 4 neck failures were identified. The apparent diffusion coefficient (ADC) of lymph node failures was lower (1220 vs 1910 µm2 /s; p = .003) than non-failures. Using an ADC threshold of 1500 µm2 /s, the sensitivity, specificity, and positive and negative predictive values (PPV; NPV) were 100% (4/4), 92% (46/50), 50% (4/8), and 100% (46/46) for DWI, respectively, and 100% (3/3), 71% (22/31), 25% (3/12), and 100% (22/22) for PET/CT, respectively. CONCLUSION: Earlier DWI produced similar sensitivity and better specificity in identifying persistent neck disease as 3-month PET/CT. © 2016 Wiley Periodicals, Inc. Head Neck 39: 432-438, 2017.

Magnetic Resonance Imaging of the Craniovertebral Junction Ligaments: Normal Anatomy and Traumatic Injury.

The superb stability and flexibility of the craniovertebral junction (CVJ) are enabled by the ligaments that connect the occipital bone and the C1 and C2 vertebral bodies. Radiographically, these ligaments are best assessed with magnetic resonance imaging (MRI), which has excellent soft tissue contrast, but typically poor spatial resolution. With the advent of advanced MRI techniques, including volumetric sequences, high spatial resolution and contrast resolution can both be attained, allowing for detailed analysis of the ligaments, particularly in trauma settings. We have instituted a cervical spine trauma protocol which utilizes a high resolution (1-mm voxel) volumetric proton density sequence to detect injuries to the ligaments of the CVJ in all trauma patients who receive a cervical spine MRI in our emergency room. In this article, we review techniques for imaging the ligaments at the CVJ, the normal imaging anatomy and the function of the CVJ ligaments, and their appearance in cases of traumatic injury.

Basic Imaging of Skull Base Trauma.

Skull base fractures extend through the floor of the anterior, middle, or posterior cranial fossa. They are frequently associated with complex facial fractures and serious complications such as cranial nerve or vascular injury, cerebrospinal fluid leak, or meningitis. Several distinct patterns of skull base fractures have been recognized, each of them associated with different complications. Recognition of, often subtle, skull base fracture is essential to prevent or allow early treatment of these serious complications.

Oscillations Go the Distance: Low-Frequency Human Hippocampal Oscillations Code Spatial Distance in the Absence of Sensory Cues during Teleportation.

Low-frequency (delta/theta band) hippocampal neural oscillations play prominent roles in computational models of spatial navigation, but their exact function remains unknown. Some theories propose they are primarily generated in response to sensorimotor processing, while others suggest a role in memory-related processing. We directly recorded hippocampal EEG activity in patients undergoing seizure monitoring while they explored a virtual environment containing teleporters. Critically, this manipulation allowed patients to experience movement through space in the absence of visual and self-motion cues. The prevalence and duration of low-frequency hippocampal oscillations were unchanged by this manipulation, indicating that sensorimotor processing was not required to elicit them during navigation. Furthermore, the frequency-wise pattern of oscillation prevalence during teleportation contained spatial information capable of classifying the distance teleported. These results demonstrate that movement-related sensory information is not required to drive spatially informative low-frequency hippocampal oscillations during navigation and suggest a specific function in memory-related spatial updating.