Progressive subcortical calcifications secondary to venous hypertension in an intracranial dural arteriovenous fistula.

Intracranial dural arteriovenous fistulas (dAVF) are acquired lesions, with the most commonly reported findings on CT haemorrhage or focal oedema. We describe a case of progressive subcortical calcification on CT secondary to venous hypertension from a high grade dAVF.

Minimally invasive endovascular stent-electrode array for high-fidelity, chronic recordings of cortical neural activity.

High-fidelity intracranial electrode arrays for recording and stimulating brain activity have facilitated major advances in the treatment of neurological conditions over the past decade. Traditional arrays require direct implantation into the brain via open craniotomy, which can lead to inflammatory tissue responses, necessitating development of minimally invasive approaches that avoid brain trauma. Here we demonstrate the feasibility of chronically recording brain activity from within a vein using a passive stent-electrode recording array (stentrode). We achieved implantation into a superficial cortical vein overlying the motor cortex via catheter angiography and demonstrate neural recordings in freely moving sheep for up to 190 d. Spectral content and bandwidth of vascular electrocorticography were comparable to those of recordings from epidural surface arrays. Venous internal lumen patency was maintained for the duration of implantation. Stentrodes may have wide ranging applications as a neural interface for treatment of a range of neurological conditions.

Pacing and implantable cardioverter defibrillator lead perforation as assessed by multiplanar reformatted ECG-gated cardiac computed tomography and clinical correlates.

INTRODUCTION: We aimed to assess the utility of cardiac computed tomography (CT) in the evaluation of right atrial (RA) and right ventricular (RV) pacemaker and implantable cardiac defibrillator lead perforation. METHODS: Images from a 320-slice electrocardiogram-gated cardiac CT scanner were retrospectively independently analyzed by two reviewers for lead position, pericardial effusion, and perforation.Perforation results were correlated with pacing sensing, impedance, and threshold measurements. RESULTS: A total of 52 patients had RV leads and 35 had RA leads. Five of 17 RV apical, one of 35 RV nonapical, and none of the 35 RA leads perforated through the myocardium on CT imaging criteria. Two "clinically" perforated leads (that had protruded 5 mm and 15 mm from the outer edge of the myocardium)had pericardial effusions and changes in pacing parameters, and required RV lead repositioning. In contrast,there were four apparent "radiologic" perforations (that had protruded only an average 1.5±0.5 mm from the outer edge of the myocardium) that did not require repositioning. These had the radiologic appearance of perforation on cardiac CT; however, they were not associated with pericardial effusions or significant changes in RV pacing lead sensing, impedance, and threshold measurements. CONCLUSIONS: Cardiac CT scanning with multiplanar reformatting is useful for documenting lead position and assessing for possible cardiac perforation. The clinical significance and natural history of leads with only the appearance of perforation on cardiac CT is uncertain.

Magnetic resonance imaging in adults with epilepsy: a pictorial essay.

This pictorial essay highlights the role of the radiologist as a member of the adult epilepsy multidisciplinary team, and gives an overview of MRI-evident epileptogenic lesions.

Psychosis with obsessive-compulsive symptoms in tuberous sclerosis.

We present a case of tuberous sclerosis complex (TSC) diagnosed in adulthood in a man initially referred for specialist neuropsychiatric assessment with psychosis and obsessive-compulsive symptoms (OCS) on a background of epilepsy and intellectual disability. To our knowledge, this is the first reported patient with TSC featuring both psychosis and OCS. This patient highlights the importance of comprehensive re-evaluation of atypical presentations of intellectual disability, epilepsy and associated neuropsychiatric symptoms, even in adulthood. This is particularly relevant in the context of significant advances in genetics, neuroscience, imaging and treatments for heritable neurogenetic disorders.

Validation of conventional fluoroscopic and ECG criteria for right ventricular pacemaker lead position using cardiac computed tomography.

INTRODUCTION: It is hypothesized that pacing the right ventricular (RV) septum is associated with less deleterious outcomes than RV apical pacing. Our aim was to validate fluoroscopic and electrocardiography (ECG) criteria for describing pacemaker and implantable cardioverter defibrillator RV "septal" lead position against the proposed gold standard: cardiac computed tomography (CT). METHODS: Using the conventional fluoroscopic criteria, we intended to place RV nonapical leads on the interventricular septum. Lead positions were later retrospectively analyzed with CT and correlated with ECGs and fluoroscopic projections: posterior-anterior, 40° left anterior oblique (LAO), 40° right anterior oblique (RAO), and left lateral. RESULTS: Only 21% (nine of 35) of presumed "septal" RV nonapical leads using the conventional fluoroscopic criteria were on the true septum. A schema developed to define septal position in the RAO fluoroscopic view had high agreement with CT images. ECG criteria had only fair to moderate agreement with CT. The paced QRS duration was significantly longer (P < 0.001) with RV apical pacing (176 ± 10.7 ms), compared to RV nonapical pacing (144.5 ± 14.3 ms). CONCLUSION: Using the conventional fluoroscopic criteria, only a minority of RV leads were implanted on the true RV septum. Instead, aiming for the middle of the cardiac silhouette in the RAO fluoroscopic view, confirming rightward orientation in the LAO view, and having a paced QRS duration <140 ms may allow the implanting cardiologist a simple, more accurate method to achieve true RV septal lead positioning.

Proximity of pacemaker and implantable cardioverter-defibrillator leads to coronary arteries as assessed by cardiac computed tomography.

INTRODUCTION: There have been rare case reports of damage to adjacent coronary arteries by screw-in pacemaker and implantable cardioverter-defibrillator (ICD) leads. Our aim was to assess the proximity of pacemaker and ICD leads to the major coronary anatomy using cardiac computed tomography (CT). METHODS: Cardiac CT images were retrospectively analyzed to assess the spatial relationship of device lead tips to the major coronary anatomy. RESULTS: Fifty-two right ventricular (RV) leads (17 apical, 35 nonapical) and 35 right atrial (RA) leads were assessed. Leads on the RV antero-septal junction (20 of 52) were close (median 4.7 mm) to, and orientated toward, the left anterior descending (LAD) coronary artery. RA leads in the anterior (26 of 35) and lateral (seven of 35) walls of the RA appendage were not close to (16.9 ± 7.7 mm and 18.9 ± 12.4 mm, respectively) and directed away from the right coronary artery. However, an RA lead adjacent to the superior border of the tricuspid valve was 4.3 mm from the right coronary artery and an RA lead on the medial wall of the RA appendage was 1.6 mm away from the aorta. An RV pacemaker lead in the lateral wall of the RV inlet was 3.4 mm from the right coronary artery. CONCLUSIONS: In our cohort, a majority of RV leads were on the antero-septal junction and close to the overlying LAD coronary artery. RA leads adjacent to the tricuspid valve or on the medial RA appendage were in close proximity to the right coronary artery and aorta, respectively.

Efficacy of patient questionnaire in predicting renal dysfunction in outpatients older than 60 years of age prior to contrast-enhanced computed tomography.

INTRODUCTION: Contrast-induced nephropathy (CIN), a common iatrogenic cause of acute renal failure, is preventable. Identification of impaired renal function prior to intravenous contrast is important. Questionnaire screening has been useful to negate the need for cumbersome and costly renal function testing on all patients prior to contrast-enhanced CT (CECT). The Royal Australian and New Zealand College of Radiologists guidelines include age older than 60 as a risk marker requiring renal function testing. The aim of this retrospective study is to assess the efficacy of the pre-CT questionnaire in identifying patients with pre-existing renal impairment even in this older than 60 age group. METHODS: All outpatients were given questionnaires containing 11 CIN risk markers prior to CECT. Radiographers documented age, gender, serum creatinine and/or estimated glomerulofiltration rate (eGFR mL/min/1.72 m(2) ) within 3 months of CT. Questionnaires of all patients older than 60 years were collated. The data was tabulated and analyzed. Incomplete questionnaires were excluded. RESULTS: 134/171 (78.4%) patients had eGFR ≥ 60 and 37/171 (21.6%) had eGFR < 60, with 31/171 (18.1%) having eGFR between 30 and 60 and 3/171 (1.8%) having eGFR < 30. 47/171 (27.5%) circled 'no' to all risk markers. Percentage for sensitivity is 81.1% (95% confidence interval (CI) 64.8-92%), for specificity 29.9% (95% CI 22.3-38.4%), for positive predictive value 24.2% (95% CI 17-32.7%) and for negative predictive value 85.1% (95%CI 71.7-93.8%). Kidney disease, anaemia, myeloma and vasculitis seem to be statistically significant risk factors (P < 0.05). All three true-positive patients with eGFR < 30 indicated known kidney disease. Seven false-negative patients had eGFR 30-60, with 4/7 (57.1%) having CIN risk markers in their medical records. CONCLUSION: Questionnaire screening for CIN risk has a high negative predictive value (85.1%) even in patients older than 60 years.