Onabotulinumtoxina (craniotomy scar combined with cranial suture line injections) for persistent post craniotomy headache: Case series with long-term follow-up.

BACKGROUND: There is no defined preventive treatment protocol for persistent post-craniotomy headache. In several small case series and individual case reports onabotulinumtoxinA injected into the craniotomy scar has shown possible efficacy. What is lacking is long term follow-up and if focusing on the cranial suture lines along with the craniotomy scar can enhance improvement and provide more sustained benefit. METHODS: Retrospective chart review with case series. RESULTS: Four patients (three women, one man) with ICHD-3 defined persistent post craniotomy headache were treated using a novel onabotulinumtoxinA injection protocol. All the patients presented with continuous head pain of moderate to severe intensity. All had severe allodynia on the side of their craniotomy. All had significant reduction in quality of life. Our application of onabotulinumtoxinA involved injection into both the surgical scar and the transected/irritated cranial suture lines noted on neuroimaging and physical examination. With treatment all patients demonstrated significant benefit including a reduction in daily pain intensity (75%-100%), developing periods of pain freedom (2-7 days per week) and having a dramatic improvement in quality of life (close to 100% in all). The benefit was sustained for at least five years of follow-up. CONCLUSION: From our case series it appears that injection not only along the painful craniotomy scar but into the involved cranial suture lines provides positive efficacy and sustained improvement in patients with persistent post craniotomy headache.

Reversible cerebral vasoconstriction syndrome developing after an erenumab injection for migraine prevention.

BACKGROUND: Reversible cerebral vasoconstriction syndrome is normally triggered by vasoactive compounds or illicit drugs. A new type of migraine preventive medication blocks calcitonin gene-related peptide utilizing monoclonal antibodies. Calcitonin gene-related peptide is a potent vasodilator for the cerebrovascular system. Could blocking calcitonin gene-related peptide be a trigger for cerebral artery vasospasm in patients susceptible to developing reversible cerebral vasoconstriction syndrome (migraine patients) or in individuals using vasoactive compounds? We present a case of reversible cerebral vasoconstriction syndrome occurring after calcitonin gene-related peptide monoclonal antibody treatment. CASE REPORT: A 43-year -old woman with a history of episodic migraine developed an acute headache with orgasm two days after taking her second injection of erenumab. Ten days after erenumab injection she developed a thunderclap headache while completing a high intensity workout. These new headaches were only left sided. Computed tomography angiography demonstrated mild to moderate areas of narrowing involving the left middle and anterior cerebral arteries, concerning for reversible cerebral vasoconstriction syndrome. She denied exposure to any known reversible cerebral vasoconstriction syndrome precipitant medication or illicit drugs. She did endorse recent exposure to high altitude prior to erenumab therapy. She was started on verapamil 40 mg three times per day and her headache ceased within 24 h of initiating treatment. A repeat CT angiogram completed 4 weeks after the initial study noted resolution of the areas of vessel stenosis. CONCLUSION: A case of reversible cerebral vasoconstriction syndrome developing after treatment with a calcitonin gene-related peptide monoclonal antibody is presented. The timing of the new type of headache occurring 2 days post erenumab injection suggests a possible cause and effect relationship. Reversible cerebral vasoconstriction syndrome as a possible treatment-related complication to the usage of calcitonin gene-related peptide monoclonal antibodies needs to be studied further.

Neuroradiology in Transgender Care: Facial Feminization, Laryngeal Surgery, and Beyond.

Transgender individuals experience incongruence between their gender identity and the sex assigned to them at birth. This incongruence can cause many transgender individuals to experience distressing physical and mental discord, a diagnosis known as gender dysphoria. Craniofacial structures have distinct anthropometric characteristics that affect perceived masculinity and femininity. The face, neck, and voice are highly exposed anatomic areas that have recognizable gender-specific characteristics that may hinder a transgender individual's successful social integration and public acceptance. Reconstructive facial and laryngeal procedures are among the surgical options transgender persons may elect to undergo to better align their physical appearance with their gender identity. These include feminization surgeries such as facial feminization and reduction chondrolaryngoplasty, as well as masculinizing facial and laryngeal surgeries. Maxillofacial CT is frequently used in the preoperative evaluation of patients before facial feminization surgery (FFS). Several CT measurements guide surgeons to the optimal correction required in FFS to achieve appropriate aesthetic planes. Mapping important craniofacial landmarks to avoid untoward surgical complications is crucial. Transgender patients may encounter other neurologic complications that require neuroimaging evaluation. For example, gender-affirming hormone therapy (eg, estrogen and testosterone) may increase the risk of stroke or may influence growth of various hormone-sensitive tumors such as pituitary adenomas. Radiologists may interpret imaging examinations in transgender patients for routine care or for evaluation before and after facial and laryngeal surgeries and must be aware of the role of neuroimaging in the care of this population. An invited commentary by Callen is available online. The online slide presentation from the RSNA Annual Meeting is available for this article. ©RSNA, 2022.

Ten must know pseudolesions of the head and neck.

Patients may present in the emergency setting for a variety of head and neck complaints such as fever, trouble swallowing, or a newly palpable mass. When reviewing radiologic head and neck exams for etiology of complaints, it is important to be familiar with the multiple pseudolesions that may mimic pathology. These may be normal variant anatomy, normal anatomy located in an atypical location, as well as iatrogenic or self-introduced foreign bodies. This review article discusses ten common pseudolesions encountered in the head and neck and their typical imaging appearance so that one does not mistake them for ominous pathology, thus preventing unnecessary follow-up, biopsy, or continued concern for the patient.

Emergency radiologic approach to mastoid air cell fluid.

Mastoid air cell fluid is a commonly seen, but often dismissed finding. Given the location of the mastoid portion of the temporal bone and its location adjacent to vital structures, a careful evaluation is important for the emergency radiologist. While occasionally benign, fluid within the mastoid air cells can be an early sign of more severe pathology, and familiarity of regional anatomy allows for early identification of disease spread. This article describes the important anatomy, the common pathologies, and a radiologic approach to assessing the mastoid air cells in order to guide referring clinicians.

Facial swelling for the emergency radiologist-typical and atypical causes.

There are a wide variety of inflammatory, infectious, and cystic lesions which may lead patients to seek acute care for facial swelling. Computed tomography (CT) has become the mainstay for imaging in the urgent/emergent setting. However, magnetic resonance imaging (MRI) can also serve as a powerful problem solving tool in the modern era. As volume continues to increase, a wide variety of facial pathology will be encountered by the emergency radiologist. Recognition of both common and uncommon pathology will assist in diagnosis and value-based care. This article serves as an image-rich review of the many causes of facial swelling with an emphasis on key imaging findings and possible complications.

Emergency radiologic approach to sinus disease.

Sinus disease is commonly encountered, especially in the acute care setting. Imaging can support a diagnosis of sinusitis, help identify an etiology, and delineate intracranial and extracranial complications. Suspicion of complicated rhinosinusitis is an indication for contrast-enhanced computed tomography or magnetic resonance imaging. It is important for radiologists to be familiar with patient risk factors that predispose to uncommon but aggressive forms of sinus disease such as invasive fungal sinusitis. Lastly, many conditions, ranging from benign to malignant, can mimic rhinosinusitis clinically and on imaging. Radiologists can help by recognizing these entities and facilitating appropriate referral and follow-up. This article reviews the breadth of sinus disease commonly encountered in the emergency setting, potential complications, and mimics.

Comparison of Clinical Measures Among Interstitial Lung Disease (ILD) Patients with Usual Interstitial Pneumonia (UIP) Patterns on High-Resolution Computed Tomography.

PURPOSE: Idiopathic Pulmonary Fibrosis is a progressive and fatal interstitial lung disease (ILD) characterized by a typical radiographic or histologic usual interstitial pneumonia (UIP) pattern. In 2018, diagnostic categories of UIP based on computed tomography patterns were revised by the Fleischner Society. The study aimed to describe differences in comorbidities and spirometry in ILD patients that were characterized by high-resolution computed tomography (HRCT) images as having a typical, probable, indeterminate, and alternative diagnosis of UIP. METHODS: We retrospectively studied 80 ILD patients from 2017 to 2019. Typical UIP was defined using the Fleischner Society diagnostic criteria for IPF. Atypical UIP was reached by consensus after a multidisciplinary clinical-radiological-pathological review of patient data. Baseline characteristics, comorbidities, and spirometry were compared among the four subgroups. RESULTS: Among 80 patients, 59% were male, 61% had a history of smoking, and the mean age was 67.7 ± 10 years (SD). A typical UIP pattern was more frequently observed among patients with chronic obstructive pulmonary disease (COPD) (p < 0.001) and pulmonary hypertension (p = 0.03). Of 30 patients with COPD, 14 had emphysema, while 10 had IPF. After adjusting for forced expiratory volume in one second (FEV1) in liters, change of FEV1% from baseline to 6-12 months, age, and sex, only COPD remained significantly associated with typical UIP (p = 0.018). Tobacco use was not significantly associated with any radiographic type (p = 0.199). CONCLUSION: Typical UIP was prevalent among COPD/emphysema patients. Although smoking has a strong association with IPF, we did not find a significant association with smoking and typical UIP in our cohort.

Correction to: Radiographic review of anatomy and pathology of the masticator space: what the emergency radiologist needs to know.

Unfortunately, the original publication of this article contained a mistake in Fig. 7a. The correct figure is presented here. The original article has been corrected.

Radiographic review of anatomy and pathology of the masticator space: what the emergency radiologist needs to know.

The differential diagnosis of a masticator space (MS) lesion is broad, owing in part to the multiple structures contained within such a small region. It is also because the MS is adjacent to many of the other deep spaces within the head and neck, which can act as gateways for disease spread. Therefore, emergency radiologists must be familiar with anatomy of the MS, as well as adjacent spaces in order to provide an accurate diagnosis to the referring clinician. This article illustrates the anatomy and common pathologies within the MS using a case-based multimodality approach. Common masticator space pathologies can be categorized into inflammatory/infectious, neoplastic, and vasoformative lesions. Important imaging features of MS lesions and patterns of disease spread will be discussed, with the aim of making this complex deep space more approachable in the emergent setting.

Post-operative complications of craniotomy and craniectomy.

Craniotomy and craniectomy are widely performed emergent neurosurgical procedures and are the prescribed treatment for a variety of conditions from trauma to cancer. It is vital for the emergency radiologist to be aware of expected neuroimaging findings in post-craniotomy and craniectomy patients in order to avoid false positives. It is just as necessary to be familiar with postsurgical complications in these patients to avoid delay in lifesaving treatment. This article will review the commonly encountered normal and abnormal findings in post-craniotomy and craniectomy patients. The expected postoperative CT and MRI appearance of these procedures are discussed, followed by complications. These include hemorrhage, tension pneumocephalus, wound/soft tissue infection, bone flap infection and extradural abscesses. Complications specifically related to craniectomies include extracranial herniation, external brain tamponade, paradoxical herniation, and trephine syndrome.

The "pool sign" of metastatic adenocarcinoma.

The differential of a newly discovered solitary intracranial mass is a primary intracranial neoplasm and metastatic disease. Differentiating between the two entities on imaging is difficult, though there are clues on conventional imaging that suggest one over the other. The purpose of this article is to describe a new imaging finding on T2-weighted imaging, the "pool sign," that may be specific for metastatic adenocarcinomas and can help differentiate a solitary metastasis from a primary CNS neoplasm. We present a series of four patients with initial magnetic resonance imaging of a solitary intracranial mass demonstrating the "pool sign," and therefore predicted to be metastatic adenocarcinoma. All of these cases were confirmed to be metastatic adenocarcinoma on pathology.

Non-traumatic causes of fluid in the retropharyngeal space.

There are multiple reasons for imaging the soft tissues of the neck in the emergency setting, in particular when symptoms are vague or if there is worry for complications from a certain clinical diagnosis. When fluid is seen in the retropharyngeal space, it is important to pay attention to history and look at key structures in the neck. This article will discuss anatomy of the retropharyngeal space, followed by four causes of fluid within the space that the radiologist is likely to encounter in the emergency setting: tonsillitis/pharyngitis, acute calcific tendinitis of the longus colli muscles, internal jugular vein thrombosis, and post-radiation changes. It is important to recognize these entities because each has different clinical implications and management.

Beyond stroke-uncommon causes of diffusion restriction in the basal ganglia.

In the emergency setting, a regional area of restricted diffusion involving the basal ganglia typically represents an acute infarct due to small vessel occlusion. However, it is important to consider additional differentials, specifically systemic causes. This article will review anatomy of the basal ganglia and pertinent associated vasculature, followed by other entities that can be a cause of restricted diffusion. These include hemolytic uremic syndrome, hypereosinophilic syndrome, fat embolism, meningitis, and hypoxic-ischemic injury. It is important to recognize presenting findings in these conditions, as the radiologist may be the first to give an accurate diagnosis or prompt additional testing.

Hemorrhagic and non-hemorrhagic causes of signal loss on susceptibility-weighted imaging.

Susceptibility-weighted imaging (SWI) plays a key role in an emergency setting. SWI takes the intrinsic properties of materials being scanned and creates a visual representation of their effects on the magnetic field, thereby differentiating a number of pathologies. Magnetic resonance imaging (MRI) is now more often used, especially when computed tomography (CT) is inconclusive or even negative. Often, clinicians prefer to obtain an MRI first. This article will review the various hemorrhagic and non-hemorrhagic causes of low signal on SWI. There will be a focus on the distribution patterns of low signal on SWI in pathologies such as diffuse axonal injury, cerebral amyloid angiopathy, and cerebral fat embolism. It is important to recognize these patterns of susceptibility, as the radiologist may be the first to give an accurate diagnosis and therefore, directly impact clinical management.

Use of Tablet Devices in the Management of Agitation Among Inpatients with Dementia: An Open-Label Study.

OBJECTIVE: To investigate the feasibility, safety, and utility of tablet devices as novel nonpharmacologic tools in managing older psychiatric inpatients with agitation and dementia. METHODS: Thirty-six patients at a geriatric psychiatry inpatient unit were provided with tablets when agitated and used various apps on the tablet related to communication, games, music, web browser, and photography during their stay. Study staff documented the frequency, duration, and app usage history and rated the extent to which agitation improved after tablet use. RESULTS: All participants, regardless of dementia severity, were able to use apps and were rated by staff to have clinical benefit. Dementia severity was negatively associated with app complexity. Age was negatively associated with frequency and duration of tablet use. CONCLUSION: Tablet use as a nonpharmacologic intervention for agitation in older adults, including those with severe dementia, appears to be feasible, safe, and of potential utility.

Continuous Aspiration Mechanical Thrombectomy for the Management of Submassive Pulmonary Embolism: A Single-Center Experience.

The Indigo Mechanical Thrombectomy System (Penumbra, Inc, Alameda, California) was used to treat 6 patients with submassive pulmonary embolism (PE) and a contraindication to thrombolysis. Systolic pulmonary artery pressure (58.2 mm Hg vs 43.0 mm Hg, P < .05), right ventricular/left ventricular ratio (1.7 vs 1.1, P < .05), Miller index (15.0 vs 9.8, P < 0.01), and CT obstructive index (60.4% vs 47.0%, P < .01) were significantly reduced after mechanical thrombectomy. There were no procedural or periprocedural complications. Continuous aspiration mechanical thrombectomy is a feasible and promising technique for management of submassive PE to decrease thrombus burden and reduce right heart strain.

Acute ocular traumatic imaging: what the radiologist should know [corrected].

Acute ocular trauma accounts for a substantial number of emergency department visits in the USA, and represents a significant source of disability to patients; however, the orbits remain a potential blind spot for radiologists. The goal of this article is to review the relevant anatomy of the orbit and imaging findings associated with commonly encountered acute ocular traumatic pathology, while highlighting the salient information which should be reported to the ordering clinician. Topics discussed include trauma to the anterior and posterior chamber, lens dislocations, intraocular foreign bodies, and open and contained globe injuries.