49-year-old woman • headache and neck pain radiating to ears and eyes • severe hypertension • Dx?

► headache and neck pain radiating to ears and eyes ► severe hypertension.

Utilization of Artificial Intelligence-based Intracranial Hemorrhage Detection on Emergent Noncontrast CT Images in Clinical Workflow.

Authors implemented an artificial intelligence (AI)-based detection tool for intracranial hemorrhage (ICH) on noncontrast CT images into an emergent workflow, evaluated its diagnostic performance, and assessed clinical workflow metrics compared with pre-AI implementation. The finalized radiology report constituted the ground truth for the analysis, and CT examinations (n = 4450) before and after implementation were retrieved using various keywords for ICH. Diagnostic performance was assessed, and mean values with their respective 95% CIs were reported to compare workflow metrics (report turnaround time, communication time of a finding, consultation time of another specialty, and turnaround time in the emergency department). Although practicable diagnostic performance was observed for overall ICH detection with 93.0% diagnostic accuracy, 87.2% sensitivity, and 97.8% negative predictive value, the tool yielded lower detection rates for specific subtypes of ICH (eg, 69.2% [74 of 107] for subdural hemorrhage and 77.4% [24 of 31] for acute subarachnoid hemorrhage). Common false-positive findings included postoperative and postischemic defects (23.6%, 37 of 157), artifacts (19.7%, 31 of 157), and tumors (15.3%, 24 of 157). Although workflow metrics such as communicating a critical finding (70 minutes [95% CI: 54, 85] vs 63 minutes [95% CI: 55, 71]) were on average reduced after implementation, future efforts are necessary to streamline the workflow all along the workflow chain. It is crucial to define a clear framework and recognize limitations as AI tools are only as reliable as the environment in which they are deployed. Keywords: CT, CNS, Stroke, Diagnosis, Classification, Application Domain © RSNA, 2022.

SMART Syndrome (Stroke-like migraine attacks after radiation therapy): When to suspect it?

BACKGROUND: Stroke-like migraine attacks after radiation therapy (SMART) syndrome is a benign complication of brain radiation therapy, which presents circa a decade after radiation treatment. Symptoms are stroke-like deficits, epileptic seizures, and migraine. Cranial magnetic resonance imaging is characteristic for alterations in the form of unilateral cortical hyperintensities and gyriform enhancement, most prominent in the parieto-occipital regions. Prompt diagnosis is essential to avoid unnecessary investigations (e.g., brain biopsy and angiography). CASE DESCRIPTION: We describe a 51-year-old female patient treated initially with cranial irradiation for a left-sided occipital metastatic lung adenocarcinoma. Five years later, she presented with migraine headache, aphasia, and a right sided hemiparesis. CONCLUSION: The triad of migraine, seizure, and hemiparesis within the context of a prior brain radiotherapy should promptly raise the suspicion of SMART syndrome. Prompt diagnosis is essential to avoid unnecessary invasive investigations.

New Horizons for Diagnostic Pitfalls of Cerebral Venous Thrombosis: Clinical Utility of a Newly Developed Cerebral Venous Thrombosis Diagnostic Score: A Case Report and Literature Review.

BACKGROUND Diagnosing cerebral venous thrombosis (CVT) poses significant challenges owing to a nonspecific clinical presentation, poorly correlated laboratory biomarkers, and low sensitivity of non-contrast head computed tomography (CT). We describe a case of missed CVT diagnosis, due to low clinical suspicion and nonrecognition of anemia as a prothrombotic factor, especially during an ulcerative colitis (UC) flare. A recently proposed CVT clinical probability score can guide clinicians in pursuing further neurovascular imaging. CASE REPORT A 35-year-old man, with treatment-naive UC, presented to the Emergency Department (ED) with new-onset diffuse headache, 4 weeks of bloody diarrhea, and weight loss. Initial ED laboratory studies revealed severe anemia and unremarkable non-contrast head CT. Two days later, the patient returned to the ED for worsening headache. Non-contrast head CT revealed a left temporal hypodensity. This was later confirmed as acute ischemia on magnetic resonance imaging (MRI). MR venogram revealed thrombosis of the left transverse and sigmoid sinuses, leading to initiation of therapeutic subcutaneous anticoagulation. Repeat MRI, secondary to worsening headache, revealed the development of petechial hemorrhages within the core of venous ischemia in the left temporal lobe. Therapeutic anticoagulation, along with symptomatic management of UC, led to clinical stabilization. CONCLUSIONS CVT should be suspected in patients with UC, especially in the context of anemia, presenting with new-onset or worsening headaches. Recognizing anemia as a thrombogenic factor is crucial. Diagnosis of CVT is challenging due to non-focal symptoms and poorly correlating diagnostic tests. We endorse implementing the CVT clinical probability score into AHA/ASA CVT guidelines to enhance diagnostic accuracy.