Distinguishing Cerebral Infarction With Neck Pain and Hemiparesis From Cervical Spinal Epidural Hematoma Without MRI: A Case Report.

In patients presenting neck pain and hemiparesis, differentiation between cerebral infarction and cervical spinal epidural hematoma is vital yet challenging, particularly when magnetic resonance imaging (MRI) is not feasible. A 59-year-old woman presented with a sudden onset of left-sided hemiparesis and neck pain. MRI was contraindicated because the patient underwent embolization in childhood. Head computed tomography (CT) revealed no evidence of hemorrhage or early ischemic signs. Cervical CT revealed no evidence of hematoma within the spinal canal. Myelography and CT myelography revealed no significant cervical spine abnormalities. The diagnosis was cerebral infarction. Cervical spine MRI is the gold standard examination for diagnosing cervical spinal epidural hematoma, but cervical spine CT, myelography, and CT myelography may be useful when MRI is contraindicated.

Spinal dementia: Don't miss it, it's treatable.

BACKGROUND & PURPOSE: Around 5% of dementia patients have a treatable cause. To estimate the prevalence of two rare diseases, in which the treatable cause is at the spinal level. METHODS: A radiology information system was searched using the terms CT myelography and the operation and classification system (OPS) code 3-241. The clinical charts of these patients were reviewed to identify patients with a significant cognitive decline. RESULTS: Among 205 patients with spontaneous intracranial hypotension (SIH) and proven CSF leaks we identified five patients with a so-called frontotemporal brain sagging syndrome: Four of those had CSF venous fistulas and significantly improved by occluding them either by surgery or transvenous embolization. Another 11 patients had infratentorial hemosiderosis and hearing problems and ataxia as guiding symptoms. Some cognitive decline was present in at least two of them. Ten patients had ventral dural tears in the thoracic spine and one patient a lateral dural tear at C2/3 respectively. Eight patients showed some improvement after surgery. DISCUSSION: It is mandatory to study the (thoracic) spine in cognitively impaired patients with brain sagging and/ or infratentorial hemosiderosis on MRI. We propose the term spinal dementia to draw attention to this region, which in turn is evaluated with dynamic digital subtraction and CT myelography.

Spontaneous Intracranial Hypotension: Clinical Presentation, Diagnosis, and Treatment Strategies.

Spontaneous intracranial hypotension (SIH) typically presents as an acute orthostatic headache during an upright position, secondary to spinal cerebrospinal fluid leaks. New evidence indicates that a lumbar puncture may not be essential for diagnosing every patient with SIH. Spinal neuroimaging protocols used for diagnosing and localizing spinal cerebrospinal fluid leaks include brain/spinal MRI, computed tomography myelography, digital subtraction myelography, and radionuclide cisternography. Complications of SIH include subdural hematoma, cerebral venous thrombosis, and superficial siderosis. Treatment options encompass conservative management, epidural blood patches, and surgical interventions. The early application of epidural blood patches in all patients with SIH is suggested.

High yield clinical applications for photon counting CT in neurovascular imaging.

Photon-counting CT (PCCT) uses a novel X-ray detection mechanism that confers many advantages over that used in traditional energy integrating CT. As PCCT becomes more available, it is important to thoroughly understand its benefits and highest yield areas for improvements in diagnosis of various diseases. Based on our early experience, we have identified several areas of neurovascular imaging in which PCCT shows promise. Here, we describe the benefits in diagnosing arterial and venous diseases in the head, neck, and spine. Specifically, we focus on applications in head and neck CT angiography (CTA), spinal CT angiography, and CT myelography for detection of CSF-venous fistulas. Each of these applications highlights the technological advantages of PCCT in neurovascular imaging. Further understanding of these applications will not only benefit institutions incorporating PCCT into their practices but will also help guide future directions for implementation of PCCT for diagnosing other pathologies in neuroimaging.

Lumbar disc herniation: Epidemiology, clinical and radiologic diagnosis WFNS spine committee recommendations.

Objective: To formulate the most current, evidence-based recommendations regarding the epidemiology, clinical diagnosis, and radiographic diagnosis of lumbar herniated disk (LDH). Methods: A systematic literature search in PubMed, MEDLINE, and CENTRAL was performed from 2012 to 2022 using the search terms "herniated lumbar disc", "epidemiology", "prevention" "clinical diagnosis", and "radiological diagnosis". Screening criteria resulted in 17, 16, and 90 studies respectively that were analyzed regarding epidemiology, clinical diagnosis, and radiographic diagnosis of LDH. Using the Delphi method and two rounds of voting at two separate international meetings, ten members of the WFNS (World Federation of Neurosurgical Societies) Spine Committee generated eleven final consensus statements. Results: The lifetime risk for symptomatic LDH is 1-3%; of these, 60-90% resolve spontaneously. Risk factors for LDH include genetic and environmental factors, strenuous activity, and smoking. LDH is more common in males and in 30-50 year olds. A set of clinical tests, including manual muscle testing, sensory testing, Lasegue sign, and crossed Lasegue sign are recommended to diagnose LDH. Magnetic resonance imaging (MRI) is the gold standard for confirming suspected LDH. Conclusions: These eleven final consensus statements provide current, evidence-based guidelines on the epidemiology, clinical diagnosis, and radiographic diagnosis of LDH for practicing spine surgeons worldwide.

Spinal Cerebrospinal Fluid Leak Localization with Digital Subtraction Myelography: Tips, Tricks, and Pitfalls.

Cerebrospinal fluid (CSF) leak can cause spontaneous intracranial hypotension (SIH) which can lead to neurologic symptoms, such as orthostatic headache. Over time, imaging techniques for detecting and localizing CSF leaks have improved. These techniques include computed tomography (CT) myelography, dynamic CT myelography, cone-beam CT, MRI, MR myelography, and digital subtraction myelography (DSM). DSM provides the highest sensitivity for identifying leak sites and has comparable radiation exposure to CT myelography. The introduction of the lateral decubitus DSM has proven invaluable in localizing leaks when other imaging tests have been inconclusive.

A new modified technique of dynamic CT myelography to detect dural tears in spontaneous intracranial hypotension.

We propose a modified dynamic CT-myelography technique for patients with fast CSF leaks caused by ventral dural tears in order to reduce radiation exposure and complications. A fluoroscopy-guided lumbar puncture using an epidural anesthesia kit replaces a CT-guided lumbar puncture, and a smaller volume of less concentrated contrast media is used. This approach has advantages, including speeding up the procedure, reduced radiation exposure, and elimination of the risk of contrast injection into the epidural space.

Spontaneous Intracranial Hypotension: A Review of Neuroimaging and Current Concepts.

Spontaneous intracranial hypotension (SICH) is the emerging cause of orthostatic headache as it has been better recognized in recent years. SICH happens due to spinal cerebrospinal fluid (CSF) leak; however, the manifestations are predominantly cranial and hence imaging in SICH includes brain and spine. There are few characteristic brain imaging features to be concerned about to diagnose SICH in patients with vague symptoms or low clinical suspicion. Spine screening is recommended in these patients to assess spinal CSF leaks. While neuroradiologists play a significant role from the time of diagnosis to treatment of SICH, there is a need for all the general radiologists to be aware of the condition. Computed tomography myelogram and digital subtraction myelogram are performed for diagnostic and therapeutic management of SICH. There is a known risk for SICH recurrence in patients with sagittal longitudinal epidural collection and hence, targeted blood patch should be used instead of blind patch. Most importantly, slow mobilization is recommended following the patch to avoid recurrence.

A technique to localize posteriorly located spinal dural leaks associated with spontaneous intracranial hypotension: Dorsal-decubitus dynamic CT myelography.

BACKGROUND: Precise localization and understanding of the origin of cerebrospinal fluid (CSF) leak is crucial to allow targeted treatment. We report the technical feasibility and utility of dorsal-decubitus dynamic computed tomography (DDDCT) myelography to localize posteriorly located dural defects in patients with suspicion of posterolateral dural tears. METHODS: This study reports a series of four consecutive patients with posteriorly located SLEC and suspicion of posterolateral CSF leak who received DDDCT to localize the site of the leak. Patients were collected between October 2022 and October 2023. The technique of DDDCT and its efficacy to detect the site of CSF leak are reported. RESULTS: In all four patients (three females, one male, mean age 39 years), DDDCT myelography was technically successful and precisely demonstrated the site of the CSF leak. In one patient with both anterior and posterior SLEC, DDDCT allowed to exclude the presence of a posteriorly located leak, while a subsequent ventral decubitus dynamic CT myelography localized the leak. Leak sites were all thoracic, except for one that was cervical. Information obtained from the DDDCT myelography was considered useful to target the treatment of the leak. CONCLUSIONS: Based on our experience, DDDCT provided sufficient spatial and temporal resolution to pinpoint fast CSF leaks and it may be considered to localize posterolateral dural defects.

Incremental diagnostic yield and clinical outcomes of lateral decubitus CT myelogram immediately following negative lateral decubitus digital subtraction myelogram.

INTRODUCTION: Spontaneous intracranial hypotension (SIH) caused by a spinal cerebrospinal fluid (CSF) leak classically presents with orthostatic headache. Digital subtraction myelography (DSM) has a well-established diagnostic yield in the absence of extradural spinal collection. At our institution, DSM is followed by lateral decubitus CT myelogram (LDCTM) in the same decubitus position to increase diagnostic yield of the combined study. We evaluated the incremental diagnostic yield of LDCTM following negative DSM and reviewed patient outcomes. METHODS: Retrospective review of consecutive DSMs with subsequent LDCTM from April 2019 to March 2021 was performed. Combined reports were reviewed, and studies with positive DSMs were excluded. Of the exams with negative DSM, only studies with LDCTM reports identifying potential leak site were included. Interventions and follow-up clinical notes were reviewed to assess symptoms improvement following treatment. RESULTS: Of the 83 patients with negative DSMs, 11 (13.2%) had positive leak findings on LDCTMs, and 21 (25.3%) were equivocal. Of 11 positive LDCTMs, 6 leaks were nerve sheath tears (NSTs) and 5 were CSF-venous fistulas (CVFs). 10/11 (90.9%) had intervention and follow-up, with 9/10 (90%) having positive clinical outcome. Of the 21 equivocal LDCTM patients (19 CVFs and 2 NSTs), 15 (71.4%) had interventions and follow-up, with 3/15 (20.0%) with positive clinical outcomes. CONCLUSION: LDCTM following negative DSM has an incremental diagnostic yield up to 38.6%, with up to 14.5% of positive patient outcomes following treatment. LDCTM should be considered after DSM to maximize diagnostic yield of the combined exam.

Dosimetric analysis on computed tomography myelography based treatment planning in stereotactic body radiotherapy for spinal metastases.

This study aimed to quantitatively evaluate the influence of enhanced contrast on the CT myelography image of the spinal cord and/or cauda equina in addition to the target volume in spine SBRT treatment planning. In total, 19 patients who had previously undergone spine SBRT were randomly selected. The rigid image registration accuracy of CT myelography that aligned with the treatment planning CT was evaluated by calculating the normalized mutual information (NMI) and Pearson's correlation coefficient for the vertebral landmarks. At postregistration, the contrast-enhanced region of the CT myelography image was replaced with water-mass density, and the original treatment plan was recalculated on this image. For comparison, the dose was also recalculated on the contrast-enhanced CT myelography images. The NMI and Pearson's correlation coefficients for landmarks were 0.39 ± 0.12 and 0.97 ± 0.04, respectively. The mean D0.035cc of the spinal cord and/or cauda equina on the CT myelography image with the contrast-enhanced region replaced by water-mass density showed -0.37% ± 0.64% changes compared with that of the treatment planning CT. Conversely, the mean D0.035cc in contrast-enhanced CT myelography changed by -1.39% ± 0.51%. The percentage change in D98% for the planning target volume was confirmed to be small by replacing the contrast-enhanced region with water-mass density (p < 0.01). The dose calculation of the target volume, spinal cord, and/or cauda equina using the CT myelography image that replaced the contrast-enhanced region with water-mass density could be a more appropriate procedure with less dose calculation uncertainty.

Spontaneous intracranial hypotension: updates from diagnosis to treatment.

Spontaneous intracranial hypotension (SIH) is caused by spinal cerebrospinal fluid (CSF) leaks, which result in continued loss of CSF volume and multiple debilitating clinical manifestations. The estimated annual incidence of SIH is 5/100,000. Diagnostic methods have evolved in recent years due to improved understanding of pathophysiology and implementation of advanced myelographic techniques. Here, we synthesize recent updates and contextualize them in an algorithm for diagnosis and treatment of SIH, highlighting basic principles and points of practice variability or continued debate. This discussion includes finer points of SIH diagnosis, CSF leak classification systems, less common types and variants of CSF leaks, brain MRI Bern scoring, potential SIH complications, key technical considerations, and positioning strategies for different types of dynamic myelography. The roles of conservative measures, non-targeted or targeted blood patches, surgery, and recently developed endovascular techniques are presented.

Spinal Canal and Spinal Cord in Rat Continue to Grow Even after Sexual Maturation: Anatomical Study and Molecular Proposition.

Although rodents have been widely used for experimental models of spinal cord diseases, the details of the growth curves of their spinal canal and spinal cord, as well as the molecular mechanism of the growth of adult rat spinal cords remain unavailable. They are particularly important when conducting the experiments of cervical spondylotic myelopathy (CSM), since the disease condition depends on the size of the spinal canal and the spinal cord. Thus, the purposes of the present study were to obtain accurate growth curves for the spinal canal and spinal cord in rats; to define the appropriate age in weeks for their use as a CSM model; and to propose a molecular mechanism of the growth of the adult spinal cord in rats. CT myelography was performed on Lewis rats from 4 weeks to 40 weeks of age. The vertical growth of the spinal canal at C5 reached a plateau after 20 and 12 weeks, and at T8 after 20 and 16 weeks, in males and females, respectively. The vertical growth of the C5 and T8 spinal cord reached a plateau after 24 weeks in both sexes. The vertical space available for the cord (SAC) of C5 and T8 did not significantly change after 8 weeks in either sex. Western blot analyses showed that VEGFA, FGF2, and BDNF were highly expressed in the cervical spinal cords of 4-week-old rats, and that the expression of these growth factors declined as rats grew. These findings indicate that the spinal canal and the spinal cord in rats continue to grow even after sexual maturation and that rats need to be at least 8 weeks of age for use in experimental models of CSM. The present study, in conjunction with recent evidence, proposes the hypothetical model that the growth of rat spinal cord after the postnatal period is mediated at least in part by differentiation of neural progenitor cells and that their differentiation potency is maintained by VEGFA, FGF2, and BDNF.

Co-existing fast CSF leaks and CSF-venous fistulas on dynamic CT myelography.

Spontaneous intracranial hypotension can be caused by spinal dural tears or CSF-venous fistulas. It is rare for patients to have more than one type of leak at any given time. Here, we illustrate 3 examples of dural tears that co-existed with CSF-venous fistulas, with both being seen on dynamic CT myelography. To our knowledge, coexistent CSF-venous fistulas and dural tears have not been previously illustrated on dynamic CT myelography, even though this is one of the most commonly used modalities to work-up patients with CSF leaks. We discuss the clinical importance of the rare co-occurrence of these leaks with regard to diagnosis and treatment, as well as implications for understanding and classifying CSF leaks.

Lateral decubitus dynamic CT myelography for fast cerebrospinal fluid leak localization.

Dynamic CT myelography is used to precisely localize fast spinal CSF leaks. The procedure is most commonly performed in the prone position, which successfully localizes most fast ventral leaks. We have recently encountered a small subset of patients in whom prone dynamic CT myelography is unsuccessful in localizing leaks. We sought to determine the added value of lateral decubitus dynamic CT myelography, which is occasionally attempted in our practice, in localizing the leak after failed prone dynamic CT myelography. We retrospectively identified 6 patients who underwent lateral decubitus dynamic CT myelography, which was performed in each case because their prone dynamic CT myelogram was unrevealing. Two neuroradiologists independently reviewed preprocedural spine MRI and all dynamic CT myelograms for each patient. Lateral decubitus positioning allowed for precise leak localization in all 6 patients. Five of six patients were noted to have dorsal and/or lateral epidural fluid collections on spine MRI. One patient had a single prominent diverticulum on spine MRI (larger than 6 mm), whereas the others had no prominent diverticula. Our study suggests that institutions performing dynamic CT myelography to localize fast leaks should consider a lateral decubitus study if performing the study in the prone position is unrevealing. Furthermore, the presence of dorsal and/or lateral epidural fluid collections on spine MRI may suggest that a lateral decubitus study is of higher yield and could be considered initially.

Radiographic imaging modalities for perinatal brachial plexus palsy: a systematic review.

PURPOSE: Perinatal brachial plexus palsy (PBPP) has a wide spectrum of clinical symptoms that can range from incomplete paresis of the affected extremity to flaccid arm paralysis. Although there is a high rate of spontaneous recovery within the first two years of life, it remains challenging to determine which patients will benefit most from surgical intervention. The diagnostic and predictive use of various imaging modalities has been described in the literature, but there is little consensus on approach or algorithm. The anatomic, pathophysiological, and neurodevelopmental characteristics of the neonatal and infant patient population affected by PBPP necessitate thoughtful consideration prior to selecting an imaging modality. METHODS: A systematic review was conducted using six databases. Two reviewers independently screened articles published through October 2021. RESULTS: Literature search produced 10,329 publications, and 22 articles were included in the final analysis. These studies included 479 patients. Mean age at time of imaging ranged from 2.1 to 12.8 months and investigated imaging modalities included MRI (18 studies), ultrasound (4 studies), CT myelography (4 studies), and X-ray myelography (1 study). Imaging outcomes were compared against surgical findings (16 studies) or clinical examination (6 studies), and 87.5% of patients underwent surgery. CONCLUSION: This systematic review addresses the relative strengths and challenges of common radiologic imaging options. MRI is the most sensitive and specific for identifying preganglionic nerve injuries such as pseudomeningoceles and rootlet avulsion, the latter of which has the poorest prognosis in this patient population and often dictates the need for surgical intervention.

Dual energy CT for the identification of CSF-Venous Fistulas and CSF leaks in spontaneous intracranial hypotension: Report of four cases.

Spontaneous intracranial hypotension (SIH) is a debilitating condition caused by spinal CSF leaks or CSF-venous fistulas (CVFs). Localizing the causative CSF leak or CVF is critical for definitive treatment but can be difficult using conventional myelographic techniques because these lesions are often low contrast compared to background, diminutive, and in some cases may be mistaken for calcified structures. Dual energy CT (DECT) can increase the conspicuity of iodinated contrast compared to background and can provide the ability to distinguish materials based on differing anatomic properties, making it well suited to address the shortcomings of conventional myelography in SIH. The purpose of this report is to illustrate the potential benefits of using DECT as an adjunct to traditional myelographic techniques in order to increase the conspicuity of these often-subtle CVFs and CSF leaks. This retrospective case series included 4 adult patients with SIH who demonstrated findings equivocal for either CVF or CSF leak using our institution's standard initial CT myelogram and in whom subsequent evaluation with DECT ultimately helped to identify the CVF or CSF leak. DECT demonstrated utility by increasing the conspicuity of two subtle CVFs compared to background and also helped to differentiate between calcified osteophytes and extradural contrast in 2 CSF leaks, confirming their presence and identifying the causative pathology. Our observations demonstrate the benefit of DECT as a problem-solving tool in the accurate diagnosis and localization of CVFs and CSF leaks.

Osseous spicules of the posterior elements causing fast cerebrospinal fluid leaks.

PURPOSE: Dural tears are a common cause of spontaneous spinal CSF leaks. The majority of such leaks occur ventrally along the thecal sac, typically due to ventral osseous spicules that cause a rent in the dura. A minority of dural leaks are posterolateral in location. These leaks usually do not have an identifiable anatomic cause. We have anecdotally observed cases of posterolateral leaks caused by osseous spicules and sought to describe this phenomenon. METHODS: We retrospectively reviewed our imaging database, searching for cases of posterolateral CSF leaks caused by osseous spicules. We identified and included three such patients and reviewed imaging and clinical information from each patient. RESULTS: All three patients had been diagnosed using hyperdynamic CT myelography or conventional CT myelography. Their imaging showed dorsal epidural fluid collections that were related to posterolateral leaks adjacent to dorsal osseous spicules. CONCLUSION: Dorsal osseous spicules have the potential to cause posterolateral CSF leaks.

Scalpel Sign in Spine Pathology: Presentation in 3 Different Rare Diagnoses.

BACKGROUND: The scalpel sign is a radiological finding observed on sagittal magnetic resonance imaging and computed tomography myelography corresponding to an indentation in the dorsal aspect of the spinal cord resembling a surgical scalpel blade. It is said to be a pathognomonic imaging discovery linked to dorsal arachnoid webs. However, other spine-related conditions may mimic dorsal arachnoid webs on magnetic resonance imaging, such as spinal arachnoid cysts or ventral spinal cord herniation, leading to misdiagnosis. METHODS: A retrospective review was performed of cases involving 3 different diagnoses at our institution in the last 5 years that shared in common the characteristic focal dorsal indentation of the spinal cord. RESULTS: Of 7 cases identified, all but 1 were treated and confirmed intraoperatively. All lesions were located at the dorsal spinal cord. Magnetic resonance imaging was the study of choice for evaluation. Clinical manifestations included back pain and lower extremity numbness and weakness together with compressive myelopathy signs and urinary symptoms. Mean follow-up was 16.8 months with satisfactory postoperative results. CONCLUSIONS: Isolated radiological presentation of the scalpel sign is not sufficient to distinguish between dorsal arachnoid webs, arachnoid cysts, and ventral herniation of the spine. However, awareness of its importance is relevant for accurate curative surgical planning.

Incidence of Spinal CSF Leakage on CT Myelography in Patients with Nontraumatic Intracranial Subdural Hematoma.

The aim of the present study was to demonstrate the incidence of spinal cerebrospinal fluid (CSF) leaks in patients with nontraumatic intracranial subdural hematoma (SDH) and determine clinical parameters favoring such leaks. This retrospective study was approved by the institutional review board. Patients diagnosed with nontraumatic intracranial SDH who underwent computed tomography (CT) myelography between January 2012 and March 2018 were selected. 60 patients (male: female, 39:21; age range, 20-82 years) were enrolled and divided into CSF leak-positive and CSF leak-negative groups according to CT myelography data. Clinical findings were statistically compared between the two groups. Spinal CSF leak was observed in 80% (48/60) of patients, and it was significantly associated with an age of <69 years (p = 0.006). However, patients aged ≥69 years also had a tendency to exhibit spontaneous intracranial hypotension (SIH)-induced nontraumatic intracranial SDH (60.87%; 14/23). Therefore, CT myelography is recommended to be performed for the evaluation of possible SIH in patients with nontraumatic intracranial SDH, particularly those aged <69 years. Patients aged ≥69 years are also good candidates for CT myelography because SIH tends to occur even in this age group.