Optic Nerve MRI T2-Hyperintensity: A Nonspecific Marker of Optic Nerve Damage.

BACKGROUND: MRI abnormalities are common in optic neuropathies, especially on dedicated orbital imaging. In acute optic neuritis, optic nerve T2-hyperintensity associated with optic nerve contrast enhancement is the typical imaging finding. In chronic optic neuropathies, optic nerve T2-hyperintensity and atrophy are regularly seen. Isolated optic nerve T2-hyperintensity is often erroneously presumed to reflect optic neuritis, frequently prompting unnecessary investigations and neuro-ophthalmology consultations. Our goal was to determine the significance of optic nerve/chiasm T2-hyperintensity and/or atrophy on MRI. METHODS: Retrospective study of consecutive patients who underwent brain/orbital MRI with/without contrast at our institution between July 1, 2019, and June 6, 2022. Patients with optic nerve/chiasm T2-hyperintensity and/or atrophy were included. Medical records were reviewed to determine the etiology of the T2-hyperintensity and/or atrophy. RESULTS: Four hundred seventy-seven patients (698 eyes) were included [mean age 52 years (SD ±18 years); 57% women]. Of the 364 of 698 eyes with optic nerve/chiasm T2-hyperintensity without atrophy, the causes were compressive (104), inflammatory (103), multifactorial (49), glaucoma (21), normal (19), and other (68); of the 219 of 698 eyes with optic nerve/chiasm T2-hyperintensity and atrophy, the causes were compressive (57), multifactorial (40), inflammatory (38), glaucoma (33), normal (7), and other (44); of the 115 of 698 eyes with optic nerve/chiasm atrophy without T2-hyperintensity, the causes were glaucoma (34), multifactorial (21), inflammatory (13), compressive (11), normal (10), and other (26). Thirty-six eyes with optic nerve/chiasm T2-hyperintensity or atrophy did not have evidence of optic neuropathy or retinopathy on ophthalmologic examination, and 17 eyes had clinical evidence of severe retinopathy without primary optic neuropathy. CONCLUSIONS: Optic nerve T2-hyperintensity or atrophy can be found with any cause of optic neuropathy and with severe chronic retinopathy. These MRI findings should not automatically prompt optic neuritis diagnosis, workup, and treatment, and caution is advised regarding their use in the diagnostic criteria for multiple sclerosis. Cases of incidentally found MRI optic nerve T2-hyperintensity and/or atrophy without a known underlying optic neuropathy or severe retinopathy are rare. Such patients should receive an ophthalmologic examination before further investigations.

Automated Registration and Color Labeling of Serial 3D Double Inversion Recovery MR Imaging for Detection of Lesion Progression in Multiple Sclerosis.

Automated co-registration and subtraction techniques have been shown to be useful in the assessment of longitudinal changes in multiple sclerosis (MS) lesion burden, but the majority depend on T2-fluid-attenuated inversion recovery sequences. We aimed to investigate the use of a novel automated temporal color complement imaging (CCI) map overlapped on 3D double inversion recovery (DIR), and to assess its diagnostic performance for detecting disease progression in patients with multiple sclerosis (MS) as compared to standard review of serial 3D DIR images. We developed a fully automated system that co-registers and compares baseline to follow-up 3D DIR images and outputs a pseudo-color RGB map in which red pixels indicate increased intensity values in the follow-up image (i.e., progression; new/enlarging lesion), blue-green pixels represent decreased intensity values (i.e., disappearing/shrinking lesion), and gray-scale pixels reflect unchanged intensity values. Three neuroradiologists blinded to clinical information independently reviewed each patient using standard DIR images alone and using CCI maps based on DIR images at two separate exams. Seventy-six follow-up examinations from 60 consecutive MS patients who underwent standard 3 T MR brain MS protocol that included 3D DIR were included. Median cohort age was 38.5 years, with 46 women, 59 relapsing-remitting type MS, and median follow-up interval of 250 days (interquartile range: 196-394 days). Lesion progression was detected in 67.1% of cases using CCI review versus 22.4% using standard review, with a total of 182 new or enlarged lesions using CCI review versus 28 using standard review. There was a statistically significant difference between the two methods in the rate of all progressive lesions (P < 0.001, McNemar's test) as well as cortical progressive lesions (P < 0.001). Automated CCI maps using co-registered serial 3D DIR, compared to standard review of 3D DIR alone, increased detection rate of MS lesion progression in patients undergoing clinical brain MRI exam.

Carotid-Cavernous Fistula Presenting as Isolated Painful Anisocoria.

A painful isolated third nerve palsy is an uncommon presenting sign of a carotid-cavernous fistula (CCF). It mostly occurs in dural CCFs with posterior drainage into the petrosal sinuses. We present a case of a 50-year-old woman who developed acute right periorbital facial pain in the territory of the first branch of the right trigeminal nerve and was noted to have a right dilated unreactive pupil with very subtle right ptosis. She was subsequently diagnosed with a posteriorly draining dural CCF.

Seizures as the Initial Manifestation of Idiopathic Intracranial Hypertension Spectrum Disorder.

Idiopathic intracranial hypertension (IIH) is a syndrome of isolated elevated intracranial pressure of unknown aetiology. The IIH spectrum has evolved over the past decade making the diagnosis and management more challenging. The neurological examination in IIH is typically normal except for papilloedema and possible cranial nerve 6 palsy. Recent publications have highlighted skull base thinning and remodelling in patients with chronic IIH. Resulting skull base defects can cause meningo-encephalocoeles, which are potential epileptogenic foci. We describe the clinical and radiological characteristics of five IIH patients with seizures and meningo-encephalocoeles as the presenting manifestations of IIH spectrum disorder.

Clinical Characteristics of Most Frequent Use of Iodinated Contrast Media for CT.

Given the integral role of CT in patient care, the current global contrast media shortage creates profound and manifold patient care implications. We used a large insurance dataset to highlight examinations (abdominopelvic and chest CT), delivery settings (emergency department and outpatient hospital), and clinical indications (acute abdominopelvic and chest disease and cancer surveillance) for which contrast-enhanced CT is most commonly used. Such information may help inform emerging national guidelines and institutional policies.

Retinal and optic nerve magnetic resonance diffusion-weighted imaging in acute non-arteritic central retinal artery occlusion.

OBJECTIVES: Diffusion weighted imaging hyperintensity (DWI-H) has been described in the retina and optic nerve during acute central retinal artery occlusion (CRAO). We aimed to determine whether DWI-H can be accurately identified on standard brain magnetic resonance imaging (MRI) in non-arteritic CRAO patients at two tertiary academic centers. MATERIALS AND METHODS: Retrospective cross-sectional study that included all consecutive adult patients with confirmed acute non-arteritic CRAO and brain MRI performed within 14 days of CRAO. At each center, two neuroradiologists masked to patient clinical data reviewed each MRI for DWI-H in the retina and optic nerve, first independently then together. Statistical analysis for inter-rater reliability and correlation with clinical data was performed. RESULTS: We included 204 patients [mean age 67.9±14.6 years; 47.5% females; median time from CRAO to MRI 1 day (IQR 1-4.3); 1.5 T in 127/204 (62.3%) and 3.0 T in 77/204 (37.7%)]. Inter-rater reliability varied between centers (κ = 0.27 vs. κ = 0.65) and was better for retinal DWI-H. Miss and error rates significantly differed between neuroradiologists at each center. After consensus review, DWI-H was identified in 87/204 (42.6%) patients [miss rate 117/204 (57.4%) and error rate 11/87 (12.6%)]. Significantly more patients without DWI-H had good visual acuity at follow-up (p = 0.038). CONCLUSIONS: In this real-world case series, differences in agreement and interpretation accuracy among neuroradiologists limited the role of DWI-H in diagnosing acute CRAO on standard MRI. DWI-H was identified in 42.6% of patients and was more accurately detected in the retina than in the optic nerve. Further studies are needed with standardized novel MRI protocols.

Teaching Physician Supervision: Medicare's Ongoing Imperative for Academic Radiologists.

OBJECTIVE. Medicare permits radiologists to bill for trainee work but only in narrowly defined circumstances and with considerable consequences for noncompliance. The purpose of this article is to introduce relevant policy rationale and definitions, review payment requirements, outline documentation and operational considerations for diagnostic and interventional radiology services, and offer practical suggestions for academic radiologists striving to optimize regulatory compliance. CONCLUSION. As academic radiology departments advance their missions of service, teaching, and scholarship, most rely on residents and fellows to support expanding clinical demands. Given the risks of technical noncompliance, institutional commitment and ongoing education regarding teaching supervision compliance are warranted.

Prediction of Postoperative Risk of Raised Intracranial Pressure After Spontaneous Skull Base Cerebrospinal Fluid Leak Repair.

BACKGROUND: A relationship between idiopathic intracranial hypertension and spontaneous skull base cerebrospinal fluid (CSF) leaks has been proposed, by which CSF leak decreases intracranial pressure (ICP) and masks the symptoms and signs of elevated ICP. These patients are at risk of developing papilledema, symptoms of elevated ICP, or a recurrent CSF leak after CSF leak repair. The objective of this study was to assess whether radiographic signs of raised ICP on preoperative magnetic resonance or computed venography (MRI or CTV) are predictors of postoperative papilledema, recurrence of CSF leak, or need for CSF shunt surgery. METHODS: We performed a retrospective review of systematically collected demographics, fundus examination, and presurgical brain MRI and magnetic resonance venography/computed tomography venography (MRV/CTV) in patients seen at 1 institution between 2013 and 2019 with spontaneous skull base CSF leak repair. Patients were divided into 2 groups depending on whether they developed papilledema, recurrent CSF leak, or required CSF shunting (Group 1) or not (Group 2). RESULTS: Fifty-seven patients were included, among whom 19 were in Group 1. There was no difference in demographic characteristics or clinical features between patients in Group 1 and Group 2. Controlling for other imaging features, bilateral transverse venous sinus stenosis (TVSS) on preoperative imaging increased the odds of being in Group 1 by 4.2 times (95% confidence interval [CI], 1.04-21.2, P = 0.04), optic nerve tortuosity decreased the odds of being in Group 1 by 8.3 times (95% CI: 1.4-74.6, P = 0.02). CONCLUSION: Imaging of the intracranial venous system with MRV or CTV is warranted before repair of spontaneous CSF leak, as bilateral TVSS is an independent risk factor for postoperative papilledema, CSF leak recurrence, or need for a CSF shunting procedure.

Optic Nerve Angle in Idiopathic Intracranial Hypertension.

BACKGROUND: The tortuosity of the optic nerve can be quantified radiologically by measuring the angle of optic nerve deformation (the "optic nerve angle" [ONA]). In patients with idiopathic intracranial hypertension (IIH), lowering the intracranial pressure (ICP) to a normal range by lumbar puncture leads to straightening of the optic nerve and an increase in the measured sagittal ONA on MRI. It is uncertain whether there is any correlation between ONA and cerebrospinal fluid (CSF) opening pressure or visual function. METHODS: Retrospective study of patients with and without IIH who had MRI of the brain followed by lumbar puncture with CSF opening pressure within 24 hours of MRI. Before LP and within 24 hours of MRI of the brain, all patients with IIH had neuro-ophthalmologic assessment including visual acuity, Humphrey Visual Field (HVF), and fundus photography. Sagittal ONA was measured on multiplanar T2-SPACE images on a DICOM viewer. Papilledema on the fundus photographs was graded using the Frisén scale. RESULTS: Fifty-four patients with IIH and 30 unmatched controls were included. The IIH group was 6.3 years younger (95% CI 2.4-10.3, P = 0.002), had 8.7 kg/m2 higher body mass index (4.9-12.5, P < 0.001), and 26.3% more women (P = 0.011) compared with controls. In both eyes, the ONA was significantly smaller in patients with IIH by 12° compared with controls (7°-17°, P < 0.00001). In the IIH group, no correlation between ONA and the CSF opening pressure was present in either eye (right eye r = 0.19, P = 0.15; left eye r = 0.18, P = 0.19) The ONA did not correlate with logarithm of the minimum angle of resolution visual acuity (right eye r = 0.26, P = 0.063; left eye r = 0.15, P = 0.27), HVF mean deviation (right eye r = 0.0059, P = 0.97; left eye r = -0.069, P = 0.63), or Frisén grade (Spearman's rho right eye 0.058, P = 0.67; left eye 0.14, P = 0.30). CONCLUSIONS: The ONA is significantly smaller in patients with IIH compared to controls, but does not correlate with CSF opening pressure, severity of papilledema, or visual function. The ONA may be useful in identifying patients with raised ICP, but not necessarily those with a poor visual prognosis.

Simultaneous perfusion and permeability assessments using multiband multi-echo EPI (M2-EPI) in brain tumors.

PURPOSE: To study a multiband multi-echo EPI (M2-EPI) sequence for dynamic susceptibility contrast (DSC) perfusion imaging with leakage correction and vascular permeability measurements, and to evaluate the benefits of increased temporal resolution provided by this acquisition strategy on the accuracy of perfusion and permeability estimations. METHODS: A novel M2-EPI sequence was developed, and a pharmacokinetic model accounting for contrast agent extravasation was used to produce perfusion maps and additional vascular permeability maps. The advantage of M2-EPI for DSC perfusion imaging was demonstrated in vivo in 5 patients with brain tumors, and numerical simulations were performed to evaluate the advantage of improved temporal resolution afforded by the technique. RESULTS: In contrast to underestimations of cerebral blood volume (CBV) in tumors using the single-echo acquisition strategy, M2-EPI provided more plausible estimates of CBV. A quantitative evaluation showed higher estimated values of CBV and mean transit time in tumor tissues using M2-EPI (CBV: 3.08 ± 0.78 mL/100 g versus 1.56 ± 1.38 mL/100 g [P = .006]; mean transit time: 4.94 ± 1.17 seconds versus 1.83 ± 2.06 seconds [P = 0.033]). Numerical simulations showed that higher temporal resolution provided by M2-EPI was associated with more accurate estimates of cerebral blood flow, CBV, and permeability parameters. CONCLUSION: The novel M2-EPI acquisition strategy for DSC imaging facilitates leakage-corrected perfusion measurements with additional permeability assessments and more accurate estimates of perfusion/permeability parameters, and may be used as a quantitative tool for the diagnosis, prognosis, and treatment monitoring of brain tumors.

Stereotactic laser amygdalohippocampotomy for mesial temporal lobe epilepsy.

OBJECTIVE: To evaluate the outcomes 1 year and longer following stereotactic laser amygdalohippocampotomy for mesial temporal lobe epilepsy in a large series of patients treated over a 5-year period since introduction of this novel technique. METHODS: Surgical outcomes of a consecutive series of 58 patients with mesial temporal lobe epilepsy who underwent the surgery at our institution with at least 12 months of follow-up were retrospectively evaluated. A subgroup analysis was performed comparing patients with and without mesial temporal sclerosis. RESULTS: One year following stereotactic laser amygdalohippocampotomy, 53.4% (95% confidence interval [CI] = 40.8-65.7%) of all patients were free of disabling seizures (Engel I). Three of 9 patients became seizure-free following repeat ablation. Subgroup analysis showed that 60.5% (95% CI = 45.6-73.7%) of patients with mesial temporal sclerosis were free of disabling seizures as compared to 33.3% (95% CI = 15.0-58.5%) of patients without mesial temporal sclerosis. Quality of Life in Epilepsy-31 scores significantly improved at the group level, few procedure-related complications were observed, and verbal memory outcome was better than historical open resection data. INTERPRETATION: In an unselected consecutive series of patients, stereotactic laser amygdalohippocampotomy yielded seizure-free rates for patients with mesial temporal lobe epilepsy lower than, but comparable to, the outcomes typically associated with open temporal lobe surgery. Analogous to results from open surgery, patients without mesial temporal sclerosis fared less well. This novel procedure is an effective minimally invasive alternative to resective surgery. In the minority of patients not free of disabling seizures, laser ablation presents no barrier to additional open surgery. Ann Neurol 2018;83:575-587.

Mechanisms and Risk Factors Contributing to Visual Field Deficits following Stereotactic Laser Amygdalohippocampotomy.

Selective laser amygdalohippocampotomy (SLAH) is a minimally invasive surgical treatment for medial temporal lobe epilepsy. Visual field deficits (VFDs) are a significant potential complication. The objective of this study was to determine the relationship between VFDs and potential mechanisms of injury to the optic radiations and lateral geniculate nucleus. We performed a retrospective cross-sectional analysis of 3 patients (5.2%) who developed persistent VFDs after SLAH within our larger series (n = 58), 15 healthy individuals and 10 SLAH patients without visual complications. Diffusion tractography was used to evaluate laser catheter penetration of the optic radiations. Using a complementary approach, we evaluated evidence for focal microstructural tissue damage within the optic radiations and lateral geniculate nucleus. Overablation and potential heat radiation were assessed by quantifying ablation and choroidal fissure CSF volumes as well as energy deposited during SLAH.SLAH treatment parameters did not distinguish VFD patients. Atypically high overlap between the laser catheter and optic radiations was found in 1/3 VFD patients and was accompanied by focal reductions in fractional anisotropy where the catheter entered the lateral occipital white matter. Surprisingly, lateral geniculate tissue diffusivity was abnormal following, but also preceding, SLAH in patients who subsequently developed a VFD (all p = 0.005).In our series, vision-related complications following SLAH, which appear to occur less frequently than following open temporal lobe -surgery, were not directly explained by SLAH treatment parameters. Instead, our data suggest that variations in lateral geniculate structure may influence susceptibility to indirect heat injury from transoccipital SLAH.

Cerebrospinal Fluid Pressure Reduction Results in Dynamic Changes in Optic Nerve Angle on Magnetic Resonance Imaging.

BACKGROUND: Optic nerve sheath tortuosity is a previously reported, but incompletely characterized, finding in idiopathic intracranial hypertension (IIH). We hypothesized that optic nerve angle (ONA), as a quantitative measure of tortuosity, would change dynamically with cerebrospinal fluid (CSF) pressure status of patients with IIH immediately before and after lumbar puncture (LP). METHODS: Consecutive patients with suspected IIH referred for MRI and diagnostic LP were prospectively enrolled in this single institution, institutional review board-approved study. Each patient underwent a pre-LP MRI, diagnostic LP with opening pressure (OP) and closing pressure (CP), and then post-LP MRI all within 1 session. Sagittal and axial ONAs were measured on multiplanar T2 SPACE images by 2 neuroradiologists on pre- and post-LP MRI. Effects of measured pressure and CSF volume removal on changes in ONA were analyzed as was interrater reliability for ONA measurement. RESULTS: Ten patients with IIH were included {all female, median age 29 (interquartile range [IQR] 25-32)}. All patients had elevated OP (median 37, IQR 34-41 cm H2O), and significantly reduced CP (median 18, IQR 16-19 cm H2O, P < 0.001) after CSF removal (IQR 13-16 mL). Within patients, mean ONAs (sagittal and axial) were significantly lower before (162 ± 9°, 163 ± 10°) than after (168 ± 7°, 169 ± 5°) LP (P = 0.001, 0.008, respectively). Interrater reliability was higher with sagittal ONA measurements (0.89) than axial (0.72). CONCLUSIONS: ONA changes with short-term CSF pressure reduction in patients with IIH, establishing optic nerve tortuosity as a dynamic process related to CSF status.

Do Most Patients With a Spontaneous Cerebrospinal Fluid Leak Have Idiopathic Intracranial Hypertension?

BACKGROUND: The association between cerebrospinal fluid (CSF) leaks at the skull base and raised intracranial pressure (ICP) has been reported since the 1960s. It has been suggested that spontaneous CSF leaks might represent a variant of idiopathic intracranial hypertension (IIH). We review the evidence regarding the association between spontaneous CSF leaks and IIH, and the role of ICP in the pathophysiology of nontraumatic skull base defects. We also discuss the management of ICP in the setting of CSF leaks and IIH. EVIDENCE ACQUISITION: References were identified by searches of PubMed from 1955 to September 2018 with the terms "idiopathic intracranial hypertension" and "cerebrospinal fluid leak." Additional references were identified using the terms "pseudotumor cerebri," "intracranial hypertension," "benign intracranial hypertension," and by hand search of relevant articles. RESULTS: A CSF leak entails the egress of CSF from the subarachnoid spaces of the skull base into the surrounding cavitary structures. Striking overlaps exist regarding demographic, clinical, and radiological characteristics between IIH patients and those with spontaneous CSF leaks, suggesting that some (if not most) of these patients have IIH. However, determining whether a patient with spontaneous CSF leak may have IIH may be difficult, as signs and symptoms of raised ICP may be obviated by the leak. The pathophysiology is unknown but might stem from progressive erosion of the thin bone of the skull base by persistent pulsatile high CSF pressure. Currently, there is no consensus regarding the management of ICP after spontaneous CSF leak repair when IIH is suspected. CONCLUSIONS: IIH is becoming more widely recognized as a cause of spontaneous CSF leaks, but the causal relationship remains poorly characterized. Systematic evaluation and follow-up of patients with spontaneous CSF leaks by neuro-ophthalmologists will help clarify the relation between IIH and spontaneous CSF leaks.

The use of contrast-enhanced, time-resolved magnetic resonance angiography in cerebrovascular pathology.

Digital subtraction angiography (DSA) has long been the imaging gold standard in the evaluation, treatment, and follow-up of cerebro- and spinovascular disorders. However, DSA has the disadvantages of invasiveness, contrast allergy or nephropathy, the impracticality of procedural preparation and recovery, and expense. Contrast-enhanced (CE), time-resolved (TR) magnetic resonance angiography (CE TR-MRA) is a sophisticated, relatively novel imaging modality that provides multiphasic contrast-enhanced visualization of the neurovasculature. Given the crucial role of angiography in all aspects of care for patients with complex neurovascular disorders, it is incumbent on those who care for these patients to understand the usefulness and pitfalls of novel imaging in this arena to ensure best practices, and to deliver cutting edge care to these patients in a way that minimizes cost, but does not compromise quality. CE TR-MRA has the potential to play an expanded role in the workup and follow-up across the spectrum of neurovascular disease, and this review is aimed to help neurosurgeons better understand how CE TR-MRA can be used to better manage patients in this cohort.

Papilloedema from Dural Venous Sinus Compression by Meningiomas.

Intracranial mass lesions may cause intracranial hypertension secondary to venous hypertension when they compress the dural venous sinuses (DVS) and may present with isolated papilloedema, mimicking idiopathic intracranial hypertension. We report a series of 16 patients with isolated papilloedema related to meningiomas compressing the DVS seen from 2012 to 2016 at three institutions. Correct diagnosis was delayed in 10/16 patients and treatment required a multidisciplinary approach, often with multiple sequential interventions, including combinations of acetazolamide, cerebrospinal fluid-shunt, optic nerve sheath fenestration, surgical resection of the meningioma, radiation therapy, and endovascular venous stenting. Two patients also received anticoagulation for venous thrombosis secondary to venous sinus compression.

Effects of Height and Blood Volume on Venous Enhancement After Gadolinium-Based Contrast Administration in MR Venography: A Paradigm Challenge and Implications for Clinical Imaging.

OBJECTIVE: The purpose of this study was to analyze quantitative and qualitative effects of estimated blood volume on venous enhancement in patients undergoing cerebral MR venography (MRV) with standard weight-based dosing of a gadolinium-based contrast agent. MATERIALS AND METHODS: Fifty-two patients with normal 1.5-T cerebral MRV findings and contemporaneous height and weight measurements were included. Estimated blood volume was calculated with the Nadler formula for blood volume. Standard weight-based cerebral MRV was performed after administration of gadobenate dimeglumine (0.1 mmol/kg up to 20 mL). Venous enhancement within the superior sagittal sinus, right jugular bulb, and left jugular bulb was measured. Patients were dichotomized on the basis of administration of less than versus a maximum weight-based gadolinium-based contrast dose of 20 mL. Venographic quality was assigned by two neuroradiologists. Correlational and multiple linear regression analyses were performed. RESULTS: Among patients receiving less than the maximum 20 mL of gadolinium, no significant correlations were observed between weight and vascular enhancement (p > 0.05). Significant correlations between height and enhancement were observed in the superior sagittal sinus and left jugular bulb. This finding suggests that differences in estimated blood volume driven by height remain unaccounted for (p < 0.05). With the 20-mL maximal dose, a significant inverse relation was noted between estimated blood volume and contrast enhancement of all vascular segments (p < 0.05). Within all vascular segments, significant correlations were observed between enhancement and user-defined quality scores (p < 0.05). This finding suggests that optimized dosing may affect reader confidence. CONCLUSION: Standard weight-based dosing for cerebral MRV insufficiently accounts for differences in circulating blood volume. An expanded biometric dosing paradigm leveraging readily attainable subject data may mitigate unintended variations in enhancement affecting venography and other clinical imaging modalities.

Diagnostic Performance of MRI Sequences for Evaluation of Dural Venous Sinus Thrombosis.

OBJECTIVE: The purpose of this study is to assess the performance of routinely used MRI sequences with and without contrast enhancement in the diagnostic evaluation of dural venous sinus thrombosis (DVST). MATERIALS AND METHODS: We identified consecutive patients older than 18 years who underwent concurrent standardized brain MRI and contrast-enhanced (CE) MR venography (MRV) examinations for suspected DVST. The seven MRI sequences that were used (axial unenhanced T1-weighted, T1-weighted CE, T2-weighted, DWI, T2-weighted FLAIR, T2-weighted gradient-recalled echo [GRE], and sagittal 3D T1-weighted GRE CE sequences) were randomized, anonymized, and reviewed independently by two neuroradiologists who were blinded to the final diagnosis. Ten separate venous sinus segments were evaluated. CE MRV was the reference standard for determining the presence or absence of DVST, and it was performed using the following imaging parameters: TR/TE, 4.1-77/1.4-9.5; flip angle, 12-35°; and slice thickness, 0.8-1.4 mm. The diagnostic performance of and interobserver variability for each sequence was assessed per patient and per segment. RESULTS: Thirty-six patients with DVST (72% of whom had acute thrombosis and 28% of whom had chronic thrombosis) and 29 patients without DVST were included in the study. For each sequence, the AUC values for the detection of DVST per patient, as determined by reviewer 1 and reviewer 2, respectively, were as follows: for T1-weighted unenhanced sequences, 55% and 61%; for T1-weighted CE sequences, 79% and 80%; for T2-weighted sequences, 77% and 76%; for DWI sequences, 59% and 64%; for T2-weighted FLAIR sequences, 70% and 72%; for T2-weighted GRE sequences, 64% and 66%; and for the 3D T1-weighted GRE CE sequence, 77% and 81%. The diagnostic performance of the 3D T1-weighted GRE CE sequences was statistically significantly greater than that of the other sequences. Interobserver variability ranged from 0.26 (for T1-weighted unenhanced sequences) to 0.73 (for the DWI sequence). Overall, for each reviewer and with the use of all evaluated sequences, MRI had a high sensitivity (> 99% for both reviewers) but low specificity (14% for reviewer 1 and 48% for reviewer 2) for the detection of DVST. CONCLUSION: Sequences used in routine brain MRI performed with and without contrast enhancement have varying strengths that are important to recognize when the likelihood of DVST is assessed, but they do not replace the utility of dedicated CE MRV.

Safety and Quality of 1.5-T MRI in Patients With Conventional and MRI-Conditional Cardiac Implantable Electronic Devices After Implementation of a Standardized Protocol.

OBJECTIVE: The purpose of this study was to evaluate the safety and diagnostic utility of 1.5-T MRI examinations of individuals with conventional and MRI-conditional cardiac implantable electronic devices (CIEDs). SUBJECTS AND METHODS: Patients with a CIED who were referred for MRI were evaluated by radiologists and cardiac electrophysiologists for study participation. CIED interrogation was performed immediately before and after MRI, and cardiac telemetry monitoring was performed during MRI. CIED programming changes, malfunctions, and intraprocedural events were documented. Whether diagnostic questions were answered and whether artifacts related to the CIED were present and negatively affected image interpretation were recorded. RESULTS: One hundred thirteen MRI examinations were performed for 104 patients with CIEDs (74 pacemakers [60 conventional, 14 MRI conditional]; 39 implantable cardiac defibrillators). Device reprogramming was required before MRI for 62.8% of studies (71/113). No significant changes in lead parameters were noted during or after MRI. Electromagnetic noise was detected on at least one lead in 7.1% of studies. Three patients reported transient symptoms (one case each of heating at the pocket site, tingling at the pocket site, and palpitations). All images were considered diagnostic for the original clinical query. Artifacts related to CIEDs were described in 3.5% of MRI reports (4/113) and were present only when the pulse generator was included in the FOV. CIED-related artifacts limited evaluation of tissues immediately adjacent to the pulse generator. CONCLUSION: Establishment of a multidisciplinary work flow allows individuals with conventional and MRI-conditional CIEDs to safely undergo 1.5-T MRI with diagnostic questions consistently answered.