Ectopic pituitary adenomas: common presentations of a rare entity.

PURPOSE: Ectopic pituitary adenomas (EPA) are rare tumors thought to arise from embryological remnants along the route of normal pituitary migration. Clinically, these tumors vary in hormonal activity and can exert mass effect based on location and size. METHODS: We performed a single-center retrospective analysis of patients with diagnosis of ectopic pituitary adenoma from 2001 to 2018. RESULTS: Five patients were identified with EPA: a 48-year-old woman with suprasellar EPA treated with transsphenoidal removal of the tumor, a 44-year-old woman with cavernous EPA treated with transsphenoidal removal of the tumor, a 48-year-old woman with sphenoid EPA treated with cabergoline, a 45-year-old man with clival EPA treated with cabergoline and transsphenoidal surgical resection, and a 54-year-old man with clival EPA treated with cabergoline therapy. CONCLUSIONS: EPA should be considered as a differential diagnosis of juxta-sellar lesions. Appropriate hormonal testing may lead to early diagnosis, avoidance of unnecessary biopsy or surgery, and improved outcomes.

Pharmacotherapy for Patients with Atrial Fibrillation and Cerebral Microbleeds.

BACKGROUND: Patients with cerebral microbleeds have increased risk of intracranial hemorrhage and ischemic stroke. No trial specifically informs antithrombotic therapy for patients with cerebral microbleeds and atrial fibrillation. We investigated the safety of anticoagulation versus no anticoagulation with regard to cerebrovascular outcomes and mortality. METHODS: All consecutive atrial fibrillation patients from 2015 to 2018 with MRI evidence of ≥1 cerebral microbleed at time of imaging were reviewed. Patients were treated with warfarin, direct oral anticoagulants, or neither. Primary outcome was all-cause mortality informed by National Death Registry and the composite of ischemic and hemorrhagic stroke. All statistical tests were 2-sided and significant at P < .05. RESULTS: The median interval from patient identification until the end of electronic health record surveillance was 9.93 months (interquartile range, 2.83-19.17 months). We identified 308 atrial fibrillation patients with cerebral microbleeds; 128(41.6%) were on warfarin, 88(28.6%) on direct oral anticoagulants, and 92(29.9%) on neither. Over the surveillance interval, 87 deaths, 51 ischemic strokes, and 14 hemorrhagic strokes occurred. The estimated likelihoods of the composite stroke outcome and ischemic stroke only did not differ significantly among the 3 groups. However, patients taking direct oral anticoagulants had a significantly smaller likelihood of all-cause mortality than patients who were not anticoagulated (adjusted hazard ratio: .44[.23, .83], P=.012). CONCLUSIONS: In patients with coprevalent atrial fibrillation and cerebral microbleeds, we did not detect differences in subsequent ischemic stroke, hemorrhagic stroke, or both, comparing warfarin, direct oral anticoagulants, or neither. Patients treated with direct oral anticoagulants had better survival than nonanticoagulated patients.

CT perfusion in stroke: Comparing conventional and RAPID automated software.

CT perfusion (CTP) imaging is increasingly used for routine evaluation of acute ischemic stroke. Knowledge about the different types of CTP software, imaging acquisition and post-processing, and interpretation is crucial for appropriate patient selection for reperfusion therapy. Conventional vendor-provided CTP software differentiates between ischemic penumbra and core infarct using the tiebreaker of critically reduced cerebral blood volume (CBV) values within brain regions showing abnormally elevated time parameters like mean transit time (MTT) or time to peak (TTP). On the other hand, RAPID automated software differentiates between ischemic penumbra and core infarct using the tiebreaker of critically reduced cerebral blood flow (CBF) values within brain regions showing abnormally elevated time to maximum (Tmax). Additionally, RAPID calculates certain indices that confer prognostic value, such as the hypoperfusion and CBV index. In this review, we aim to familiarize the reader with the technical principles of CTP imaging, compare CTP maps generated by conventional and RAPID software, and discuss important thresholds for reperfusion and prognostic indices. Lastly, we discuss common pitfalls to help with the accurate interpretation of CTP imaging.

Compressive lesions of the head and neck: Common and uncommon must-know entities.

There are many lesions that cause compression of nerves and vessels in the head and neck, and they can often be overlooked in the absence of adequate history or if not suspected by the radiologist. Many of these lesions require a high index of suspicion and optimal positioning for imaging. While a multimodality approach is critical in the evaluation of compressive lesions, an MRI utilizing high-resolution (heavily weighted) T2-weighted sequence is extremely useful as a starting point. In this review, we aim to discuss the radiological features of the common and uncommon compressive lesions of the head and neck which are broadly categorized into vascular, osseous, and miscellaneous etiologies.

Review of the demographic and educational profiles of abdominal imaging fellowship program directors in the United States.

PURPOSE: To evaluate demographics, academic backgrounds, and scholarly activities of Program Directors (PDs) in Abdominal Imaging Fellowships in the United States (US), emphasizing gender representation, international origins, and academic milestones. METHODS: A list of Fellowships in Abdominal Imaging programs in the US was obtained from the Society of Abdominal Radiology. The search was expanded using the Fellowship and Residency Electronic Interactive Database. Data for PDs were sourced from program websites, Healthgrades, Doximity, and Elsevier's Scopus. Metrics such as age, gender, education, academic rank, additional qualifications, prior leadership roles, publications, and h-indices were analyzed using R software. A two-tailed unpaired t-test was used to calculate the difference in means of scholarly activity between male and female PDs. RESULTS: 113 programs were identified: South (36.28%), Northeast (25.66%), Mid-West (20.35%), West (17.69%). Of 107 PDs, 54% male, 41% female, and average age 48 ± 9.4 years. 66.6% were US graduates, 29.2% were international graduates. Most were Assistant Professors (36.28%). 19.46% had degrees like M.P.H. or M.B.A. 45% had prior leadership roles. Average year of residency graduation was 2007. Mean publication count was 54.16, and mean h-index was 14.663. Male PDs had higher publication counts and h-indices than female PDs (p= 0.009 and p= 0.0019 respectively). CONCLUSION: In Abdominal Imaging Fellowship programs in the US, there is an increasing representation of females in Program Director roles. However, research led by female PDs remains less prevalent. The field of Abdominal Imaging values contributions from international graduates and insights from Assistant Professors.

Lumbar vertebral diskitis-osteomyelitis with mycotic abdominal aortic aneurysm caused by Streptococcus mitis.

Vertebral osteomyelitis is a well-documented disease entity in literature with various known etiologies. However, vertebral diskitis-osteomyelitis secondary to an infected aortic aneurysm is an uncommon and life-threatening complication. We present the case of a 65-year-old male patient who presented with chronic low back pain that acutely worsened for 1 to 1.5 months and was diagnosed with vertebral diskitis-osteomyelitis secondary to a contiguous infection from an adjacent mycotic aortic aneurysm. To our knowledge, this is one of the few cases reported of vertebral diskitis-osteomyelitis secondary to mycotic aortic aneurysm. We discuss the findings on CT and MRI, as well as the value of imaging in guiding management.

MR imaging differentiating features between lytic and degenerative lumbosacral spondylolisthesis.

Spondylolisthesis is characterized by the displacement of one vertebral body in relation to the adjacent vertebra. It is commonly observed in the lower lumbar region and can be caused by a variety of factors, including spondylolysis (a fracture in the pars interarticularis) or degenerative disease. Magnetic resonance imaging (MRI) is becoming increasingly popular as the primary modality for evaluation of low back pain and is often used in the absence of radiographs or Computed Tomography. However, it can be challenging for radiologists to differentiate between the two types of spondylolisthesis based on MRI alone. The goal of this article is to identify key imaging features on MRI that can aid radiologists in differentiating between spondylolysis and degenerative spondylolisthesis on MRI. Five key concepts are discussed: the "step-off" sign, the "wide canal" sign, T2 cortical bone signal on MRI, epidural fat interposition, and fluid in the facet joints. The utility, limitations and potential pitfalls of these concepts are also discussed to provide a comprehensive understanding of their use in differentiating between the two types of spondylolisthesis on MRI.

Recurrent sporadic malignant triton tumor in the carotid sheath in the absence of neurofibromatosis.

Malignant Triton Tumors (MTTs) are a rare and aggressive subtype of malignant peripheral nerve sheath tumors (MPNSTs), often associated with neurofibromatosis type 1. This case report describes a unique instance of recurrent sporadic MTT within the carotid sheath in a 33-year-old male without any personal or familial history of neurofibromatosis. The patient initially presented with a biopsy-confirmed MTT in the right neck, involving the carotid body and brachial plexus, and underwent partial resection, radiation therapy, and chemotherapy. Six months later, the patient presented with recurrent MTT, and subsequently underwent radical tumor resection, segmental right carotid artery resection, and deep femoral vein interposition. Recovery was complicated by hematoma formation, and the patient developed vocal fold paralysis and a left vocal fold cyst, necessitating further surgeries. Yearly follow-ups for 8 years revealed no recurrence. This case emphasizes the importance of comprehensive patient evaluation, including clinical history, imaging, and biopsy findings, for accurate diagnosis and prompt surgical intervention in managing such rare and aggressive tumors. Further research is needed to identify novel therapies and improve survival rates for patients with MTTs.

Ischemia of the parotid gland and adjacent muscles of mastication following middle meningeal artery embolization.

Middle meningeal artery (MMA) embolization is commonly performed as either a first-line or adjunct treatment for chronic subdural hematomas (cSDH). We present the case of a 59 year-old male patient who presented with right hemibody weakness and cognitive impairment and was diagnosed with left-sided cSDH. A left MMA embolization was performed due to the recurrent nature of the chronic subdural hemorrhage and the history of prior craniotomy. On postoperative day 1, the patient developed sudden onset left facial swelling and tenderness, and a contrast computed tomography (CT) of the neck revealed acute ischemia in the left parotid gland, adjacent superior aspect of the left masseter muscle, the left lateral pterygoid, and left temporalis muscles. The patient was treated conservatively with antibiotics, steroids, and analgesics and reported resolution of symptoms on the three-month follow-up. To our knowledge, this is the first reported case of the ipsilateral parotid gland, temporalis muscle, adjacent superior aspect of the masseter muscle, and pterygoid muscle ischemia secondary to non-target particle embolization following MMA embolization in cSDH. Knowledge of normal and variant origin of the MMA and various anastomoses of this vessel with branches of the internal carotid artery (ICA), external carotid artery (ECA), and vertebrobasilar system is crucial to avoid complications during embolization.

Cerebellar, hippocampal, and basal nuclei transient edema with restricted diffusion (CHANTER) syndrome in the setting of opioid and phencyclidine use.

Cerebellar, hippocampal, and basal nuclei transient edema with restricted diffusion (CHANTER) syndrome is a constellation of specific imaging findings characterized by cytotoxic edema in the bilateral hippocampi, cerebellar cortices, and basal ganglia in patients presenting with altered mental status in the setting of substance intoxication. Previous case reports have demonstrated a strong correlation between CHANTER syndrome and polysubstance abuse, particularly with opioid intoxication. The patient we present in this case was found unresponsive following opioid use and demonstrated a constellation of findings on initial and follow-up imaging, consistent with CHANTER syndrome. While cases of irreversible brain damage or death during hospitalization have been reported in the literature, our patient demonstrated near-full recovery a few days after admission to the hospital. We aim to highlight the presentation and progression of CHANTER syndrome and alert clinicians and radiologists to include this entity in their diagnostic checklist for patients with polysubstance abuse and altered mental status.

Establishing an Online Educational Teaching File on Instagram for an Academic Radiology Department: Proof-of-Concept.

Instagram is a powerful social media platform, which can serve as the ideal educational companion app for a visually rich discipline such as Radiology. Instagram facilitates easy content creation allowing for educators to utilize this resource for easy and rapid dissemination of educational content. The authors describe their experience of creating an online publicly available radiology teaching file on Instagram as a proof-of-concept, to help other individuals and institutions in leveraging social media to create and share quality educational content for current and future trainees.

Trends in Neuroradiology Fellowship Match in the United States: Analysis of the 13-Year National Resident Matching Program Data.

The neuroradiology fellowship match is conducted by the National Resident Matching Program (NRMP) every year. The purpose of this study is to report the trends in neuroradiology match results from 2008 to 2020 in the United States (US) using data available from the NRMP. The fellowship match data was obtained from the NRMP archives. Data specific to programs (number of programs and filled positions) were obtained. Using the NRMP's "Charting Outcomes in the Match: Specialty Matching Service'' report, a detailed analysis of applicant characteristics broken down for each specialty, was also obtained for neuroradiology for the year 2018. Neuroradiology programs in the NRMP Match increased from 71 to 77 and the number of positions increased from 158 to 270 between 2008 and 2020. The fill rate of fellowship spots has remained steady at 75.9% in 2008 and 74.4% in 2020. The proportion of US allopathic medical graduates (US MD) amongst the filled spots decreased from 79.2% (2008) to 64.2% (2020), while the proportion of international medical graduates (IMGs) increased from 11.7% to 25.4%. US MD and IMG fill trends did not reach statistical significance (P = 0.78 and P = 0.92, respectively). US MDs had a higher number of research experiences and publications (23.2 and 26, respectively) when compared to US IMGs (5 and 7) and non-US IMGs (6.8 and 14.2). To conclude, over the last 13 years, the neuroradiology fellowship programs in the US have increased in number and expanded in size, with an almost stable fill rate of around 75%.

Critical Evaluation of Interventional Neuroradiology Fellowship Program Websites in North America.

OBJECTIVE: To investigate the accessibility and content of interventional neuroradiology (INR) fellowship program websites in North America. METHODS: We obtained a list of INR/endovascular surgical neuroradiology (ESN) fellowship programs from the Accreditation Council for Graduate Medical Education, the Committee on Advanced Subspecialty Training, the Society of NeuroInterventional Surgery, and the Neurosurgical Fellowship Training Program Directory websites. Individual program websites were evaluated for 27 different fellow recruitment and education criteria. U.S. programs were grouped based on census region and national ranking, and differences between these groups with regard to fellow recruitment and education characteristics were analyzed using nonparametric statistics. RESULTS: A total of 79 INR/ESN fellowship websites were evaluated for presence of fellow recruitment and education features. Approximately one third of all features pertinent to recruitment (32.11%) and approximately 1 in 5 features regarding education (19.11%) were described in these websites. Program description (69.6%), program coordinator/administrator contact e-mail (59.5%), program director's name (59.5%), program eligibility requirements (51.9%), research opportunities (40.5%), and faculty listing (39.2%) were among the most frequently described features, whereas details about parking (1.3%), interview day itinerary (1.3%), meal allowance (2.5%), retirement and benefits (3.8%), and call schedule (5.1%) were the least frequently described features. There was no significant difference between surveyed features and programs when stratified by U.S. census region, neurosurgery/neurology hospital rankings, or accreditation status. CONCLUSIONS: INR/ESN fellowship website content is variable across North America and there is room for improvement to develop and enhance comprehensiveness of program website content.

Chronic inferior vena cava filter thrombosis presenting with low back pain and radiculopathy: Treatment with thrombolysis, filter removal, and stenting.

BACKGROUND: Epidural venous congestion secondary to inferior vena cava (IVC) stenosis is a well-documented cause of low back pain and radiculopathy secondary to compressive effects from the epidural veins, decreased tissue perfusion, and resultant ischemia. METHODS: Single patient case report. CASE DESCRIPTION: We report a unique case of a 62-year-old male with low back pain secondary to IVC stenosis from a chronically occluded IVC filter. The patient's pain resolved with endovascular removal of the occluded filter and recanalization of the IVC. CONCLUSION: We demonstrated that by treating the underlying cause of secondary epidural venous engorgement (occluded IVC filter in this case), the patient experienced resolution of back pain and radiculopathy.