Cerebrospinal Fluid Leaks: Challenges in Localizing Spontaneous Spinal Leak Sites and Minimally Invasive Treatment.

The confirmation of cerebrospinal fluid (CSF) leaks in the setting of spontaneous intracranial hypotension (SIH) by imaging involves a growing toolset of multimodal advanced spinal and skull base imaging techniques, for which exists a unique set of challenges for each CSF leak type. Furthermore, the repertoire of minimally invasive CSF leak treatment beyond nontargeted epidural blood patch administration has grown widely, with varied practices across institutions. This review describes current diagnostic imaging and treatment modalities as they apply to the challenges of CSF leak localization and management.

Oral contraceptive use is associated with smaller hypothalamic and pituitary gland volumes in healthy women: A structural MRI study.

The effects of hormonal contraceptives on structural features of the hypothalamus and pituitary are incompletely understood. One prior study reported microstructural changes in the hypothalamus with oral contraceptive pill (OCP) use. However, effects on hypothalamic volume have not been reported. One prior study reported volumetric changes in the pituitary. However, this study was limited by including participants evaluated for neurological symptoms. We sought to determine if OCP use is associated with alteration of hypothalamic or pituitary volume. High-resolution 3T MRI was performed for a prospective cohort of 50 healthy women from 2016 to 2018, which comprised 21 OCP users (age, 19-29) and 29 naturally cycling women (age, 18-36). Participants were excluded if they were pregnant or had significant medical conditions including neurological, psychiatric, and endocrine disorders. After confirming reliability of the image analysis techniques, 5 raters independently performed manual segmentation of the hypothalamus and semi-automated intensity threshold-based segmentation of the pituitary using ITK-SNAP. Total intracranial volume was estimated using FreeSurfer. A general linear model tested the association of OCP use with hypothalamic and pituitary volumes. Hypothalamic (B = -81.2 ± 24.9, p = 0.002) and pituitary (B = -81.2 ± 38.7, p = 0.04) volumes in OCP users were smaller than in naturally cycling women. These findings may be related to interference with known trophic effects of sex hormones and suggest a structural correlate of central OCP effects.

Acute Imaging Findings Predict Recovery of Cognitive and Motor Function after Inpatient Rehabilitation for Pediatric Traumatic Brain Injury: A Pediatric Brain Injury Consortium Study.

Traumatic brain injury (TBI) is a major cause of morbidity and mortality in children; survivors experience long-term cognitive and motor deficits. To date, studies predicting outcome following pediatric TBI have primarily focused on acute behavioral responses and proxy measures of injury severity; unsurprisingly, these measures explain very little of the variance following heterogenous injury. In adults, certain acute imaging biomarkers help predict cognitive and motor recovery following moderate to severe TBI. This multi-center, retrospective study, characterizes the day-of-injury computed tomographic (CT) reports of pediatric, adolescent, and young adult patients (2 months to 21 years old) who received inpatient rehabilitation services for TBI (n = 247). The study also determines the prognostic utility of CT findings for cognitive and motor outcomes assessed by the Pediatric Functional Independence Measure, converted to age-appropriate developmental functional quotient (DFQ), at discharge from rehabilitation. Subdural hematomas (66%), contusions (63%), and subarachnoid hemorrhages (59%) were the most common lesions; the majority of subjects had less severe Rotterdam CT scores (88%, ≤ 3). After controlling for age, gender, mechanism of injury, length of acute hospital stay, and admission DFQ in multivariate regression analyses, the highest Rotterdam score (ß = -25.2, p < 0.01) and complete cisternal effacement (ß = -19.4, p < 0.05) were associated with lower motor DFQ, and intraventricular hemorrhage was associated with lower motor (ß = -3.7, p < 0.05) and cognitive DFQ (ß = -4.9, p < 0.05). These results suggest that direct detection of intracranial injury provides valuable information to aid in prediction of recovery after pediatric TBI, and needs to be accounted for in future studies of prognosis and intervention.

Radiological imaging features of the basal ganglia that may predict progression to hemicraniectomy in large territory middle cerebral artery infarct.

PURPOSE: Predicting which patients are at risk for hemicraniectomy can be helpful for triage and can help preserve neurologic function if detected early. We evaluated basal ganglia imaging predictors for early hemicraniectomy in patients with large territory anterior circulation infarct. METHODS: This retrospective study evaluated patients with ischemic infarct admitted from January 2005 to July 2011. Patients with malignant cerebral edema refractory to medical therapy or with herniating signs such as depressed level of consciousness, anisocoria, and contralateral leg weakness were triaged to hemicraniectomy. Admission images were reviewed for presence of caudate, lentiform nucleus (putamen and globus pallidus), or basal ganglia (caudate + lentiform nucleus) infarction. RESULTS: Thirty-one patients with large territory MCA infarct, 10 (32%), underwent hemicraniectomy. Infarction of the caudate nucleus (9/10 vs 6/21, p = 0.002) or basal ganglia (5/10 vs 2/21, p = 0.02) predicted progression to hemicraniectomy. Infarction of the lentiform nucleus only did not predict progression to hemicraniectomy. Sensitivity for patients who did and did not have hemicraniectomy were 50% (5/10) and 90.5% (19/21). For caudate nucleus and caudate plus lentiform nucleus infarcts, the crude- and age-adjusted odds of progression to hemicraniectomy were 9.5 (1.4-64.3) and 6.6 (0.78-55.4), respectively. CONCLUSION: Infarction of the caudate nucleus or basal ganglia correlated with patients progressing to hemicraniectomy. Infarction of the lentiform nucleus alone did not.

Use of low-dose heparin with bivalirudin for ad-hoc transradial coronary interventions: experience from a single center.

BACKGROUND: The majority of coronary angioplasty is done via the femoral artery, with vascular complications being a major adverse event. Bivalirudin has been shown to reduce bleeding complication and improve outcomes. The use of bivalirudin in radial interventions has largely been limited due to the routine use of heparin for the diagnostic procedure. In current practice there is a concern with using the traditional 5,000 Units of heparin during radial sheath insertion and administration of bivalirudin when proceeding to percutaneous coronary intervention (PCI). We describe outcome analysis of the use of low-dose heparin (2,500 Units) with bivalirudin in patients who underwent PCI comparing the adverse outcomes related to bleeding and radial artery occlusion. METHODS: The study was an institutional review board-approved retrospective analysis of patients who underwent coronary intervention using the radial approach and the use of bivalirudin over 9-month period. Patients on heparin/low-molecular-weight heparin (LMWH), acute myocardial infarction or allergy to bivalirudin were excluded from the study. RESULTS: We evaluated 155 patients in the radial and 100 patients in the femoral group. The mean age of the population was 63 ± 11 years (males 68%, weight 88 ± 18 kg) and 66 ± 12 years (males 56%, weight 82 ± 16 kg) in the radial and femoral groups, respectively. Ninety-two percent of the radial and 98% of the femoral cases were elective. The vessels intervened upon were similar in the two groups (left main: 0.65% vs. 2%, left anterior descending artery: 39% vs. 38%, diagonal: 3.8% vs.7%, left circumflex: 16% vs. 21%, obtuse marginal: 7 vs. 11%, right coronary artery: 30% vs.31%, grafts: 1% vs. 5%, in the radial and femoral groups, respectively; p > 0.05). The mean activated clotting time at the end of infusion was 376 ± 47 seconds in the radial and 331 ± 18 seconds in the femoral group. There was only 1 case of documented radial artery occlusion that resolved with 2 weeks of LMWH. Six patients in the radial group and 5 in the femoral group reported minor bruising. There were no reported events related to any major bleeding or transfusions. CONCLUSIONS: Bivalirudin in combination with low-dose heparin (2,500 Units) is safe to use in patients undergoing radial angioplasty with similar event rates to the femoral approach.