Skull Base CSF Leaks: Potential Underlying Pathophysiology and Evaluation of Brain MR Imaging Findings Associated with Spontaneous Intracranial Hypotension.

BACKGROUND AND PURPOSE: Cerebrospinal fluid (CSF) leaks of the skull base and spine share a common process of CSF volume loss, and yet only the latter has been associated with spontaneous intracranial hypotension (SIH). Despite published claims that only spinal leaks cause SIH, no prior studies have evaluated brain MR imaging in patients with skull base leaks for findings associated with SIH such as dural enhancement. The purpose of our study was to use a validated brain MR imaging scoring system to evaluate skull base CSF leak patients for findings associated with SIH. MATERIALS AND METHODS: We included patients with confirmed skull base CSF leaks and contrast enhanced pre-operative brain MRI. The pre-operative MR images were reviewed for findings associated with SIH using the Bern score. Patient age, presenting symptoms and their duration, and leak site were also recorded. RESULTS: 31 patients with skull base CSF leaks were included. Mean Bern score was 0.9 (range 0-4, SD 1.1), and only 1 patient (3%) had dural enhancement. Mean age was 53 years (range 18-76). Mean symptom duration was 1.3 years, with 22 patients presenting within one year of symptom onset. 23 patients (74.2%) had intraoperative confirmation of leak from the middle cranial fossa, involving the temporal bone, while 7 (22.6%) had leaks from the anterior skull base. One patient, who had dural enhancement, had an infratentorial CSF leak along the petrous segment of the internal carotid artery. CONCLUSIONS: Our study provides further evidence that skull base and spinal CSF leaks represent distinct pathophysiologies and present with different brain MRI findings.ABBREVIATIONS: SIH = Spontaneous Intracranial Hypotension; IIH = Idiopathic Intracranial Hypertension.

Radiology-pathology correlation: Giant tumefactive perivascular spaces.

Dilated perivascular spaces (PVSs) are common and easily recognized on imaging. However, rarer giant tumefactive PVSs (GTPVSs) can have unusual multilocular cystic configurations, and are often confused for other pathologic entities, including neoplasms, cystic infarctions, and neuroepithelial cysts. Because GTPVSs are scarcely encountered and even more infrequently operated upon, many radiologists are unaware of the imaging and pathologic features of these lesions. Here, a case of a resected GTPVS is presented, highlighting both its radiologic and histologic characteristics, and discussing how such lesions can be differentiated from their closest mimickers on imaging.

Impact of SUSAN Denoising and ComBat Harmonization on Machine Learning Model Performance for Malignant Brain Neoplasms.

BACKGROUND AND PURPOSE: Feature variability in radiomics studies due to technical and magnet strength parameters is well known and may be addressed through various pre-processing methods. However, very few studies have evaluated downstream impact of variable pre-processing on model classification performance in a multi-class setting. We sought to evaluate the impact of SUSAN denoising and ComBat harmonization on model classification performance. MATERIALS AND METHODS: A total of 493 cases (410 internal and 83 external dataset) of glioblastoma (GB), intracranial metastatic disease (IMD) and primary CNS lymphoma (PCNSL) underwent semi-automated 3D-segmentation post baseline image processing (BIP) consisting of resampling, realignment, co-registration, skull stripping and image normalization. Post BIP, two sets were generated, one with and another without SUSAN denoising (SD). Radiomics features were extracted from both datasets and batch corrected to produce four datasets: (a) BIP, (b) BIP with SD, (c) BIP with ComBat and (d) BIP with both SD and ComBat harmonization. Performance was then summarized for models using a combination of six feature selection techniques and six machine learning models across four mask-sequence combinations with features derived from one-three (multi-parametric) MRI sequences. RESULTS: Most top performing models on the external test set used BIP+SD derived features. Overall, use of SD and ComBat harmonization led to a slight but generally consistent improvement in model performance on the external test set. CONCLUSIONS: The use of image pre-processing steps such as SD and ComBat harmonization may be more useful in a multiinstitutional setting and improve model generalizability. Models derived from only T1-CE images showed comparable performance to models derived from multiparametric MRI.

Intracranial findings in spontaneous intracranial hypotension: Does the severity of abnormalities correspond with certainty and/or multifocality of cerebrospinal fluid leaks?

BACKGROUND AND PURPOSE: Spontaneous intracranial hypotension (SIH) is caused by spinal cerebrospinal fluid (CSF) leaks. This study assessed whether the certainty and/or multifocality of CSF leaks is associated with the severity of intracranial sequelae of SIH. MATERIALS AND METHODS: A retrospective review was completed of patients with suspected SIH that underwent digital subtraction myelogram (DSM) preceded by brain MRI. DSMs were evaluated for the presence or absence of a CSF leak, categorized both as positive/negative/indeterminate and single versus multifocal. Brain MRIs were assessed for intracranial sequelae of SIH based on two probabilistic scoring systems (Dobrocky and Mayo methods). For each system, both an absolute "numerical" score (based on tabulation of findings) and "categorized" score (classification of probability) were tabulated. RESULTS: 174 patients were included; 113 (64.9%) were female, average age 52.0 ± 14.3 years. One or more definite leaks were noted in 76 (43.7%) patients; an indeterminate leak was noted in 22 (12.6%) patients. 16 (16.3%) had multiple leaks. There was no significant difference in the severity of intracranial findings between patients with a single versus multiple leaks (p values ranged from .36 to .70 using categorized scores and 0.22-0.99 for numerical scores). Definite leaks were more likely to have both higher categorized intracranial scores (Mayo p = .0008, Dobrocky p = .006) and numerical scores (p = .0002 for Mayo and p = .006 for Dobrocky). CONCLUSIONS: Certainty of a CSF leak on diagnostic imaging is associated with severity of intracranial sequelae of SIH, with definite leaks having significantly more intracranial findings than indeterminate leaks. Multifocal leaks do not cause greater intracranial abnormalities.

High-Grade Astrocytoma with Piloid Features: A Dual Institutional Review of Imaging Findings of a Novel Entity.

High-grade astrocytoma with piloid features (HGAP) is a recently identified brain tumor characterized by a distinct DNA methylation profile. Predominantly located in the posterior fossa of adults, HGAP is notably prevalent in individuals with neurofibromatosis type 1. We present an image-centric review of HGAP and explore the association between HGAP and neurofibromatosis type 1. Data were collected from 8 HGAP patients treated at two tertiary care institutions between January 2020 and October 2023. Demographic details, clinical records, management, and tumor molecular profiles were analyzed. Tumor characteristics, including location and imaging features on MR imaging, were reviewed. Clinical or imaging features suggestive of neurofibromatosis 1 or the presence of NF1 gene alteration were documented. The mean age at presentation was 45.5 years (male/female = 5:3). Tumors were midline, localized in the posterior fossa (n = 4), diencephalic/thalamic (n = 2), and spinal cord (n = 2). HGAP lesions were T1 hypointense, T2-hyperintense, mostly without diffusion restriction, predominantly peripheral irregular enhancement with central necrosis (n = 3) followed by mixed heterogeneous enhancement (n = 2). Two NF1 mutation carriers showed signs of neurofibromatosis type 1 before HGAP diagnosis, with one diagnosed during HGAP evaluation, strengthening the HGAP-NF1 link, particularly in patients with posterior fossa masses. All tumors were IDH1 wild-type, often with ATRX, CDKN2A/B, and NF1 gene alteration. Six patients underwent surgical resection followed by adjuvant chemoradiation. Six patients were alive, and two died during the last follow-up. Histone H3 mutations were not detected in our cohort, such as the common H3K27M typically seen in diffuse midline gliomas, linked to aggressive clinical behavior and poor prognosis. HGAP lesions may involve the brain or spine and tend to be midline or paramedian in location. Underlying neurofibromatosis type 1 diagnosis or imaging findings are important diagnostic cues.

Benefits of Photon-Counting CT Myelography for Localization of Dural Tears in Spontaneous Intracranial Hypotension.

Photon-counting CT is an increasingly used technology with numerous advantages over conventional energy-integrating detector CT. These include superior spatial resolution, high temporal resolution, and inherent spectral imaging capabilities. Recently, photon-counting CT myelography was described as an effective technique for the detection of CSF-venous fistulas, a common cause of spontaneous intracranial hypotension. It is likely that photon-counting CT myelography will also have advantages for the localization of dural tears, a separate type of spontaneous spinal CSF leak that requires different myelographic techniques for accurate localization. To our knowledge, prior studies on photon-counting CT myelography have been limited to techniques for detecting CSF-venous fistulas. In this technical report, we describe our technique and early experience with photon-counting CT myelography for the localization of dural tears.

Evaluation of MR Elastography as a Noninvasive Diagnostic Test for Spontaneous Intracranial Hypotension.

BACKGROUND AND PURPOSE: Spontaneous intracranial hypotension is a condition resulting from a leak of CSF from the spinal canal arising independent of a medical procedure. Spontaneous intracranial hypotension can present with normal brain MR imaging findings and nonspecific symptoms, leading to the underdiagnosis in some patients and unnecessary invasive myelography in others who are found not to have the condition. Given the likelihood that spontaneous intracranial hypotension alters intracranial biomechanics, the goal of this study was to evaluate MR elastography as a potential noninvasive test to diagnose the condition. MATERIALS AND METHODS: We performed MR elastography in 15 patients with confirmed spontaneous intracranial hypotension from September 2022 to April 2023. Age, sex, symptom duration, and brain MR imaging Bern score were collected. MR elastography data were used to compute stiffness and damping ratio maps, and voxelwise modeling was performed to detect clusters of significant differences in mechanical properties between patients with spontaneous intracranial hypotension and healthy control participants. To evaluate diagnostic accuracy, we summarized each examination by 2 spatial pattern scores (one each for stiffness and damping ratio) and evaluated group-wise discrimination by receiver operating characteristic curve analysis. RESULTS: Patients with spontaneous intracranial hypotension exhibited significant differences in both stiffness and damping ratio (false discovery rate-corrected, Q < 0.05). Pattern analysis discriminated patients with spontaneous intracranial hypotension from healthy controls with an area under the curve of 0.97 overall, and the area under the curve was 0.97 in those without MR imaging findings of spontaneous intracranial hypotension. CONCLUSIONS: Results from this pilot study demonstrate MR elastography as a potential imaging biomarker and a noninvasive method for diagnosing spontaneous intracranial hypotension, including patients with normal brain MR imaging findings.

Identifying Patients with CSF-Venous Fistula Using Brain MRI: A Deep Learning Approach.

BACKGROUND AND PURPOSE: Spontaneous intracranial hypotension is an increasingly recognized condition. Spontaneous intracranial hypotension is caused by a CSF leak, which is commonly related to a CSF-venous fistula. In patients with spontaneous intracranial hypotension, multiple intracranial abnormalities can be observed on brain MR imaging, including dural enhancement, "brain sag," and pituitary engorgement. This study seeks to create a deep learning model for the accurate diagnosis of CSF-venous fistulas via brain MR imaging. MATERIALS AND METHODS: A review of patients with clinically suspected spontaneous intracranial hypotension who underwent digital subtraction myelogram imaging preceded by brain MR imaging was performed. The patients were categorized as having a definite CSF-venous fistula, no fistula, or indeterminate findings on a digital subtraction myelogram. The data set was split into 5 folds at the patient level and stratified by label. A 5-fold cross-validation was then used to evaluate the reliability of the model. The predictive value of the model to identify patients with a CSF leak was assessed by using the area under the receiver operating characteristic curve for each validation fold. RESULTS: There were 129 patients were included in this study. The median age was 54 years, and 66 (51.2%) had a CSF-venous fistula. In discriminating between positive and negative cases for CSF-venous fistulas, the classifier demonstrated an average area under the receiver operating characteristic curve of 0.8668 with a standard deviation of 0.0254 across the folds. CONCLUSIONS: This study developed a deep learning model that can predict the presence of a spinal CSF-venous fistula based on brain MR imaging in patients with suspected spontaneous intracranial hypotension. However, further model refinement and external validation are necessary before clinical adoption. This research highlights the substantial potential of deep learning in diagnosing CSF-venous fistulas by using brain MR imaging.

7T MRI for Cushing Disease: A Single-Institution Experience and Literature Review.

BACKGROUND AND PURPOSE: Cushing disease is typically caused by a pituitary adenoma that frequently is small and challenging to detect on conventional MR imaging. High-field-strength 7T MR imaging can leverage increased SNR and contrast-to-noise ratios compared with lower-field-strength MR imaging to help identify small pituitary lesions. We aimed to describe our institutional experience with 7T MR imaging in patients with Cushing disease and perform a review of the literature. MATERIALS AND METHODS: We performed a retrospective analysis of 7T MR imaging findings in patients with pathology-proved Cushing disease from a single institution, followed by a review of the literature on 7T MR imaging for Cushing disease. RESULTS: Our institutional experience identified Cushing adenomas in 10/13 (76.9%) patients on 7T; however, only 5/13 (38.5%) lesions were discrete. Overall, the imaging protocols used were heterogeneous in terms of contrast dose as well as type of postcontrast T1-weighted sequences (dynamic, 2D versus 3D, and type of 3D sequence). From our institutional data, specific postgadolinium T1-weighted sequences were helpful in identifying a surgical lesion as follows: dynamic contrast-enhanced, 2/7 (28.6%); 2D FSE, 4/8 (50%); 3D sampling perfection with application-optimized contrasts by using different flip angle evolution (SPACE), 5/6 (83.3%); and 3D MPRAGE, 8/11 (72.7%). The literature review identified Cushing adenomas in 31/33 (93.9%) patients on 7T. CONCLUSIONS: 7T MR imaging for pituitary lesion localization in Cushing disease is a new technique with imaging protocols that vary widely. Further comparative research is needed to identify the optimal imaging technique as well as assess the benefit of 7T over lower-field-strength MR imaging.

Back to the Future: Dynamic Contrast-Enhanced Photon-Counting Detector CT for the Detection of Pituitary Adenoma in Cushing Disease.

Historically, MR imaging has been unable to detect a pituitary adenoma in up to one-half of patients with Cushing disease. This issue is problematic because the standard-of-care treatment is surgical resection, and its success is correlated with finding the tumor on imaging. Photon-counting detector CT is a recent advancement that has multiple benefits over conventional energy-integrating detector CT. We present the use of dynamic contrast-enhanced imaging using photon-counting detector CT for the detection of pituitary adenomas in patients with Cushing disease.

Direct pseudomeningocele contrast injection for spinal CSF leak localization.

CT myelography has been traditionally used to evaluate post-operative paraspinal fluid collections to discern CSF leaking into a pseudomeningocele versus a contained seroma. Rather than performing a lumbar puncture and injecting intrathecal contrast for myelography, we present the first report of direct contrast injection into a post-operative paraspinal pseudomeningocele for CSF leak confirmation and localization. This is a simple procedure that has several advantages over a conventional CT myelogram for the evaluation of post-operative paraspinal fluid collections.

Diagnostic Performance of Decubitus Photon-Counting Detector CT Myelography for the Detection of CSF-Venous Fistulas.

BACKGROUND AND PURPOSE: CSF-venous fistulas are a common cause of spontaneous intracranial hypotension. Lateral decubitus digital subtraction myelography and CT myelography are the diagnostic imaging standards to identify these fistulas. Photon-counting CT myelography has technological advantages that might improve CSF-venous fistula detection, though no large studies have yet assessed its diagnostic performance. We sought to determine the diagnostic yield of photon-counting detector CT myelography for detection of CSF-venous fistulas in patients with spontaneous intracranial hypotension. MATERIALS AND METHODS: We retrospectively searched our database for all decubitus photon-counting detector CT myelograms performed at our institution since the introduction of the technique in our practice. Per our institutional workflow, all patients had prior contrast-enhanced brain MR imaging and spine MR imaging showing no extradural CSF. Two neuroradiologists reviewed preprocedural brain MRIs, assessing previously described findings of intracranial hypotension (Bern score). Additionally, 2 different neuroradiologists assessed each myelogram for a definitive or equivocal CSF-venous fistula. The yield of photon-counting detector CT myelography was calculated and stratified by the Bern score using low-, intermediate-, and high-probability tiers. RESULTS: Fifty-seven consecutive photon-counting detector CT myelograms in 57 patients were included. A single CSF-venous fistula was definitively present in 38/57 patients. After we stratified by the Bern score, a definitive fistula was seen in 56.0%, 73.3%, and 76.5% of patients with low-, intermediate-, and high-probability brain MR imaging, respectively. CONCLUSIONS: Decubitus photon-counting detector CT myelography has an excellent diagnostic performance for the detection of CSF-venous fistulas. The yield for patients with intermediate- and high-probability Bern scores is at least as high as previously reported yields of decubitus digital subtraction myelography and CT myelography using energy-integrating detector scanners. The yield for patients with low-probability Bern scores appears to be greater compared with other modalities. Due to the retrospective nature of this study, future prospective work will be needed to compare the sensitivity of photon-counting detector CT myelography with other modalities.

Likelihood of Discovering a CSF Leak Based on Intracranial MRI Findings in Patients without a Spinal Longitudinal Extradural Collection: A New Probabilistic Scoring System.

BACKGROUND AND PURPOSE: The likelihood of discovering a CSF leak can be determined by assessing intracranial abnormalities. However, the Dobrocky scoring system, which is used to determine this likelihood, did not incorporate patients with CSF-venous fistulas. This study sought to create a new probabilistic scoring system applicable to patients without a spinal longitudinal extradural collection. MATERIALS AND METHODS: A retrospective review was completed of patients with suspected spontaneous intracranial hypotension who underwent brain MR imaging followed by digital subtraction myelography with same-day CT myelography. Patients with and without leaks found on digital subtraction myelography were included. MRIs were assessed for numerous reported stigmata of spontaneous intracranial hypotension and were compared between cohorts. RESULTS: One hundred seventy-four patients were included; 113 (64.9%) were women (average age, 52.0 [SD, 14.3] years). A CSF leak was found in 98 (56.3%) patients, nearly all of which (93.9%) were CSF-venous fistulas. Diffuse dural enhancement, internal auditory canals dural enhancement, non-Chiari cerebellar descent, pituitary engorgement, brain sag, dural venous sinus engorgement, and decreased suprasellar cistern size were associated with a CSF leak. A probabilistic scoring system was made in which a single point value was assigned to each of those findings: 0-2 considered low probability and ≥3 considered intermediate-to-high probability of a CSF leak. CONCLUSIONS: This study offers a new probabilistic scoring system for evaluating the likelihood of discovering a CSF leak on the basis of intracranial MR imaging findings, though the new system is not superior to that of the Dobrocky method for predicting the presence of CSF leaks.

MR Imaging Appearance of Ruptured Rathke Cleft Cyst and Associated Bone Marrow Enhancement.

Rathke cleft cysts are common cystic pituitary lesions seen on MR imaging. A subset of Rathke cleft cysts can rupture within the sella and are uncommon. The imaging appearance of a ruptured Rathke cleft cyst has been previously described with nonspecific imaging findings. We present 7 cases of ruptured Rathke cleft cysts and basisphenoid bone marrow enhancement below the sella that could be used to potentially distinguish a ruptured Rathke cleft cyst from other cystic lesions.

Updated ultrafast dynamic computed tomography myelography technique for cerebrospinal fluid leaks.

We present an updated ultrafast dynamic computed tomography myelography technique that can be used for the localization of spontaneous spinal cerebrospinal fluid leaks in the setting of spontaneous intracranial hypotension. This has over twice the temporal resolution of previously described techniques at the same radiation dose output.

Neurite orientation dispersion and density imaging of white matter microstructure in sensory processing dysfunction with versus without comorbid ADHD.

Introduction: Sensory Processing Dysfunction (SPD) is common yet understudied, affecting up to one in six children with 40% experiencing co-occurring challenges with attention. The neural architecture of SPD with Attention Deficit and Hyperactivity Disorder (ADHD) (SPD+ADHD) versus SPD without ADHD (SPD-ADHD) has yet to be explored in diffusion tensor imaging (DTI) and Neurite Orientation Dispersion and Density Imaging (NODDI) has yet to be examined. Methods: The present study computed DTI and NODDI biophysical model parameter maps of one hundred children with SPD. Global, regional and voxel-level white matter tract measures were analyzed and compared between SPD+ADHD and SPD-ADHD groups. Results: SPD+ADHD children had global WM Fractional Anisotropy (FA) and Neurite Density Index (NDI) that trended lower than SPD-ADHD children, primarily in boys only. Data-driven voxelwise and WM tract-based analysis revealed statistically significant decreases of NDI in boys with SPD+ADHD compared to those with SPD-ADHD, primarily in projection tracts of the internal capsule and commissural fibers of the splenium of the corpus callosum. Conclusion: We conclude that WM microstructure is more delayed/disrupted in boys with SPD+ADHD compared to SPD-ADHD, with NODDI showing a larger effect than DTI. This may represent the combined WM pathology of SPD and ADHD, or it may result from a greater degree of SPD WM pathology causing the development of ADHD.

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.

Lateral Decubitus Dynamic CT Myelography with Real-Time Bolus Tracking (dCTM-BT) for Evaluation of CSF-Venous Fistulas: Diagnostic Yield Stratified by Brain Imaging Findings.

BACKGROUND AND PURPOSE: CSF-venous fistulas (CVFs) associated with spontaneous intracranial hypotension (SIH) may have a transient appearance, relative to contrast arrival, which may influence the diagnostic performance of lateral decubitus CT myelography (CTM). We developed a dynamic CTM protocol using real-time bolus-tracking (dCTM-BT) to improve the temporal resolution and standardize the timing of CTM acquisitions post-intrathecal contrast administration. The purpose of our study was to evaluate the feasibility of the dCTM-BT technique and evaluate its diagnostic yield for CVF detection, stratified by brain MRI SIH findings. MATERIALS AND METHODS: Patients with suspected SIH without extradural fluid collection on spine MRI who underwent dCTM-BT were retrospectively reviewed. CT bolus monitoring was performed at the upper thoracic level. Following the visualization of dense intrathecal contrast, at least 3 CTM acquisitions of the spine were obtained and reviewed by 2 neuroradiologists. The Bern SIH score was calculated on the brain MRI. The diagnostic yield for CVF detection was evaluated, stratified by Bern score categories and a receiver operating characteristic (ROC) analysis. RESULTS: Out of 48 patients, 23 (48%) had a CVF on dCTM-BT, located at T1-5 (n = 4), T6-12 (n = 18), L1 (n = 1), with 70% on the right. CVF was identified in 22/22 (100%) of patients who had a high Bern score, 1/7 (14%) of those who had an intermediate score, and 0/19 (0%) of those who had a low score. The area under the ROC curve was 0.99 (95% CI, 0.98-1.00). The optimal cutoff was a Bern score of ≥5 (96% sensitivity, 100% specificity). CONCLUSIONS: dCTM-BT is feasible and has excellent diagnostic performance for CVF identification/localization. The Bern score is strongly associated with CVF detection and may help inform who will benefit from dCTM-BT.

Application of a Denoising High-Resolution Deep Convolutional Neural Network to Improve Conspicuity of CSF-Venous Fistulas on Photon-Counting CT Myelography.

Photon-counting detector CT myelography is a recently described technique that has several advantages for the detection of CSF-venous fistulas, one of which is improved spatial resolution. To maximally leverage the high spatial resolution of photon-counting detector CT, a sharp kernel and a thin section reconstruction are needed. Sharp kernels and thin slices often result in increased noise, degrading image quality. Here, we describe a novel deep-learning-based algorithm used to denoise photon-counting detector CT myelographic images, allowing the sharpest and thinnest quantitative reconstruction available on the scanner to be used to enhance diagnostic image quality. Currently, the algorithm requires 4-6 hours to create diagnostic, denoised images. This algorithm has the potential to increase the sensitivity of photon-counting detector CT myelography for detecting CSF-venous fistulas, and the technique may be valuable for institutions attempting to optimize photon-counting detector CT myelography imaging protocols.

Role of Computed Tomography and Magnetic Resonance Imaging in the Evaluation of Headache Due to Paranasal Sinus and Teeth Disorder.

When brain imaging is performed as a first-line investigation for headaches and no intracranial abnormality is found, attention should always be paid to potential non-CNS causes of headache including paranasal sinus inflammatory, infectious, and occasionally malignant disease, and also to odontogenic sinusitis. Non-enhanced CT (NECT) head offers an initial evaluation of these areas which may be an unexpected source of symptomatology. Further imaging may then be required with either dedicated sinus NECT [particularly if surgical intervention is necessary for paranasal sinus disease], a contrast-enhanced (CECT) head and sinus CT, or an MRI if intracranial complications of sinonasal disease or acute invasive fungal sinusitis is suspected.