Lumbar Puncture Complications: A Review of Current Literature.

PURPOSE OF REVIEW: This paper reviews the complications of lumbar puncture with a focus on post-dural puncture headache including pathophysiology, risk factors, prevention, and treatment. RECENT FINDINGS: Recent research has focused on understanding the multifactorial mechanisms of post-dural puncture headache and improving prevention and treatment strategies. Small caliber, pencil-point type needles are encouraged to minimize the risk of post-dural puncture headaches, especially in populations that are at higher risk for complication. While new medications and procedures show promise in small cohorts, conservative medical management and epidural blood patch are still the first and second-line treatments for PDPH. Post-dural puncture headache is the most frequent complication of lumbar puncture. There are both modifiable and nonmodifiable risk factors to consider when performing this procedure. Conservative medical management and procedure-based therapies exist for when complications of lumbar puncture arise.

Imaging assessment of spine infection.

This article comprehensively reviews current imaging concepts in spinal infection with primary focus on infectious spondylodiscitis (IS) as well as the less common entity of facet joint septic arthritis (FSA). This review encompasses the multimodality imaging appearances (radiographs, CT, MRI, and nuclear imaging) of spinal infection-both at initial presentation and during treatment-to aid the radiologist in guiding diagnosis and successful management. We discuss the pathophysiology of spinal infection in various patient populations (including the non-instrumented and postoperative spine) as well as the role of imaging-guided biopsy. We also highlight several non-infectious entities that can mimic IS (both clinically and radiologically) that should be considered during image interpretation to avoid misdiagnosis. These potential mimics include the following: Modic type 1 degenerative changes, acute Schmorl's node, neuropathic spondyloarthropathy, radiation osteitis, and inflammatory spondyloarthropathy (SAPHO syndrome).

Progressive superficial siderosis from Chronic CSF leak as a long-term complication of cervical anterior corpectomy: A case report and review of the literature.

Background: Superficial siderosis of the central nervous system (SSCNS) is a rare progressive neurological disorder resulting from chronic subarachnoid hemorrhage and subsequent subpial hemosiderin deposition. A prolonged cerebrospinal fluid (CSF) leak is a known cause of SSCNS. We present a novel case where progressive SSCNS resulted from a chronic CSF leak related to an anterior cervical corpectomy. Case Description: A 73-year-old man presented with gait ataxia and progressive hearing loss. Thirteen years before, he had undergone a combined anterior-posterior cervical decompression for symptomatic ossification of the posterior longitudinal ligament (OPLL). The presenting MR imaging showed extensive superficial siderosis and focal spinal cord herniation at the site of a ventral dural defect at the corpectomy site. A CT myelogram showed extensive CSF leakage into the corpectomy surgical site and a communicating pseudomeningocele in the anterior neck. Conclusion: This is the first reported case of progressive SSCNS as a long-term complication of an anterior cervical corpectomy for OPLL. Clinicians should be aware of SSCNS secondary to a chronic CSF leak in patients with a prior corpectomy.

CSF-Venous Fistula.

PURPOSE OF REVIEW: To provide an update on recent developments in the understanding, diagnosis, and treatment of CSF-venous fistula (CVF). RECENT FINDING: CVF is a recently recognized cause of spontaneous intracranial hypotension (SIH), an important secondary headache, in which an aberrant connection is formed between the spinal subarachnoid space and an adjacent spinal epidural vein permitting unregulated loss of CSF into the circulatory system. CVFs often occur without a concurrent epidural fluid collection; therefore, CVF should be considered as a potential etiology for patients with SIH symptomatology but without an identifiable CSF leak. Imaging plays a critical role in the detection and localization of CVFs, with a number of imaging techniques and provocative maneuvers described in the literature to facilitate their localization for targeted and definitive treatment. Increasing awareness and improving the localization of CVFs can allow for improved outcomes in the SIH patient population. Future prospective studies are needed to determine the diagnostic performance of currently available imaging techniques as well as their ability to inform workup and guide treatment decisions.

CT-Guided Fine-Needle Aspiration Biopsy of Pulmonary Nodules 8 mm or Less Has a Higher Diagnostic Accuracy than Positron Emission Tomography-CT.

PURPOSE: To compare diagnostic accuracy of CT-guided fine-needle aspiration biopsy (FNA-B) with positron emission tomography (PET)-CT for pulmonary nodules ≤ 8 mm. MATERIALS AND METHODS: A retrospective review of all CT-guided lung FNA-Bs performed between 2011 and 2014 at a single institution was undertaken to evaluate patients who had FNA-B and PET-CT imaging of nodules of ≤ 8 mm. Patients without surgical pathology or 2-year follow-up CT scans were excluded. Of 1,896 patients, 41 patients with 43 subcentimeter pulmonary nodules met study criteria. The McNemar test was used to compare FNA-B with PET-CT results. RESULTS: FNA-B had a sensitivity and diagnostic accuracy of 88.9% and 81.4%, respectively. PET-CT had an overall sensitivity and diagnostic accuracy of 38.9% and 46.5%, respectively. FNA-B had a significantly higher sensitivity and diagnostic accuracy for malignant nodules compared with PET-CT (P < .001). Pneumothorax rate after FNA-B was 13.9%, and chest tube insertion rate was 0%. CONCLUSIONS: FNA-B is a safe procedure with superior sensitivity and higher diagnostic accuracy compared with PET-CT in pulmonary nodules ≤ 8mm in size.

Long term follow up of kidney donors with asymptomatic renal stones.

Patients with asymptomatic kidney stones have a high rate of progression to becoming symptomatic kidney stones when followed for several years. Small kidney stones are often found incidentally on imaging when evaluating patients for kidney donation, and there is a concern that after nephrectomy, the donor may become symptomatic and incur damage to the remaining kidney. We reviewed kidney donors at our institution with asymptomatic stones and surveyed them several years after donation to see if the stones became clinically active.

Improving Care and Education Through a Radiology Resident-driven Clinical Consultation Service.

RATIONALE AND OBJECTIVE: As health care moves toward bundled payment systems and merit-based incentive models, increasing awareness of the value of the radiologist is essential. A resident-driven clinical imaging rounds (CIR) program initiated at our institution allows radiologists to actively and directly participate in the team-based medical model. A retrospective review of survey data evaluated the qualitative and quantitative effects of CIR on clinical management, communication, and education of referring providers and radiology residents. MATERIALS AND METHODS: The initial 10 months of a resident-organized CIR were evaluated in a retrospective study. Twenty radiology residents and 150 internal medicine physicians and medical students participated in imaging rounds. An anonymous survey of participants was performed and results were analyzed. RESULTS: Eighty-five percent of radiology resident participants completed the survey (N = 17). Approximately 30% of internal medicine participants completed the survey (N = 45). There was an overwhelming positive review of imaging rounds, with a large majority of all groups agreeing that imaging rounds improve education, communication, and patient care. CONCLUSIONS: Resident-driven imaging rounds provide a valuable opportunity to improve communication, education, and patient care. We have created a CIR with a sustainable workflow that allows direct and regularly scheduled imaging-medicine consultation valued by both radiologists and internal medicine physicians, improving the quality of patient care and providing education to our radiology residents in value-based care.

Diffusion Weighted/Tensor Imaging, Functional MRI and Perfusion Weighted Imaging in Glioblastoma-Foundations and Future.

In this article, we review the basics of diffusion tensor imaging and functional MRI, their current utility in preoperative neurosurgical mapping, and their limitations. We also discuss potential future applications, including implementation of resting state functional MRI. We then discuss perfusion and diffusion-weighted imaging and their application in advanced neuro-oncologic practice. We explain how these modalities can be helpful in guiding surgical biopsies and differentiating recurrent tumor from treatment related changes.

Herpes Simplex Virus Hepatitis in an Immunocompetent Host Resembling Hepatic Pyogenic Abscesses.

Herpes simplex virus (HSV) hepatitis represents a rare complication of HSV infection, which can progress to acute liver failure and, in some cases, death. We describe an immunocompetent 67-year-old male who presented with one week of fever and abdominal pain. Computed tomography (CT) scan and magnetic resonance imaging (MRI) of the abdomen showed multiple bilobar hepatic lesions, some with rim enhancement, compatible with liver abscesses. Subsequent liver biopsy, however, revealed hepatocellular necrosis, HSV-type intranuclear inclusions, and immunostaining positive for herpes virus type 2 (HSV-2). Though initially treated with broad-spectrum antibiotics, following histologic diagnosis of HSV hepatitis, the patient was transitioned to intravenous acyclovir for four weeks and he achieved full clinical recovery. Given its high mortality and nonspecific presentation, one should consider HSV hepatitis in all patients with acute hepatitis with multifocal hepatic lesions of unknown etiology. Of special note, this is only the second reported case of HSV liver lesions mimicking pyogenic abscesses on CT and MRI.

Central venous occlusion mimics carotid cavernous fistula: a case report and review of the literature.

A patient presented with signs and symptoms of a left carotid cavernous fistula (CCF). Computed tomography angiography confirmed filling of the cavernous sinus in the arterial phase. Cerebral digital subtraction angiography demonstrated no evidence of CCF. The workup, diagnosis, and treatment of this patient are discussed, and the literature is reviewed.