Lowering Platelet Threshold to 20,000/µL for Fluoroscopy-Guided Lumbar Puncture Does Not Result in Observed Clinical Adverse Outcomes.

PURPOSE: Fluoroscopic-guided lumbar puncture (FG-LP) is a common neuroradiologic procedure. Traditionally, a minimum platelet count (MPC) of 50,000/µL for this procedure has been required; however, we recently adopted a lower MPC threshold of 20,000/µL. The purpose of this study was to compare adverse events in patients undergoing FG-LP with MPCs above to those below the conventional 50,000/µL threshold. MATERIALS: This was an institutional review board-approved, retrospective study on adult patients with hematologic malignancy undergoing FG-LP in the neuroradiology division between May 2021 and December 2022, after lowering the minimal required MPC to 20,000/µL. Recorded data included indication for FG-LP, preprocedure and postprocedure MPC, need for and number of platelet transfusions within 24 hours of FG-LP, presence of traumatic tap, FG-LP-related complications, and any platelet transfusion-related adverse event. Patients were classified into 2 groups based on MPC: (1) those above 50,000/µL and (2) those below 50,000/µL. Descriptive statistics were used comparing these 2 groups. RESULTS: One hundred twenty-eight patients underwent FG-LP, with 46 having an MPC between 20,000 and 50,000/µL and 82 having an MPC above 50,000/µL. No postprocedural complications were encountered in either group. Traumatic taps occurred in 10/46 (22%)​ with MPC below 50,000/µL versus 10/82 (12%)​ in those with MPC above 50,000/µL. Forty of 46 patients (87%) were transfused with platelets within 24 hours prior to FG-LP. One patient developed a transfusion-related reaction. CONCLUSION: Lowering the MPC threshold from 50,000/µL to 20,000/µL for FG-LP did not result in a higher incidence of spinal hematoma.

Coronal Diffusion-Weighted Imaging Does Not Improve Detection of Posterior Fossa Infarcts Compared With Conventional Axial Diffusion-Weighted Imaging.

PURPOSE: Recent publications have suggested incorporating coronal diffusion-weighted imaging (DWI) sequences and axial DWI sequences to enhance the detection of posterior fossa infarcts (PFIs). This study evaluated the utility of coronal DWIs compared with axial DWIs for assessing PFIs in the emergency department (ED). METHODS: A retrospective, institutional review board-approved study was conducted at a level I stroke center, including 118 patients who presented to the ED between 2016 and 2023 with suspected PFI. Inclusion criteria involved patients who underwent emergent 1.5 T magnetic resonance imaging (MRI) and had axial and coronal DWI sequences. Two neuroradiologists independently evaluated the DWI sequences for PFI detection in 2 rounds, with a 4-week interval between rounds. The neuroradiologists assessed the quality of axial and coronal DWIs using a 5-point Likert scale. Descriptive statistics, interrater reliability, and marginal homogeneity tests were performed. RESULTS: Among the 118 MRI scans, 23 (19%) showed PFI on axial and coronal DWI sequences. All 23 cases were identified on axial DWI, whereas 8 cases of PFI (35%) were not detected on coronal DWI ( P value = 0.013). No PFIs were observed on coronal DWI that was not identified on axial DWI. The quality scores for both raters were significantly higher for axial DWIs than coronal DWIs ( P value <0.00001). CONCLUSION: Despite recent recommendations advocating for the inclusion of coronal DWI in PFI detection, this study's findings indicate no improvement in PFI detection or image quality using coronal DWI. Further research is necessary to validate these results and explore the potential benefits of incorporating coronal DWI in assessing posterior fossa strokes.

Multisystem factors contributing to redundant intracranial vascular imaging in the ED.

PURPOSE: To evaluate the multisystem factors contributing to redundant neurovascular orders in the ED. METHODS: This was an IRB-approved, retrospective study, performed at a single institution examining a 5-year history of redundant CTA/MRA head and neck (HN) exams performed in the ED for patients with no documented clinical change in mental status/neurological exam necessitating additional imaging. Factors contributing to redundant ordering including provider experience, synchronous order placement, and radiologist recommendations were examined. Additionally, the impact of duplicative imaging in terms of medical cost and ED length of stay was evaluated. RESULTS: 250 patients met inclusion criteria with both CTA/MRA of the HN performed during a single ED encounter (total 500 exams). 190 (76%) redundant exams were not recommended by a radiologist and contributed to an added ED length of stay of 3.6 h on average. Provider experience was not a significant contributing factor. 60 (24%) of redundant exams were recommended by a radiologist and were most frequently CTAs needed to clarify an area of artifact/high-grade stenosis/occlusion on a primary MRA exam. CONCLUSION: Evaluation of contributing factors to redundant CTA/MRA HN exams ordering has highlighted multiple associated factors including provider experience, recommendations by radiologists for clarification of MRA findings, as well as systems processes related to synchronous CTA/MRA order placement.

The "Crossing Collection Sign": A Diagnostic Tool on Spine Magnetic Resonance Imaging For Localizing Cerebrospinal Fluid Leak.

OBJECTIVE: The aim of the study is to determine whether the site of "cross" between ventral and dorsal spinal longitudinal extradural CSF collections (SLECs) seen on magnetic resonance imaging during initial workup of patients with suspected CSF leaks can predict the subsequently confirmed leakage site on computed tomography myelography or surgical repair. METHODS: This was an institutional review board-approved, retrospective study performed from 2006 to 2021. Patients with SLECs who underwent total spine magnetic resonance imaging at our institution, followed by myelography and/or surgical repair for CSF leak, were included. Patients with incomplete workup including lack of computed tomography myelography and/or surgical repair and patients severely motion degraded imaging were excluded from our study. The site of cross between ventral and dorsal SLECs was defined as the "crossing collection sign" and was compared with the anatomically confirmed site of leak on myelography and/or at surgical repair. RESULTS: Thirthy-eight patients met inclusion criteria with 18 females and 11 males ranging in age from 27 to 60 years (median, 40 years; interquartile range, 14 years). The crossing collection sign was seen in 76% of patients (n = 29). The distributions of confirmed CSF leak were as follows: cervical (n = 9), thoracic (n = 17), and lumbar spine (n = 3). The crossing collection sign predicted the site of CSF leak in 14 of 29 patients (48%) and was within 3-vertebral segments in 26 of 29 cases (90%). CONCLUSIONS: The crossing collection sign can help prospectively identify spinal regions with highest likelihood for CSF leak in patients with SLECs. This can potentially help optimize the more invasive subsequent steps in the workup for these patients, including dynamic myelography and surgical exploration for repair.

Imaging, Clinical, and Demographic Differences in Patients With Type III Spinal Cerebrospinal Fluid Leak (Cerebrospinal Venous Fistulas) Compared With Patients With Types I and II Spinal Cerebrospinal Fluid Leak.

OBJECTIVE: Spinal cerebrospinal fluid (CSF) leaks are an underdiagnosed cause of neurologic symptoms. The most common types of spinal CSF leaks are from dural tears (type I) and meningeal diverticula (type II). Cerebrospinal fluid-venous fistulas (type III) are less common and underrecognized. The purpose of this study was to evaluate the intracranial and spinal imaging findings in patients with types I/II versus type III leaks. MATERIALS AND METHODS: This was a retrospective, institutional review board-approved study performed on adult patients between January 2020 to September 2021 with surgically confirmed type I/II/III spinal CSF leak. Patients had preoperative brain magnetic resonance imaging (MRI) with contrast and medical records detailing symptoms and clinical diagnoses. Patients were excluded for nondiagnostic brain MRIs. Demographic and clinical information were recorded. The presence of extra-axial collections, pachymeningeal thickening, brain sagging, and decreased pontomamillary distance were evaluated on MRI. RESULTS: Seven patients had type III leaks, and 16 had type I/II leaks. Patients with type III leaks were older ( P = 0.0003) and had higher rates of initial misdiagnosis (100% vs 31%) and longer times to correct diagnosis ( P = 0.03) compared with type I/II leaks. Intracranial extra-axial collections were never seen with type III leaks but were seen in 50% of type I/II leaks. Pachymeningeal thickening and brainstem sagging occurred in nearly equal frequency between groups. Smaller pontomamillary distances were seen in type III leaks versus type I/II leaks ( P = 0.047). CONCLUSIONS: When evaluating patients with suspected spinal CSF leak, findings of older age, absence of intracranial extra-axial collections, and small pontomamillary distances may raise suspicion for type III versus type I/II leak.

Long-term neuroimaging follow-up of COVID-19-related leukoencephalopathy.

More than a year after the start of the COVID-19 pandemic, long-term neurological manifestations of COVID-19 are increasingly being reported. The long-term sequelae of COVID-19-related leukoencephalopathy, however, remain unclear. Here, we present long-term neuroimaging follow-up in two cases of COVID-19-related leukoencephalopathy. The two cases demonstrate the utility of brain MRI for evaluating neurologic symptoms in critically ill patients with COVID-19, for diagnosis of underlying neural injury and prognostication of future recovery. The presence of leukoencephalopathy may result in chronic neurologic manifestations and may represent a poor prognosticator of neurologic recovery. The presence of leukoencephalomalacia on follow-up neuroimaging is potentially an indicator of irreversible white matter damage, which may be associated with more severe chronic deficits.

Early experience with hippocampal avoidance whole brain radiation therapy and simultaneous integrated boost for brain metastases.

PURPOSE: Cranial irradiation results in cognitive decline, which is hypothesized to be partially attributable to hippocampal injury and stem cell loss. Recent advances allow for targeted reduction of radiation dose to the hippocampi while maintaining adequate dose coverage to the brain parenchyma and additional increasing dose to brain metastases, a approach called hippocampal avoidance whole brain radiation therapy with a simultaneous integrated boost (HA-WBRT + SIB.) We review our early clinical experience with HA-WBRT + SIB. MATERIALS AND METHODS: We evaluated treatments and clinical outcomes for patients treated with HA-WBRT + SIB between 2014 and 2018. RESULTS: A total of 32 patients (median age, 63.5 years, range 45.3-78.8 years) completed HA-WBRT + SIB. Median follow-up for patients alive at the time of analysis was 11.3 months. The most common histology was non-small cell lung cancer (n = 22). Most patients (n = 25) were prescribed with WBRT dose of 30 Gy with SIB to 37.5 Gy in 15 fractions. Volumetric modulated arc therapy reduced treatment time (p < 0.0001). Median freedom from intracranial progression and overall survival from completion of treatment were 11.4 months and 19.6 months, respectively. Karnofsky Performance Status was associated with improved survival (p = 0.008). The most common toxicities were alopecia, fatigue, and nausea. Five patients developed cognitive impairment, including grade 1 (n = 3), grade 2 (n = 1), and grade 3 (n = 1). CONCLUSION: HA-WBRT + SIB demonstrated durable intracranial disease control with modest side effects and merits further investigation as a means of WBRT toxicity reduction while improving long-term locoregional control in the brain.

Lung apical findings in coronavirus disease (COVID-19) infection on neck and cervical spine CT.

PURPOSE: To evaluate the prevalence and features of lung apical findings on neck and cervical spine CTs performed in patients with COVID-19. METHODS: This was a retrospective, IRB-approved study performed at a large academic hospital in the USA. Between March 3, 2020, and May 6, 2020, 641 patients with COVID-19 infection diagnosed by RT-PCR received medical care at our institution. A small cohort of patients with COVID-19 infection underwent neck or cervical spine CT imaging for indications including stroke, trauma, and neck pain. The lung apices included in the field of view on these CT scans were reviewed for the presence of findings suspicious for COVID-19 pneumonia, including ground-glass opacities, consolidation, or crazy-paving pattern. The type and frequency of these findings were recorded and correlated with clinical information including age, gender, and symptoms. RESULTS: Thirty-four patients had neck or spine CTs performed before or concurrently with a chest CT. Of this group, 17 (50%) had unknown COVID-19 status at the time of neck or spine imaging and 10 (59%) of their CT studies had findings in the lung apices consistent with COVID-19 pneumonia. CONCLUSION: Lung apical findings on cervical spine or neck CTs consistent with COVID-19 infection are common and may be encountered on neuroimaging performed for non-respiratory indications. For these patients, the emergency radiologist may be the first physician to suspect underlying COVID-19 infection.

Increase of pseudoprogression and other treatment related effects in low-grade glioma patients treated with proton radiation and temozolomide.

INTRODUCTION: Concurrent radiotherapy and temozolomide (TMZ) is associated with radiographic pseudoprogression (PsP) in glioblastoma. The occurrence of PsP and other treatment effects is less well understood in low-grade gliomas (LGG). The purpose of this study is to evaluate whether the addition of TMZ to radiotherapy increases the incidence of PsP in adults with LGG treated with proton radiotherapy (PRT). METHODS: Chart review and volumetric MRI-analysis was performed on radiotherapy-naive adults with WHO grade II or IDH mutant WHO grade III gliomas treated with PRT between 2005 and 2015. Progression was defined by histology, new chemotherapy initiation, or progressive increase in lesion volume beyond 40% from baseline. Post treatment related effects (PTRE) were defined as new/increased T2/FLAIR or abnormal enhancement which eventually resolved or stabilized without evidence of progression for a period of 6-12 months. PsP was defined as the subset of PRTE suspicious for progression or volumetrically increased at least 40% from baseline. Pearson's chi-squared test and Cox-proportional hazards models were used for statistical analysis. RESULTS: There were 119 patients meeting inclusion criteria. There was an increased risk of PsP following PRT + TMZ versus PRT-alone (HR = 2.2, p = 0.006, on Cox univariate analysis). Presence of PsP was associated with improved OS (p = 0.02 with PsP as time-varying covariate). CONCLUSIONS: TMZ use, when added to PRT, was associated with increased PsP in patients with LGG; however, patients with PsP tended to achieve longer survival.

Does including neck CTA in work-up of suspected intracranial hemorrhage add value?

PURPOSE: Neck CT angiography (CTA) is frequently performed in conjunction with head CTA in patients presenting with clinical signs and symptoms concerning for acute intracranial hemorrhage, despite relatively low appropriateness (ACR Appropriateness Criteria 2-6). This decision is sometimes justified by suggesting that CTA neck findings are useful in planning subsequent catheter angiography. METHODS: We investigated the value of neck CTA in patients with suspected acute intracranial hemorrhage by reviewing 220 head and neck CTAs performed in our emergency room over a 24-month period for the indication of hemorrhage or headache. Images were reviewed by two neurointerventionalists to address the value of the neck CTA for planning catheter angiography. RESULTS: Findings helpful for performing catheter angiography were observed on neck CTA in 22% (Cohen kappa 0.65), and included anatomical arch variants such as a bovine arch, direct vertebral artery arch origin, and aberrant subclavian artery. However, findings that might substantially prolong angiography for more than 10 min if unknown occurred in 5% (Cohen kappa 0.69). Incidental findings prompting additional imaging or significant clinical action occurred in 20%. Subarachnoid hemorrhage on noncontrast head CT was strongly associated with a need for subsequent angiography. CONCLUSIONS: Although CTA neck can provide helpful information for planning catheter angiography, it rarely uncovers findings that would significantly prolong the procedure if unknown. Neck CTA is therefore only recommended in patients with a confirmed intracranial hemorrhage in a pattern consistent with aneurysm or arteriovenous shunt.

What is the diagnostic value of head MRI after negative head CT in ED patients presenting with symptoms atypical of stroke?

The diagnostic value of head magnetic resonance imaging after negative head computed tomography for emergency department patients with vague neurologic symptoms, such as dizziness and altered mental status, remains an ongoing discussion. The objective of this study is to detect the subgroup of patients with such presentations having minor strokes whom may benefit from primary and secondary stroke prevention. We conducted a retrospective analysis and stratified patient risk factors associated with positive findings on subsequent head MRI ordered by the emergency department physician following a normal head CT. Two hundred fifty-two patients presenting with atypical stroke symptoms to the emergency department had a negative head CT followed by head MRI within 24 h ordered by emergency department clinician (123 males and 129 females; mean age of 59.4). Twenty nine of the 252 patients (11.5 %) had findings of acute to subacute infarct on the subsequent MRI. Positive MRI findings were statistically correlated with the following variables: age (p < 0.001), history of hyperlipidemia (p = 0.019), hypertension (p < 0.001), diabetes (p = 0.004), anticoagulation use (p = 0.029), and prior transient ischemic attack or stroke (p < 0.001). The mean age of the MRI-positive group was 74.1 years, with a mean difference of 16.7 ± 2.4 years more than the MRI-negative group (95 % CI, 11.8-21.5 years) (t = 6.8, p < 0.001). Emergency physicians caring for patients with vague neurologic complaints should maintain a lower threshold for ordering a head MRI despite a negative head CT for elderly patients with a history of prior stroke or transient ischemic attack to exclude a CT occult or minor ischemic stroke.

Pediatric Orbital Depth and Growth: A Radiographic Analysis.

BACKGROUND: Orbital reconstruction requires knowledge of orbital depth in order to prevent optic nerve injury. Numerous analyses of adult orbital dimensions have been undertaken previously in order to characterize this measurement, including skull specimen and computerized tomography studies. However, there is a paucity of information regarding the pediatric orbit. METHODS: The authors used pediatric magnetic resonance imaging (MRI) studies in order to quantify the change in orbital depth in relationship to patient age, and to develop methods to estimate and calculate orbital depth for individual pediatric patients. MRIs of the head in normal pediatric patients were reviewed retrospectively. Orbital depths were measured and correlated with age and cephalometric dimensions. In a randomly selected subgroup of patients, measurements were repeated by an independent investigator to determine interobserver reliability. RESULTS: Measurements were obtained in 72 patients ranging from 3 months to 18 years of age (mean=7.8 years). There was a significant exponential relationship between orbital depth and patient age (r=0.81, F(2,69)=143.97, P<0.001). Depth increased more rapidly in the first 6 years of life, but leveled off in the early teen years toward a horizontal asymptote of approximately 45 mm. There was also a significant relationship between orbital depth and the sum of the biparietal width plus the anterior-posterior length (r=0.72, F(2,69)=87.44, P<0.0001). There was high interobserver reliability in measurements between 2 independent investigators (r=0.79, P<0.0001). CONCLUSION: In children, orbital depth increases predictably with rising age and increasing head size. Knowledge of this growth curve and the relationship between head size and orbital depth can complement careful surgical dissection to improve safety and efficacy in pediatric orbital reconstructions.

Volumetric Changes in the Choroid Plexus Associated with Spontaneous Intracranial Hypotension in Patients with Spinal CSF Leak.

BACKGROUND AND PURPOSE: The choroid plexus contains specialized ependymal cells responsible for CSF production. Recent studies have demonstrated volumetric and perfusion changes in the choroid plexus with age and neurodegenerative disorders, however, volumetric changes in the choroid plexus in low pressure states is not known. The purpose of this study is to evaluate volumetric differences in choroid plexus size in patients with spontaneous intracranial hypotension (SIH) resultant from spinal CSF leaks compared with healthy controls. MATERIALS AND METHODS: This was a retrospective, institutional review board-approved study. Patients with MRI evidence of SIH and a spinal CSF leak diagnosed on myelography and subsequently confirmed at surgery were included in this study. All patients included in this study including age-matched healthy controls had a brain MRI performed on a either a 1.5 or 3T scanner with acquisition of 3D T1 postcontrast (eg, BRAVO, MPRAGE, etc). In all patients, the trigonum ventriculi volume, in the atria of the lateral ventricles, was contoured by using Visage-7 segmentation tools on the volumetric postcontrast T1 sequence. A basic 2-tailed t test was used to compare choroid plexus volumes between the 2 groups. RESULTS: Thirty-four patients were included with 17 patients with SIH with spinal CSF leak and 17 healthy control patients who were age- and sex-matched. The mean age of patients was 45 years, standard deviation 14 years. The mean volume of the choroid plexus for patients with SIH with spinal CSF leak was 1.2 cm3 (standard deviation = 0.26) compared with 0.63 cm3 (standard deviation = 0.31) in the control group (P < .0001). CONCLUSIONS: Results of this study demonstrate a higher choroid plexus volume in patients with SIH with spinal CSF leak compared with age- and sex-matched healthy controls. This likely reflects compensatory mechanisms to counteract intracranial hypotension by increasing CSF production as well as increased vascularity of the choroid plexus through expansion of the intracranial blood pool.

No Surprises Act: Legal Challenges and Implications for Radiology.

When the word "surprise" is used as a noun, it generally describes an unexpected event. When "surprise" is used in conjunction with "billing", it conjures up images with which even the most hardened backroom medical administrator can empathize. One's first reaction is likely patient based, that a person received medical services from a health care provider or facility that are larger than anticipated in-network charges. As a result, the bill for services incorporates that, no-doubt unpleasant, surprise. The whole truth is understandably more complex. Radiology groups contract with insurance companies who for their own reasons, might have historically preferred progressively narrower networks. Nonetheless, these contracts allow providers the opportunity to negotiate reasonable payments for services rendered. Events have changed the historic dynamic between providers and insurance companies.

Evaluation of an Artificial Intelligence Model for Identification of Mass Effect and Vasogenic Edema on CT of the Head.

BACKGROUND AND PURPOSE: Mass effect and vasogenic edema are critical findings on CT of the head. This study compared the accuracy of an artificial intelligence model (Annalise Enterprise CTB) with consensus neuroradiologists' interpretations in detecting mass effect and vasogenic edema. MATERIALS AND METHODS: A retrospective stand-alone performance assessment was conducted on data sets of noncontrast CT head cases acquired between 2016 and 2022 for each finding. The cases were obtained from patients 18 years of age or older from 5 hospitals in the United States. The positive cases were selected consecutively on the basis of the original clinical reports using natural language processing and manual confirmation. The negative cases were selected by taking the next negative case acquired from the same CT scanner after positive cases. Each case was interpreted independently by up-to-three neuroradiologists to establish consensus interpretations. Each case was then interpreted by the artificial intelligence model for the presence of the relevant finding. The neuroradiologists were provided with the entire CT study. The artificial intelligence model separately received thin (≤1.5 mm) and/or thick (>1.5 and ≤5 mm) axial series. RESULTS: The 2 cohorts included 818 cases for mass effect and 310 cases for vasogenic edema. The artificial intelligence model identified mass effect with a sensitivity of 96.6% (95% CI, 94.9%-98.2%) and a specificity of 89.8% (95% CI, 84.7%-94.2%) for the thin series, and 95.3% (95% CI, 93.5%-96.8%) and 93.1% (95% CI, 89.1%-96.6%) for the thick series. It identified vasogenic edema with a sensitivity of 90.2% (95% CI, 82.0%-96.7%) and a specificity of 93.5% (95% CI, 88.9%-97.2%) for the thin series, and 90.0% (95% CI, 84.0%-96.0%) and 95.5% (95% CI, 92.5%-98.0%) for the thick series. The corresponding areas under the curve were at least 0.980. CONCLUSIONS: The assessed artificial intelligence model accurately identified mass effect and vasogenic edema in this CT data set. It could assist the clinical workflow by prioritizing interpretation of cases with abnormal findings, possibly benefiting patients through earlier identification and subsequent treatment.

Implementation of a Survey Spine MR Imaging Protocol for Cord Compression in the Emergency Department: Experience at a Level 1 Trauma Center.

BACKGROUND AND PURPOSE: Imaging stewardship in the emergency department (ED) is vital in ensuring patients receive optimized care. While suspected cord compression (CC) is a frequent indication for total spine MR imaging in the ED, the incidence of CC is low. Recently, our level 1 trauma center introduced a survey spine MR imaging protocol to evaluate for suspected CC while reducing examination time to avoid imaging overutilization. This study aims to evaluate the time savings, frequency of ordering patterns of the survey, and the symptoms and outcomes of patients undergoing the survey. MATERIALS AND METHODS: This retrospective study examined patients who received a survey spine MR imaging in the ED at our institution between 2018 and 2022. All examinations were performed on a 1.5T GE Healthcare scanner by using our institutional CC survey protocol, which includes sagittal T2WI and STIR sequences through the cervical, thoracic, and lumbar spine. Examinations were read by a blinded, board-certified neuroradiologist. RESULTS: A total of 2002 patients received a survey spine MR imaging protocol during the study period. Of these patients, 845 (42.2%, mean age 57 ± 19 years, 45% women) received survey spine MR imaging examinations for the suspicion of CC, and 120 patients (14.2% positivity rate) had radiographic CC. The survey spine MR imaging averaged 5 minutes and 50 seconds (79% faster than routine MR imaging). On multivariate analysis, trauma, back pain, lower extremity weakness, urinary or bowel incontinence, numbness, ataxia, and hyperreflexia were each independently associated with CC. Of the 120 patients with CC, 71 underwent emergent surgery, 20 underwent nonemergent surgery, and 29 were managed medically. CONCLUSIONS: The survey spine protocol was positive for CC in 14% of patients in our cohort and acquired at a 79% faster rate compared with routine total spine. Understanding the positivity rate of CC, the clinical symptoms that are most associated with CC, and the subsequent care management for patients presenting with suspected cord compression who received the survey spine MR imaging may better inform the broad adoption and subsequent utilization of survey imaging protocols in emergency settings to increase throughput, improve allocation of resources, and provide efficient care for patients with suspected CC.

Klüver-Bucy syndrome after unilateral frontotemporal resection in a child with tuberous sclerosis.

Klüver-Bucy syndrome (KBS) is a behavioral phenotype that appears most often after bilateral temporal damage. The main features of KBS are compulsion to examine objects orally, increased sexual activity, placidity, hypermetamorphosis (irresistible impulse to notice and react to everything within sight), visual agnosia, and problems with memory. It is more rarely reported in children than in adults. We present a case of KBS in a 2-year-old boy with tuberous sclerosis complex (TSC) after left frontotemporal resection for refractory epilepsy. This is the first KBS after unilateral temporal resection in a child, although it has already been reported in two adult cases. It also is the first case reported in a TSC patient.