BACKGROUND AND PURPOSE:CT angiography (CTA) of the head and neck has experienced rapid utilization growth, yet the distribution of interpretation across physician specialties and its implications for the neuroradiology workforce are poorly characterized. We analyzed Medicare claims to assess trends in CTA utilization, provider volume, and neuroradiologists' evolving role from 2017 to 2024. METHODS:This retrospective analysis of the complete Medicare Fee-for-Service Part B claims for CPT codes 70496 and 70498 classified physicians as neuroradiologists (validated NITOS wRVU classification), other radiologists, or other specialty physicians. Within-physician changes were assessed with paired Wilcoxon signed-rank testing and Hodges-Lehmann shifts with 95% confidence intervals (CIs); group-share changes used NPI-clustered nonparametric bootstrap resampling to account for clustering of services within physicians. RESULTS:Across 2017-2024, 8,712,757 CTA services were billed by 19,143 unique physicians (3,182 neuroradiologists, 15,199 other radiologists, 762 other specialty physicians). The number of providers per year grew from 9,134 to 13,021 (+43%). Among neuroradiologists present in both endpoints (n = 1,530), the within-physician Hodges-Lehmann increase was 70 studies (95% CI 64-77; P < .001). The per-1,000 Fee-for-Service beneficiary rate grew 206% (16.5 to 50.7). Neuroradiologists' share changed by -1.42 pp (37.7% to 36.3%; 95% CI -3.51 to +0.36; P = .16), other radiologists' share rose 2.26 pp (P = .01), and other specialty physicians' share fell 0.84 pp (P < .001). Neuroradiologists comprised 57.5% of top-decile providers. Among neuroradiologists, median (IQR) annual CTA volume rose from 102 (59-169) in 2017 to 165 (88-271) in 2024. CONCLUSIONS:Head and neck CTA utilization in Medicare Fee-for-Service grew substantially from 2017 to 2024, with per-beneficiary rates tripling. Neuroradiologists dominate high-volume interpretation but their proportional share has remained essentially stable, with implications for workforce planning and neurovascular imaging training.
BACKGROUND:Neurotuberculosis is a severe form of extrapulmonary tuberculosis causing significant morbidity and mortality. PURPOSE:To compare the imaging phenotypes of adult and pediatric populations with CNS tuberculosis through a quantitative meta-analysis, and to characterize the broader spectrum of neurotuberculosis radiological findings through a systematic review emphasizing standard and advanced imaging techniques. DATA SOURCES:A systematic search was conducted across Embase, LILACS, PubMed, and Scopus databases. STUDY SELECTION:Following PRISMA guidelines, observational studies detailing CT and MRI findings in CNS tuberculosis were included. DATA ANALYSIS:Screening and data extraction were conducted using Rayyan and R software. Random-effects meta-analyses calculated pooled prevalence estimates (95% CI) stratified by age (adult vs. pediatric). DATA SYNTHESIS:From 91 studies (5,955 patients) in the systematic review, 32 low-risk-of-bias studies (1,675 patients: 24 adult, 1,415 patients; 8 pediatric, 260 patients) were meta-analyzed. Weighted mean age (by study sample size) was approximately 32.0 years in adults (23/24 studies reporting age; N=1,301) and 6.0 years in children (8/8 studies; N=260). Pooled prevalence estimates were numerically higher in pediatric than adult cohorts for meningovascular complications, including leptomeningeal enhancement (89% vs. 61%), hydrocephalus (81% vs. 36%), and brain infarctions (65% vs. 33%, with greater proportional cortical involvement). Tuberculomas showed similar prevalence (∼60%, predominantly multiple). Advanced MRI modalities (DWI, 1H-MRS, vessel wall imaging) provided detailed lesion characterization. Spinal involvement was evaluated almost exclusively in adults, precluding a quantitative comparative meta-analysis due to sparse pediatric spinal data. LIMITATIONS:High heterogeneity across primary studies, geographic concentration in endemic regions, and insufficient pediatric spinal data. CONCLUSIONS:Neurotuberculosis imaging phenotypes differed numerically by age group, with pediatric cases showing a higher pooled burden of meningovascular complications. While intracranial age-stratified differences were established, comparative spinal analysis was limited by sparse pediatric data.
BACKGROUND AND PURPOSE:VPS11-related Hypomyelinating Leukodystrophy (VPS11-HLD), also named HLD12, is an ultrarare lysosomal-autophagic disorder characterized by severe, early-onset neurodevelopmental disability and diffuse hypomyelination. The neuroimaging spectrum of VPS11-HLD had not been systematically studied. We aimed to characterize the MRI phenotype of VPS11-HLD and identify reproducible imaging features that may aid in distinguishing it from other hypomyelinating leukodystrophies. MATERIALS AND METHODS:Patients with VPS11-HLD from two tertiary centers were retrospectively identified between 2019 and 2025. Clinical and genetic data were retrieved from medical records. Brain MRIs were independently reviewed by two pediatric neuroradiologists, and inter-rater agreement was assessed. Imaging features and biometric measurements were compared with those of 21 individuals with other genetically confirmed HLDs using Mann-Whitney U and Fisher's exact tests. A systematic literature review was conducted to identify previously reported cases and provide clinical and neuroimaging data. RESULTS:Six patients (four unrelated boys and two sisters; age range 8 months to 10 years) diagnosed with a homozygous VPS11 c.2536T>G (p.Cys846Gly) variant were identified. The first MRI, obtained at a median age of 9 months (IQR 7.5,13.75), demonstrated the following findings in all patients: 1) a distinct cerebellar signature characterized by focal absence of the cerebellar cortex in the middle-anterior hemispheric portions; 2) diffuse hypomyelination; 3) a periventricular leukomalacia (PVL)-like pattern; 4) short corpus callosum with marked thinning of the posterior portion, 5) hypoplasia of the anterior commissure and 6) mild pontine volume reduction. Inter-rater agreement for MRI feature assessment was high. In a comparative analysis with 21 patients with other HLDs, the cerebellar signature was observed exclusively in VPS11-HLD (6/6 vs. 0/21, respectively, p < .001). CONCLUSION:VPS11-HLD demonstrates a reproducible MRI pattern combining a novel, peculiar cerebellar anomaly, hypomyelination with PVL-like pattern, and extremely thin and short corpus callosum.In the context of an ultra-rare disorder, this pattern may represent a candidate neuroradiologic phenotype that could support diagnostic stratification, guide targeted genetic evaluation, and provide insight into the role of autophagy-lysosome dysfunction in myelin and cerebellar development.
BACKGROUND AND PURPOSE:Iatrogenic vessel dissection is an uncommon complication of neuroendovascular therapy. Owing to its low incidence, procedure-specific incidence and associated factors have remained incompletely defined. While iatrogenic vessel dissection typically follows a benign course, severe outcomes have occasionally been reported, and the determinants of this exceptional course are unclear. We aimed to establish procedure-specific benchmark incidence, identify associated factors, and assess its outcome impact using a large nationwide registry. MATERIALS AND METHODS:We conducted a retrospective analysis using the Japanese Registry of Neuroendovascular Therapy 4, covering 2015-2019. Dissection incidence, associated baseline and procedural factors, and 30-day functional outcomes were evaluated across nine treatment categories. Procedure-specific multivariable logistic regression was used to estimate adjusted associations with 30-day mRS. Among dissection cases without other complications (isolated dissection), secondary intracranial hemorrhage or cerebral infarction and their associations with outcomes were explored. These analyses were also conducted separately for intracranial and extracranial treatment sites. RESULTS:A total of 53,402 procedures were included. Overall incidence was 0.65% (348 procedures), ranging from 0.12% in vasospasm treatment to 3.48% in intracranial angioplasty/stenting. Dissection occurred more frequently in emergency procedures and under local anesthesia. Dissection was consistently more frequent with flow diverters, angioplasty/stenting, and lesions requiring balloon dilation or stent deployment, including high-grade stenosis, total occlusion, and atherothrombotic occlusion. In multivariable models, an independent association with mRS 5-6 was observed only in aneurysm treatment (adjusted OR, 2.48; 95% CI, 1.05-5.40). Among 296 isolated dissections, no mRS decline occurred in 265 (89.5%). Decline was more frequent with secondary hemorrhage or infarction than without (26/57 [46%] vs 5/239 [2.1%]; P < .001). At intracranial treatment sites, decline was more frequent with hemorrhage than with infarction (16/25 vs 8/25; P = .047), and death occurred only after hemorrhage (6/25 vs 0/25; P = .02). CONCLUSIONS:Iatrogenic vessel dissection incidence varied substantially across neuroendovascular procedures and was most consistently associated with procedures and lesions requiring balloon dilation or stent deployment. Most dissections did not lead to clinical deterioration; early clinical impact was associated mainly with secondary intracranial hemorrhage or infarction rather than with the dissection itself.
BACKGROUND:The posterior circulation Acute Stroke Prognosis Early CT Score (pc-ASPECTS; range 0-10) is a region-based scoring system designed to quantify early ischemic change in the vertebrobasilar territory and is increasingly used to inform patient selection for endovascular therapy. However, whether its prognostic performance depends on the imaging modality used to derive the score remains incompletely characterized. METHODS:PubMed, Scopus, and Web of Science were searched for studies reporting pc-ASPECTS prior to endovascular therapy (EVT) ± IVT and 90-day modified Rankin Scale (mRS) outcomes across diffusion-weighted imaging (DWI), CT angiography source imaging (CTA-SI), and non-contrast computed tomography (NCCT). When studies reported both perfusion-derived parameters and pc-ASPECTS, only pc-ASPECTS-derived data were extracted. Between-group differences in pc-ASPECTS and other clinical metrics were quantified as Standardized Mean Differences (SMDs) using either a Bayesian framework or restricted maximum likelihood (REML) estimation. RESULTS:Forty-eight studies (4,853 patients) were included; five cohorts contributed two modality-specific datasets each, yielding 51 imaging datasets that were used only in the modality-stratified analyses. Across all imaging modalities, patients with favorable outcomes had significantly higher pc-ASPECTS values (Bayesian pooled SMD 0.78, 95% credible interval [CrI] 0.61-0.95). Modality-specific analyses showed consistent effects for DWI (SMD 1.01, 95% CrI 0.74-1.29), NCCT (SMD 0.76, 95% CrI 0.29-1.24), and CTA-SI (SMD 0.59, 95% CrI 0.26-0.92) with no statistically significant between-modality difference detected (p = 0.26). In per-point analyses, each 1-point decrease in pc-ASPECTS was associated with a 1.48-fold increase in the odds of unfavorable outcome (OR 1.48, 95% CI 1.33-1.54; I2 = 31.8% p <0.01). Sensitivity analyses confirmed the robustness of the primary findings. CONCLUSIONS:Baseline pc-ASPECTS is a clinically useful, imaging-modality-independent marker of 90-day functional outcome after EVT for posterior circulation stroke. Prognostic performance did not differ significantly across modalities; however, the absence of a statistically significant difference should not be interpreted as formal equivalence, and pc-ASPECTS is best applied as one component of multimodal risk stratification rather than as a stand-alone threshold for treatment selection.
Leptomeningeal collaterals (LMCs) strongly influence outcomes in acute ischemic stroke (AIS), but their small caliber makes visualization challenging with computed tomography angiography (CTA) and magnetic resonance angiography (MRA). Digital subtraction angiography (DSA) remains the gold standard for anatomical and functional LMC assessment but is invasive and typically reserved for patients undergoing mechanical thrombectomy. Several grading systems have been proposed to noninvasively assess LMCs on acute-phase CTA and MRA. However, no consensus exists on which system best captures the complex anatomy of LMCs, and considerable variability in interrater reliability, standardization, and clinical feasibility. Here, we review collateral grading systems based on single-phase CTA, the most widely used acute stroke imaging modality, and compare them with DSA-based collateral scoring. We summarize the relevant literature on the clinical importance of LMCs and their impact on treatment outcomes in AIS. Because automated, reproducible collateral scoring could provide clinicians with more objective ratings of LMCs but has not yet entered clinical routine, we also discuss the potential benefits and implications of incorporating automated collateral scoring into routine brain imaging and clinical practice.
BACKGROUND AND PURPOSE:The carotid bodies are small chemoreceptor organs at the carotid bifurcation. Their depiction on conventional CT angiography is inconsistent, with reported detection rates on energy-integrating detector CT (EID-CT) of 62% to 91%. This study evaluates whether photon-counting detector CT (PCD-CT) improves carotid body visualization and describes their normal imaging appearance. MATERIALS AND METHODS:This retrospective study included 37 patients who underwent both PCD-CT and EID-CT head and neck angiography, yielding 74 carotid bifurcations. Two neuroradiologists, reading in consensus, recorded whether each carotid body was definitively identifiable on each modality and rated relative image quality on a 5-point comparative Likert scale. Morphologic measurements were obtained from PCD-CT. Likert scores were analyzed with a linear mixed-effects model with a random intercept for patient; identification was compared with the McNemar test. RESULTS:Reader preference strongly favored PCD-CT (median Likert score, 5.0 [IQR, 4.0-5.0]; mixed-effects mean, 4.6; 95% CI, 4.4-4.8; P < .001). Carotid bodies were identified in all 74 bifurcations (100%) on PCD-CT versus 58 of 74 (78.4%) on EID-CT (P < .001); at least one was missed on EID-CT in 12 of 37 patients (32%). Carotid bodies were ellipsoid in 71 of 74 (95.9%), with mean anteroposterior, transverse, and superoinferior dimensions of 2.0 ± 0.7, 2.1 ± 0.7, and 2.9 ± 1.1 mm, and a median volume of 5.9 mm³ (IQR, 3.8-8.5). CONCLUSIONS:PCD-CT reliably visualizes normal carotid bodies that are frequently missed on conventional EID-CT. Familiarity with their normative appearance may reduce mischaracterization as early paraganglioma and provides a foundation for volumetric research into the carotid body's role in systemic disease.
BACKGROUND:There is a pressing demand to implement a standard acquisition and post-processing approach for proton magnetic resonance spectroscopy performed in children within the clinical setting. Clinical magnetic resonance spectroscopy data is needed to characterize and understand phenotypes and track treatment response, especially in rare genetic disorders with distinct metabolite signatures. For instance, infants and children with cerebral creatine deficiency syndromes are too often misdiagnosed, which leads to delay in life-changing supplementation especially for those with synthesis deficiencies. Quantitative information about brain creatine concentrations is useful in characterizing these syndromes, potentially tracking relevant biomarkers in relation to treatment response, and guiding future clinical trial designs for patients. METHODS:Spectroscopists began discussions about the usage of magnetic resonance spectroscopy in late 2024 with the leadership of the Association for Creatine Deficiencies (ACD). The ACD is a charitable organization established by parents of children with creatine deficiencies to provide patient, family, and public education, to advocate for early intervention through newborn screening, and to promote and fund medical research for treatments and cures for Cerebral Creatine Deficiency Syndromes. The ACD hosts a patient registry where families complete surveys and upload medical reports. Upon review of radiologist reports, the group noted the variability in acquisition, post-processing and interpretation across patient studies and clinical imaging sites. A team of spectroscopists reviewed the literature, identified common parameters across vendors and developed a harmonized approach that can serve as a starting point for imaging sites adopting magnetic resonance spectroscopy or a supplement to those already using it. KEY MESSAGE:This paper is a call for the usage and provides a recommendation of a minimum standard single voxel proton magnetic resonance spectroscopy approach that can be implemented for rapidly evaluating pediatric patients with neurodevelopmental delays consistent with genetic etiologies.
BACKGROUND AND PURPOSE:Flow diversion has transformed the treatment of intracranial aneurysms; however, data on pediatric posterior circulation aneurysms remain limited. The purpose of this study is to evaluate flow diversion in pediatric intracranial posterior circulation aneurysms. MATERIALS AND METHODS:Pediatric intracranial posterior circulation aneurysms treated by flow diverters in a tertiary referral center between 2014 and 2025 were identified and reviewed retrospectively for patient characteristics, angiographic and clinical results of flow diversion. RESULTS:During this period, all the 11 children (6 boys, median age: 14; age range: 6 - 19) who presented with 15 pediatric intracranial posterior circulation aneurysms were treated with flow diversion. Their aneurysms were of fusiform/dissecting type, yet, distinct from the dolichoectatic forms of the vertebrobasilar aneurysms as seen in adults. Two of them had bled previously. The median size/length of the index aneurysms (larger aneurysm in case of tandem aneurysms) was 27 mm and three of them were classified as complex aneurysms demanding multi-device endovascular arterial reconstructions. All embolization procedures were technically successful, without any procedure-related permanent neurological morbidity or mortality on follow-up. One child died because of the consequences of her underlying disease. At a median imaging follow-up of 47 months (3 - 89 months), residual opacification remained in one aneurysm (9.1% of patients, 6.7% of aneurysms) whereas infundibular opacification of efferent arteries was noted in 2 children. CONCLUSION:In this single-center series, pediatric posterior circulation aneurysms treated with flow diversion were predominantly large or giant fusiform/dissecting lesions requiring individualized reconstructive strategies. Flow diversion was technically feasible and associated with favorable long-term angiographic and clinical outcomes in this cohort. Flow diversion represents a viable option for these aneurysms.
BACKGROUND:Fibrocartilaginous embolism (FCE) is a rare but serious cause of spinal cord infarction. Vertical disc herniation (e.g., Schmorl's nodes) may enable FCE in the thoracolumbar spine but is unlikely in the pediatric cervical spine. We hypothesized that radial disc herniation (annular fissuring), rather than vertical herniation, may contribute to cervical spinal cord infarction in children via an FCE mechanism. METHODS:In this retrospective case-control study, the frequency of annular fissures and nuclear degeneration was assessed in patients with possible FCE from January 2004 to December 2023. The presumed diagnosis of FCE was based on clinical evaluation characteristic imaging findings of cord infarction, and exclusion of other diagnoses in electronic medical records. The two control groups included children without myelopathy (Control 1), selected during a 6-month consecutive sampling period from March to July 2014, and children with non-compressive cervical myelopathy (Control 2), selected through consecutive sampling from April 2004 to February 2014. Data analysis was performed using SPSS (IBM, version 29.0). The significance level was p<0.05. RESULTS:A total of 156 children were included, 18 with possible FCE (Case) and 138 without (Control 1 and Control 2 with 39 and 99 patients, respectively). The median ages (IQR) were 12.6 (9.0-16.5), 9.6 (5.0-15.6), and 10.3 (5.0-14.6) years for Case, Control 1, and Control 2 groups respectively and 48.1% (75/156) were female. Annular fissures were observed in 28.8% (45/156) across ≥1 disc levels, and all patients showed nuclear degeneration at one or more disc levels. Among FCE patients, 88.9% (16/18) had at least one annular fissure. The odds ratio of having an annular fissure in FCE patients compared with the total control group was 30.06 (CI [6.53-138.30]). The odds ratio compared with Control 1 was 31.60 (CI [6.70-148.83]) and compared with Control 2 was 26.66 (CI [5.13-138.56]). CONCLUSION:This study demonstrated a statistically significant association between annular fissures and cervical spinal cord infarction. This finding is consistent with the theory that disc material may embolize through a radial annular tear into the cervical spinal cord microcirculation.
BACKGROUND AND PURPOSE:Choroid plexus volume (CPV) may reflect cognitive impairment and glymphatic dysfunction. However, its clinical use is limited by time-consuming segmentation. We developed an ultrafast deep learning method for automated CPV quantification using 3D T1-weighted images (T1WI). MATERIALS AND METHODS:This retrospective study included 697 patients who underwent brain MRI for cognitive impairment. The model was developed using 3D T1WI from 103 patients as an ensemble of three 2.5D U-Nets in the axial, coronal, and sagittal planes. Imaging validation was performed for 20 patients by comparing manual segmentation, FreeSurfer, and the proposed method. Clinical validation included 574 patients classified as subjective cognitive impairment (SCI), early mild cognitive impairment (MCI), late MCI, or Alzheimer disease (AD). ComBat harmonization was applied to reduce scanner-related effects. Accuracy, processing time, group differences, and correlations with the diffusion tensor imaging analysis along the perivascular space (DTI-ALPS) index were assessed. RESULTS:After ComBat harmonization, the deep learning-based model was markedly faster than FreeSurfer (0.4 vs. 188.0 minutes; P<0.001), and its CPV measurements showed no significant difference from manual segmentation (1.89 vs. 1.84 mL; P=1.00). CPV/intracranial volume (ICV)×10³ increased progressively across cognitive stages, from 1.02 in SCI to 1.16 in AD (P=0.004). CPV/ICV measured by the deep learning-based model was negatively correlated with the DTI-ALPS index (ρ=-0.256, P<0.001). CONCLUSION:An ultrafast deep learning method enables automated CPV quantification and provides clinically relevant CPV/ICV measurements for neurodegenerative disease assessment.
BACKGROUND AND PURPOSE:Neuroradiology services report rising ED CTA head and neck demand. Although late-window thrombectomy trials increased interest in perfusion-based selection, relative growth of CTA head and neck versus CT perfusion (CTP), and how these trends compare with overall neuro-ED imaging volume, ED throughput, and coverage periods, remains incompletely characterized. We evaluated decade-long neuro-ED imaging trends at a tertiary care academic medical center. MATERIALS AND METHODS:Retrospective observational study including all neuroradiology ED examinations from two hospital ED sites from fiscal years (FY) 2016-2025. Primary outcomes included annual CTA head, CTA neck, and CTP volumes; their proportions of total neuro-ED imaging; examinations per ED encounter; and (CTA head + CTA neck)-to-CTP ratio. Encounter-normalized trends for FY2016-FY2025 were modeled using negative binomial regression. Coverage-period distribution was assessed using CTA exam-code rates per hour during regular versus on-call hours. Secondary clinical-context sub-analyses assessed baseline National Institutes of Health Stroke Scale (NIHSS) and large language model (LLM)-assisted report abstraction for indications and large vessel occlusion (LVO) yield. RESULTS:Across 303,753 neuro-ED examinations, ED encounters increased modestly from FY2016 to FY2025 (+11%, 108,948 to 121,288), while neuro-ED imaging more than doubled (+111%, 20,087 to 42,398). Combined CTA head and neck examination-code volume increased 8.5-fold (745 in FY2016 to 6,317 in FY2025). Share of CTA head and neck rose from 3.7% (745/20,087) to 14.9% (6,317/42,398) of neuro-ED imaging. Encounter-normalized utilization increased significantly for CTA head and neck (incidence rate ratio [IRR] per FY 1.22 and 1.20, respectively; both p<0.001) but did not change significantly for CTP (IRR 1.00). (CTA head + CTA neck)-to-CTP ratio increased from 4.2 in FY2018 to 9.9 in FY2025. CTA rates per hour increased during both regular and on-call coverage without differential growth. Secondary exploratory analyses suggested increasing CTA use in NIHSS 0 presentations and declining LVO yield. CONCLUSIONS:Over a decade at a tertiary academic center, ED CTA head and neck volumes rose sharply, outpacing ED throughput, overall neuro-ED imaging growth, and CTP utilization. CTA demand increased similarly across regular and on-call periods, underscoring escalating after-hours operational burden and implications for neuroradiology coverage models.
BACKGROUND AND PURPOSE:Recent advances in spontaneous intracerebral hemorrhage (ICH) management increasingly expand the role of neuroimaging beyond diagnosis to potentially guide time-sensitive therapies and targeted clinical trial enrollment. We surveyed neuroradiologists to characterize current ICH imaging and reporting practices and identify opportunities for quality improvement. MATERIALS AND METHODS:An anonymous 52-item electronic survey was distributed through the American Journal of Neuroradiology Survey Corner and REDCap between April and May 2026. Survey domains included imaging acquisition, reporting practices, hematoma volume quantification, assessment of hematoma expansion predictors, ICH localization, etiologic assessment, and follow-up imaging. Responses were summarized using descriptive statistics. RESULTS:A total of 267 neuroradiologists completed the survey. Nearly all respondents (97.3%) reported 24/7 emergency head CT interpretation coverage. However, 41.5% did not routinely quantify hematoma volume, only 45% reported routine CTA acquisition for patients with ICH, and 30% rarely or only occasionally recommended CTA when it was not performed. While 91.3% routinely reported a positive CTA spot-sign, only 43.0% almost always assessed non-contrast CT predictors of hematoma expansion. Confidence in hemorrhage localization when crossing anatomical boundaries and etiologic classification was modest, and 45.8% routinely used the Boston Criteria version 2.0 for MRI-based assessment of cerebral amyloid angiopathy. CONCLUSIONS:Contemporary neuroradiology practice demonstrates several readily addressable gaps in ICH imaging and reporting, including hematoma volume quantification, routine vascular imaging, standardized assessment of hematoma expansion imaging markers, and etiologic assessment. Standardizing these practices can improved image guided risk-stratification and facilitate implementation of emerging time-sensitive ICH therapies.
BACKGROUND AND PURPOSE:To characterize brain morphometric adaptations following targeted CSF leak closure using automated volumetry. MATERIALS AND METHODS:In this retrospective, single-center, longitudinal study, 61 patients with confirmed spontaneous intracranial hypotension (SIH) who underwent targeted treatment (neurosurgical repair for dural tears; endovascular embolization for CSF-venous fistulas) were included. Brain MRI was performed at baseline, 24 hours post-treatment (n=41), and at 3-month follow-up. Bern scores and automated volumetric Z-scores of CSF, gray matter, white matter, ventricular compartments, and brainstem subregions were derived using the DL-MorphoBox research application and compared longitudinally with Wilcoxon signed-rank tests and Bonferroni correction for multiple comparisons. RESULTS:Marked radio-clinical improvement was observed at 3 months post-treatment, with increased total CSF volume (ΔZ=+0.66; p<0.001) across all ventricular compartments (p<0.001). In parallel, brain parenchymal volume decreased (ΔZ=-0.60; p<0.001), presumably driven by gray matter contraction (ΔZ = -0.57; p<0.001), involving the temporal (ΔZ =-0.46; p < 0.001), frontal (ΔZ=-0.64; p=0.01), and prefrontal (ΔZ=-0.37; p=0.007) cortices. Finaly, brainstem volume decreased as well (ΔZ=-0.27; p=0.04). The MRI-based volumetric changes were detectable as early as 24 hours post-treatment, with lateral ventricular volume expansion continuing to 3 months. While the Bern score correlated with ventricular volume variations (p<0.001), it was unrelated to gray matter contraction. CONCLUSIONS:Targeted CSF leak closure induced a rapid, subtle reorganization of intracranial compartments, primarily characterized by ventricular expansion alongside gray matter and brainstem volume contraction. Gray matter volumetric modifications were detectable even in people with low-intermediate Bern scores. This establishes quantitative volumetry as an objective monitoring tool for treatment evaluation across the full spectrum of SIH severity.
BACKGROUND:Cancer-related fatigue (CRF) is a prevalent and debilitating symptom in cancer patients, and its underlying pathophysiology remains poorly understood, particularly in patients who have not undergone chemotherapy. This study aimed to investigate the cerebral metabolic changes associated with CRF in chemotherapy-naïve breast cancer patients using high-resolution [18F]fluorodeoxyglucose positron emission tomography/computed tomography ([18F]FDG-PET/CT). METHODS:We retrospectively identified 20 consecutive adult patients with breast cancer who were diagnosed with CRF (ICD-10-CM R53.0) and had never received chemotherapy between January 2023 and August 2025. Patients underwent whole-body [18F]FDG-PET/CT imaging on a Biograph Vision Quadra scanner at baseline (up to 1 year before CRF diagnosis while having breast cancer) and at the time of CRF diagnosis, up to three months after the date of diagnosis. Brain image slices were extracted and preprocessed. Patients with brain metastases or other known causes of fatigue were excluded. The analysis used an Atlas-based region-of-interest analysis of bilateral regions, as well as separate right and left hemispheres, to compare the two scans and identify significant metabolic changes. RESULTS:A significant increase in relative glucose metabolism was observed in the bilateral thalamus (T = -2.23, P = 0.05) and left thalamus (T = -2.59, P = 0.03). A significant decrease in relative metabolism was observed in the right anterior cingulate gyrus (T = 2.28, P = 0.05) following CRF diagnosis. A trend towards decreased metabolism in the retrosplenial cortex was also noted (1.40, P = 0.19; and 1.78, P = 0.11 for bilateral and right hemisphere, respectively). Additionally, the right Globus Pallidus (-1.53, P = 0.16) and right Amygdala (-1.62, P = 0.14) showed a trend toward increased metabolism following the diagnosis of CRF. CONCLUSION:This is the first study to investigate brain metabolic correlates of CRF in a chemotherapy-naïve breast cancer population using a high-sensitivity Brain [18F]FDG PET/CT. The observed hypermetabolism in the thalamus and other regions of the basal ganglia and limbic system suggests potential central neurobiological correlates of CRF, independent of chemotherapy effects. These findings provide a foundation for future research into imaging biomarkers for CRF and their application to the development of targeted therapeutic interventions.
Paravertebral epidural arteriovenous fistulas (EDAVFs) supplied by small radiculomeningeal or muscular branches can pose significant challenges for endovascular treatment when superselective catheterization is not feasible1,2,3. We present a patient with persistent left-sided neck and shoulder pain and an EDAVF adjacent to the left V3 segment. The fistula was presumed to be supplied by multiple minute muscular or radiculomeningeal branches and drained into the suboccipital venous plexus without cortical or perimedullary venous reflux4. Given the persistent left-sided neck and shoulder pain and relatively high-flow shunting on angiography, together with her concern arising from a prior AVM hemorrhage, the patient elected endovascular treatment after informed discussion. A Synchro-10 microwire could enter a minute feeder, but the Marathon microcatheter could not reach the fistulous point. After right vertebral angiography confirmed adequate collateral supply, a 4.0 × 15mm HyperGlide balloon was positioned in the left V3 segment across the feeder origins. Four 10-minute inflations were performed, separated by 3-minute reperfusion intervals, for a cumulative occlusion time of 40 minutes under continuous neurophysiological monitoring. Immediate postprocedural DSA showed marked flow reduction with a small residual fistula; no embolic agent was used. The patient had no new neurologic deficit and the neck and shoulder pain improved. Complete occlusion was confirmed on 18-month follow-up DSA. Previous studies suggested that alterations in shunt hemodynamics may promote thrombosis and subsequent fistula closure5. Intermittent balloon occlusion may be considered as a highly selected bailout maneuver when superselective access is not feasible, but not as a routine alternative to embolization. Careful preprocedural assessment of collateral circulation and comprehensive intraoperative neurophysiologic monitoring are essential for procedural safety. VIDEO.
PURPOSE:The purpose of this research was to determine the diagnostic accuracy of CT imaging of the paranasal sinuses for the diagnosis of acute invasive fungal rhinosinusitis (AIFRS) in children. METHODS:A retrospective review of sinus CTs performed in patients at risk for AIFRS was performed. A multi-anatomic site evaluation of CT imaging was performed with attention to soft tissue and bone abnormalities. Diagnostic accuracy of sinus CT findings was calculated for diagnosis of AIFRS with gold standard obtained from surgical biopsy and/or clinical follow-up. RESULTS:A total of 106 pediatric patients were included with a mean age was 9.4 years. The most common clinical risk factor for AIFRS was leukemia. A total of 40 children were diagnosed with AIFRS. The nasal turbinates and nasal septum were the most common sites of disease. Presence of facial symptoms, duration of ANC < 500, and duration of ANC < 200 were significantly different in AIFRS (+) versus AIFRS (-) patients (p<0.001; p=0.02; p=0.01). The sensitivity, specificity, and AUC for diagnosis of AIFRS from one or more abnormal CT findings were 83%, 97%, and 0.9 respectively. A total of seven patients (17.5%) with AIFRS were not detected by CT imaging, and the most common site of missed AIFRS was at the middle turbinate. CONCLUSION:CT imaging of the sinuses demonstrates moderate to high level of overall diagnostic accuracy for AIFRS, but with greater specificity than sensitivity. AIFRS in the nasal cavity was not identified by CT in a substantial number of children such that nasal endoscopy remains the diagnostic gold standard in the setting of a negative sinus CT when the clinical concern for AIFRS remains.
BACKGROUND AND PURPOSE:The evaluation of hypodense ischemic areas on early post-endovascular treatment (EVT) CT imaging may be hindered by contrast extravasation (CE). On the other hand, it has been suggested that regions with CE often progress to infarction. Dual-energy CT can provide multiple reconstructions, including iodine overlay maps (IOM) and virtual non-contrast (VNC), which may aid in the evaluation of CE and hypodensities. This study aims to assess whether CE on IOM, or hypodensities on VNC reconstructions correlate better with infarction on follow-up imaging compared to hypodensities on mixed-energy reconstructions (comparable to NCCT). MATERIALS AND METHODS:EVT records in our centre from 2010-2019 were screened. The main inclusion criteria were anterior circulation stroke, DECT within three hours post-EVT, and follow-up imaging performed after DECT. On DECT IOM, hyperdense CE was scored according to the ASPECTS (CE-ASPECTS). Likewise, hypodensities were scored on VNC (VNC-ASPECTS) and mixed-energy reconstructions (NCCT-ASPECTS) of DECT, as well as on the last follow-up scan performed during hospitalisation (FU-ASPECTS). Kendall's tau correlation was used to assess the relationship between the various DECT ASPECTS measures and the FU-ASPECTS. Sensitivity, specificity, positive and negative predictive value, and accuracy were assessed. RESULTS:Of 651 EVT records, 164 patients were included. The median time between DECT and follow-up imaging was 57 hours (IQR 25-120 hours). The correlation with the FU-ASPECTS was strongest for the VNC-ASPECTS (τ=0.63, P-value<.001). The correlation coefficients of the NCCT- and CE-ASPECTS were τ=0.47, P-value<.001, and τ=0.23, P-value<.001, respectively. For the VNC-ASPECTS, the average sensitivity, specificity, positive- and negative predictive value, and accuracy were 67%, 85%, 86%, 74%, and 81%, respectively. CONCLUSIONS:On immediate post-EVT imaging, hypodensities on VNC-reconstructions correlate best to infarction on follow-up imaging. CE is only weakly correlated to follow-up infarction. These results may provide an additional argument for using DECT imaging in the evaluation of the early post-EVT brain parenchyma.
PURPOSE:U.S. ACGME-approved neuroradiology fellowship positions continue to increase in the setting of a national radiologist shortage, and the challenges faced by expanding fellowship programs could vary with program size. The aim of our project was to survey neuroradiology fellowship Program Directors (PDs) at US ACGME-approved diagnostic neuroradiology fellowship programs to better understand the challenges and practices in fellow recruitment, growth of fellowship class size, and other factors. MATERIALS AND METHODS:An online 21-question survey was distributed to PDs of US ACGME-approved diagnostic neuroradiology fellowships (n=91). All variables were appropriately summarized and correlations assessed. Programs were dichotomized as large (greater than median number of approved spots) or small (less than or equal to median). Differences between large and small programs were evaluated with appropriate statistical tests. Effects associated with P<0.05 were considered statistically significant. RESULTS:PDs from 60/91(66%) institutions had evaluable responses. For the 2024-2025 academic year, 37/60(62%) programs filled all their fellowship positions. The proportion of large programs (20/25,80%) filling all their positions was higher (P=0.017) than small programs (17/35,49%). Large programs (14/25,56%) increased the number of fellowship positions more than small programs (5/35,14.3%) since 2019-2020 (P=0.002). Small programs had more difficulty filling all fellowship positions (19/34,54%) than large programs (5/25,20%) through national residency match program (P<0.001). Both large and small programs were challenged by other large programs and geographical location. Unique challenges for large and small programs were the high number of fellowship positions and competition from nearby programs, respectively. Length of PD tenure was not statistically correlated with the ability to fill the fellowship program (P=0.75). Small programs had a larger median of ABR-alternative pathway candidates [29%(0-66.7%)] than large programs [9.5%(0-16.7%)], the distribution did not differ significantly (P=0.19). CONCLUSIONS:Large neuroradiology fellowship programs filled all ACGME-approved positions with less difficulty and often increased their available fellowship positions in the last 5 years, compared to small programs. Competition from large programs and geographical location challenge recruitment for neuroradiology fellowship programs irrespective of size. Strategies for expanding and filling U.S. neuroradiology fellowships should vary based on fellowship size with a goal to help alleviate the on-going radiologist shortage.
BACKGROUND AND PURPOSE:Neuro-melioidosis is an uncommon but potentially fatal manifestation of Burkholderia pseudomallei infection with diverse and often under-recognized imaging features. Existing imaging literature is limited to isolated reports and small series. We aimed to characterize the craniospinal MRI spectrum of neuro-melioidosis in a multicentre Indian cohort and identify recurrent imaging patterns associated with diagnostic delay. MATERIALS AND METHODS:In this retrospective multicentre case series, 33 patients with microbiologically confirmed neuro-melioidosis from seven Indian tertiary centres (2019-2025) underwent systematic neuroimaging review using a pre-defined data-collection template containing 40-variables. MRI features including lesion distribution, tract involvement, diffusion restriction, susceptibility abnormalities, enhancement patterns, meningeal disease, and spinal involvement were analysed descriptively alongside clinical and microbiological data. RESULTS:Supratentorial involvement was present in 81.8% (27/33), infratentorial disease in 60.6% (20/33), and multifocal lesions in 60.6% (20/33). Brainstem involvement occurred in 57.6% (19/33). White matter tract dissemination was identified in 66.7% (22/33), with CST involvement in 63.6% (21/33); the "tunnel sign" was observed in 57.6% (19/33). Spinal involvement was present in 42.4% (14/33), including simultaneous brainstem and intramedullary disease in 33.3% (11/33). Diffusion restriction occurred in 72.7% (24/33), while SWI demonstrated haemorrhage or microbleeds in 36.4% (12/33). Initial misdiagnosis occurred in 24.2% (8/33), and 30.3% (10/33) received corticosteroids before definitive diagnosis. In-hospital mortality was 12.1% (4/33). CONCLUSIONS:Neuro-melioidosis produced extensive craniospinal disease with a disproportionate frequency of brainstem, tract-based, and spinal involvement relative to other bacterial CNS infections. Recognition of this pattern together with blood, tissue, and/or CSF culture, which remain the diagnostic standard, may facilitate earlier diagnostic consideration and targeted microbiological evaluation in endemic settings.
