Introduction While epidural blood patch can be an effective management option in lumbar pseudomeningoceles in certain clinical settings, its utility in the cervical spine is unclear. The aim of this study was to evaluate the safety and effectiveness of percutaneous aspiration and autologous blood patch for post-operative durotomy related pseudomeningoceles within the cervical spine. Methods A single institution retrospective review detailing 3 patients with durotomy related pseudomeningocele following posterior cervical spine surgery was completed. Results In all three cases, aspiration with subsequent injection of autologous epidural blood patch successfully treated each pseudomeningocele. One patient required more than one intervention, while the other two were successfully treated after one procedure. All three patients improved clinically without need for additional surgery. Conclusion Percutaneous aspiration and epidural blood patch can be used to safely manage post-operative pseudomeningoceles within the posterior cervical spine.

Objective To report our experience delivering intrathecal nusinersen through cervical puncture in patients with spinal muscular atrophy (SMA) with no lumbar access. Background SMA is a neuromuscular disorder characterized by profound muscle weakness, atrophy, and paralysis due to degeneration of the anterior horn cells. Nusinersen, the first Food and Drug Administration–approved treatment for SMA, is administered intrathecally via lumbar puncture; however, many patients with SMA have scoliosis or solid spinal fusion with hardware that makes lumbar access impossible. Studies in primates have demonstrated better spinal cord tissue concentration with intrathecal injections than with intracerebral ventricular injections. Therefore we have used C1/C2 puncture as an alternative to administer nusinersen. Method Retrospective chart review. Results Intrathecal nusinersen via cervical puncture was given to 3 patients who had thoracic and lumbosacral spinal fusion: a 12-year-old girl with type 1 SMA and 2 17-year-old girls with type 2 SMA. Cervical puncture was performed without deep sedation under fluoroscopic guidance using a 25-G or a 24-G Whitacre needle in the posterior aspect of C1-C2 interspace and full dose of nusinersen (12 mg/5 mL) was injected after visualizing free CSF flow. Patients completed their 4 loading doses and first maintenance dose of nusinersen, and 15 procedures were successful and well-tolerated. Conclusion Cervical puncture is a feasible alternative delivery route to administer intrathecal nusinersen in patients with longstanding SMA and spine anatomy precluding lumbar access when done by providers with expertise in this procedure.

BACKGROUND: Pseudomeningocele is an uncommon but problematic complication in lumbar spine surgery. Initial conservative measures frequently are successful, but persistence requires additional management. The current surgical approach can involve a range of techniques, including blood patches, hydrogel/fibrin sealants, drains, open surgical repair of the dura, or a combination of the all techniques if symptoms persist. This report demonstrates a novel technique for repair via a percutaneous approach to deliver an autologous fat graft into the pseudomeningocele. CASE DESCRIPTION: A 64-year-old woman with a history of multiple complex lumbar spinal surgeries with previous durotomy had persistent positional headaches from an unresolved pseudomeningocele from L3 to L5. The defect and symptoms remained after all available surgical options were exhausted, including blood patches, hydrogel sealants (Duraseal), and open surgical repair with muscle and Gelfoam grafts. After autologous fat harvest, the patient underwent percutaneous repair of the pseudomeningocele with simultaneous aspiration of cerebrospinal fluid and injection of fat into the defect space. CONCLUSIONS: At 3 months postoperatively, the patient's symptoms were resolved with no clinical or radiographic findings of nerve root or thecal sac impingement and complete obliteration of the pseudomeningocele. This less-invasive approach offers the option of open surgical repair for persistent pseudomeningocele with the use of autologous graft material.

Study Design. Retrospective chart review with limited prospective follow-up survey. Objective. To evaluate the efficacy and safety of blood patch injection for the treatment of positional headaches caused by postoperative lumbosacral pseudomeningoceles. Summary of Background Data. Pseudomeningocele is one of the most common complications after posterior lumbosacral spinal surgery. Common treatments include bedrest, abdominal binder use, subarachnoid lumbar drainage, and surgical re-exploration for durotomy closure. To date, only small case reports support the use of epidural blood patch injection for symptomatic pseudomeningocele treatment. Methods. A retrospective chart review analyzed the outcomes and complications of 19 consecutive patients who underwent blood patch injection, with and without pseudomeningocele aspiration, for symptomatic postoperative lumbosacral pseudomeningoceles between 2009 and 2015. An attempt was made to survey patients by phone regarding satisfaction. Results. As of last follow-up (average time = 22.3 months), 16 patients (84%) experienced headache resolution after blood patch injection and did not require further treatment of their pseudomeningocele. In addition to symptomatic improvement, 12 of the 16 successful patients had imaging, which demonstrated pseudomeningocele resolution. Persistent pseudomeningoceles were demonstrated on imaging among all three unsuccessful patients. Conclusion. Pseudomeningocele aspiration followed by blood patch is an effective treatment for symptomatic postoperative lumbosacral pseudomenigocele. This is a minimally invasive alternative to surgical re-exploration with durotomy closure. Injections are most effective when performed early after pseudomeningocele development. Level of Evidence: 4

The CT perfusion (CTP) imaging of brain has been established as a clinically useful tool in multimodality imaging of acute stroke. All abnormalities seen on perfusion CT are not specifically related to acute infarct. There are many neurologic diseases causing symptoms simulating cerebrovascular disease produce an alteration of brain perfusion and thus can result in perfusion CT abnormalities. There are many pitfalls and artifacts in acquiring the data, calculation of maps and choosing arterial input function. We analyze and classify all these aspects, to allow the technician and the radiologist to know exactly what to avoid and what to choose, and we indicate the way to improve the quality of examination. The knowledge of mimics and pitfalls in acute stroke imaging can be helpful in accurate interpretation of these examinations.

MR imaging anatomy of the infant hipND Johnson, BP Wood, KS Noh, KV Jackman, PL Westesson and RW KatzbergAudio Available | Share

Radiologists often encounter intraosseous tumors of the calvarium. Compared with parenchymal lesions, information is limited. In this review, we list the calvarial tumors and correlate the radiologic appearance with the pathologic findings. We discuss primary intraosseous tumors and tumor secondary to systemic disease as well as metastatic malignant tumor. Differentiation between primary tumors and tumors secondary to systemic disease can be difficult. Physicians should explore the systematic disease. In the case of primary tumors, it is important to verify any soft-tissue component since this is an important differential diagnostic feature with the potential for malignant transformation.

This book, now in a revised and updated second edition, remains a unique reference on postoperative neuroimaging. It is designed as a guide that will familiarize the reader with the radiological featu

Radiologists often encounter intraosseous tumors of the calvarium. Compared with parenchymal lesions, information is limited. In this review, we list the calvarial tumors and correlate the radiologic appearance with the pathologic findings. We discuss primary intraosseous tumors and tumor secondary to systemic disease as well as metastatic malignant tumor. Differentiation between primary tumors and tumors secondary to systemic disease can be difficult. Physicians should explore the systematic disease. In the case of primary tumors, it is important to verify any soft-tissue component since this is an important differential diagnostic feature with the potential for malignant transformation.

Computed tomographic angiography (CTA) is being increasingly utilized in the non-invasive diagnosis of aneurysmal subarachnoid hemorrhage (SAH). There are emerging reports of diagnosis of active aneurysmal bleeding on CTA, furthering our understanding of imaging features of active extravasation on cross-sectional studies. We demonstrate imaging characteristics of two such cases of active contrast extravasation from intracranial aneurysms. Additionally, we demonstrate that delayed CT images greatly improve the confidence of this diagnosis by demonstrating pooling of contrast in the subarachnoid space. Prompt recognition and management can improve prognosis of this potentially lethal condition.

The goal of this study is to examine workflow and information flow in the emergency department (ED) digital imaging process to identify features of an optimized system. Radiological imaging (x-rays, CT scans, etc) is unique in the ED setting, as the need for fast turn-around time and interactive communication between radiologists and emergency physicians is different than that of most other healthcare settings. The information technology systems which are used by both radiologists and emergency physicians to support these processes have been designed with a focus on the routine workflow of radiologists. We report the results of 14 hours of naturalistic observations of the use of digital imaging systems by a total of 22 ED and radiology staff. A hierarchical task analysis and an information process diagram are presented, and disparate theories that groups in the system have about other groups were discovered, particularly in the communication of clinical information.

Insomepatients withdiscdisplacement without reduction, thesymptomsofpainanddecreased rangeof motion havebeenobserved toresolve spontaneously over timewithouttreatment. Thenatural history ofthis condition, however, isnotwell-understood. Thus, tostudy thenatural course ofdisc displacement without reduction, wefollowed 40patients without treatment foraperiod of 2.5years. Thediagnosis wasestablished byhistory and physical examination andconfirmed withmagnetic resonance (MR)imaging. After 2.5years, 43%ofthepatients wereasymptomatic, 33%haddecreased symptoms, and 25%ofthepatients showednoimprovement orhad required treatment. MR evidence ofosteoarthritis and advanced stages ofinternal derangement attheinitial evaluation wasassociated withapoorprognosis. Theresult ofthisprospective cohort studyindicated thatapproxi- mately 40%ofpatients withsymptomatic disc displacement without reduction will befree ofsymptoms within 2.5years, one-third will improve, whereas one-quarter will continue tobesymptomatic. Thisknowledge should bevaluable for thetreatment planning andevaluation ofprognosis of patients withnon-reducing symptomatic disc displacement.

A child born at full term developed macrocephaly in infancy with regression of motor skills and cerebellar ataxia starting at age 3 that progressively worsened. Axial T2 weighted (T2-W) MRI (Fig. 1) shows diffuse white matter hyperintensity involving the subcortical fibers as well as sparing of the basal ganglia as thalami. Subcortical cyst formation is seen in the anterior temporal region on the sagittal T2-W image (Fig. 2, arrow). No contrast enhancement was noted. Megaloencephalic leukoencephalopathy (spongiform leukoencephalopathy or van der Knaap disease) is an autosomal-recessive, neurodegenerative disorder with macrocephaly in the first year of life but delayed onset

Neuroimaging in myotonic dystrophy type 1 A 56-year-old woman with a 10-year history of myotonic dystrophy type 1 (MD) presented with progressive lower extremity weakness.MRI showed multiple discrete and confluent areas of abnormal signal intensity throughout the subcortical white matter with predominant involvement of the frontal and anterior temporal lobes (figure 1).The confluent white matter lesions in the anterior temporal lobes seen in MD can be radiologically confused with cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL).Unlike CADASIL, MD also displays skull abnormalities (figure 2). 1,2Both syndromes should be considered in patients with confluent temporal lobe lesions on MRI.