Locating spinal cerebrospinal fluid (CSF) leaks can be a diagnostic dilemma for clinicians and radiologists, as well as frustrating for patients. Dynamic computed tomography myelography (dCTM) has emerged as a valuable tool in localizing spinal CSF leaks, aiding in accurate diagnosis, and guiding appropriate management. This article aims to provide insights into the technique, tips, tricks, and potential pitfalls associated with dCTM for spinal CSF leak localization. By understanding the nuances of this procedure, clinicians can optimize the diagnostic process and improve patient outcomes.

Spinal CSF leaks from dural tears or CSF-venous fistulas are the most common causes of spontaneous intracranial hypotension. Rarely, CSF leaks have also been associated with vascular malformations, which have primarily been discussed in case reports or small series. In this clinical report, we report the clinical features, imaging findings, and treatment of 6 children and adults with CSF leaks associated with vascular malformations in the spine and skull base depicted on CT myelography and cisternography.

Objective To assess magnetic resonance imaging (MRI) safety of stapes prostheses. Data Sources Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and Scopus databases were searched from inception to November 2021 following PRISMA guidelines. Review Methods Studies reporting evidence of stapes prosthesis displacement or interaction in adult or pediatric implant recipients undergoing MRI. Cadaveric, animal, and basic studies with nonhuman data were also included. Results From an initial search of 123 articles, 42 full-text studies were evaluated for eligibility and 19 studies that met the inclusion criteria were included. Motion artifact was reported in a few stainless steel prosthesis types in vitro; however, such displacement was not observed in human cadaver temporal bone studies and had no adverse reported outcomes. A small subgroup of patients in the 1980s received a ferromagnetic stainless steel stapes implant that was recalled and has not been used since 1987. Patients with implants performed in the 1980s should be directed to 1.5T scanners from an abundance of caution. Conclusion Modern (post-1987) stapes prostheses do not pose a risk in vivo when exposed to the magnetic fields of MRI scanners.

Spinal CSF leak care has evolved during the past several years due to pivotal advances in its diagnosis and treatment. To the reader of the American Journal of Neuroradiology (AJNR), it has been impossible to miss the exponential increase in groundbreaking research on spinal CSF leaks and spontaneous intracranial hypotension (SIH). While many clinical specialties have contributed to these successes, the neuroradiologist has been instrumental in driving this transformation due to innovations in noninvasive imaging, novel myelographic techniques, and image-guided therapies. In this editorial, we will delve into the exciting advancements in spinal CSF leak diagnosis and treatment and celebrate the vital role of the neuroradiologist at the forefront of this revolution, with particular attention paid to CSF leak-related work published in the AJNR.

BACKGROUND AND PURPOSE:CSF-venous fistula can be diagnosed with dynamic decubitus CT myelography. This study aimed to analyze the temporal characteristics of CSF-venous fistula visualization on multiphase decubitus CT myelography. MATERIALS AND METHODS:A retrospective, multisite study was conducted on patients diagnosed with CSF-venous fistula at 2 institutions between June 2017 and February 2023. Both institutions perform decubitus CT myelography with imaging immediately following injection and usually with at least 1 delayed scan. The conspicuity of CSF-venous fistula was assessed on each phase of imaging. RESULTS:Forty-eight patients with CSF-venous fistula were analyzed. CSF-venous fistulas were better visualized on the early pass in 25/48 cases (52.1%), the delayed pass in 6/48 cases (12.5%) and were seen equally on both passes in 15/48 cases (31.3%). Of 25 cases in which the CSF-venous fistula was better visualized on the early pass, 21/25 (84%) fistulas were still at least partially visible on a delayed pass. Of 6 cases in which the CSF-venous fistula was better visualized on a delayed pass, 4/6 (67%) were partially visible on the earlier pass. Six of 48 (12.5%) CSF-venous fistulas were visible only on a single pass. Of these, 4/6 (66.7%) were seen only on the first pass, and 2/6 (33.3%) were seen only on a delayed pass. One fistula was found with one pass only, and one fistula was discovered upon contralateral decubitus imaging without a dedicated second injection. CONCLUSIONS:A dynamic decubitus CT myelography imaging protocol that includes an early and delayed phase, likely increases the sensitivity for CSF-venous fistula detection. Further studies are needed to ascertain the optimal timing and technique for CSF-venous fistula visualization on dynamic decubitus CT myelography and its impact on patient outcomes.

BACKGROUND High-power, short duration (HPSD) radiofrequency ablation (RFA) is a commonly used strategy for pulmonary vein isolation (PVI). OBJECTIVES This study sought to compare HPSD with standard power, standard duration (SPSD) RFA in patients undergoing PVI. METHODS Patients with paroxysmal or persistent (<1 year) atrial fibrillation (AF) were randomized to HPSD (50 W) or SPSD (25-30 W) RFA to achieve PVI. Outcomes assessed included time to achieve PVI (primary), left atrial dwell time, total procedure time, first-pass isolation, PV reconnection with adenosine, procedure complications including asymptomatic cerebral emboli (ACE), and freedom from atrial arrhythmias. RESULTS Sixty patients (median age 66 years; 75% male) with paroxysmal (57%) or persistent (43%) AF were randomized to HPSD (n = 29) or SPSD (n = 31). Median time to achieve PVI was shorter with HPSD vs SPSD (87 minutes vs 126 minutes; P = 0.003), as was left atrial dwell time (157 minutes vs 180 minutes; P = 0.04). There were no differences in first-pass isolation (79% vs 76%; P = 0.65) or PV reconnection with adenosine (12% vs 20%; P = 0.26) between groups. At 12 months, recurrent atrial arrhythmias occurred less in the HPSD group compared with the SPSD group (n = 3 of 29 [10%] vs n =11 of 31 [35%]; HR: 0.26; P = 0.027). There was a trend toward more ACE with HPSD RFA (40% HPSD vs 17% SPSD; P = 0.053). CONCLUSIONS In patients undergoing AF ablation, HPSD compared with SPSD RFA results in shorter time to achieve PVI, greater freedom from AF at 12 months, and a trend toward increased ACE. (c) 2023 by the American College of Cardiology Foundation.

Purpose of Review To review the role of molecular imaging modalities in the evaluation of low back pain and identification of active pain generators. Recent Findings Low back pain is a common condition associated with high utilization of imaging. Identification of a pain source in patients with nonspecific low back pain is an important clinical challenge. However, there is inadequate correlation between anatomic findings on CT and MRI with symptoms of back pain, or clinical response to therapeutic procedures including injection or surgery. In contrast, molecular imaging modalities including single-photon emission-computed tomography (SPECT) or positron emission tomography (PET) with bone-targeting radiotracers like Tc-99m methylene diphosphonate (MDP) and 18 F-NaF paired with CT or MRI demonstrate promise to improve test specificity in identification of pain generators in the spine. An accurate identification of pain source in patients with back pain is important in guiding therapeutic interventions including injection and surgery. Summary Molecular imaging modalities have demonstrated improved diagnostic accuracy in identifying active pain generators and predicting response to therapeutic intervention compared to anatomic imaging alone.

Over the past 15 years, transoral robotic surgery (TORS) has emerged as a powerful, less invasive tool to treat oropharyngeal cancers. The goal of surgical treatment is de-escalation therapy to decrease treatment morbidity and improve quality of life outcomes while maintaining overall and disease-free survival.1 This may involve treatment with definitive surgery and adjuvant radiation with avoidance of adjuvant chemotherapy, or even decreasing radiation dose.2 While typical complications after TORS are well-reported in the literature, we describe a rare case of spondylodiscitis and spinal abscess treated with computed tomography (CT)-guided needle aspiration and antibiotics. This case report met criteria for University of California San Francisco Institutional Review Board exemption. A 65-year-old male with history of hypertension, gout, arthritis, and reflux presented with a cT1N1M0 left tonsil human papillomavirus positive squamous cell carcinoma with fine needle aspiration biopsy-proven metastasis to the ipsilateral neck. CT chest and positron emission tomography (PET)-CT did not identify distant metastatic disease. The patient underwent a TORS-assisted left radical tonsillectomy, left selective neck dissection levels 1b, 2a, 2b, 3, and 4, and ligation of left facial and lingual arteries, without intraoperative complication. Uniquely, we also excised a single retropharyngeal lymph node, seen on preoperative CT neck, that intraoperatively was located just deep and posterior to the left superior constrictor muscle in a paramedian location (Figure 1). Postoperatively, the patient had severe dysphagia requiring nutritional support via nasogastric feeding tube for 3 weeks. Surgical pathology demonstrated negative margins, a positive retropharyngeal lymph node, and 3/32 positive neck lymph nodes without extranodal extension, perineural invasion, or lymphovascular invasion. Four weeks postoperatively, a radiation-planning CT neck demonstrated a C2-3 epidural abscess. Magnetic resonance imaging (MRI) showed prevertebral phlegmon, C2-3 spondylodiscitis, and epidural abscess spanning C1-C3 (Figure 2). He was asymptomatic with intact neurologic examination. A small fistulous tract between the oropharynx the prevertebral site of the infection was identified on MRI, suggesting the mechanism of infection was direct extension from the oropharynx from the retropharyngeal lymph node excision. An anterior neck approach for drainage with cervical discectomy, debridement, and fusion was considered, as is customary for spinal epidural abscesses. Given the mucosal surgical defect would likely expand to a more extensive pharyngospinal fistula, this approach was thought to be unfavorable. Instead, a diagnostic and therapeutic posterior percutaneous CT-guided aspiration of the abscess was performed. Based on cultures showing polymicrobial oral flora (Streptococcus anginosus, anaerobic gram-negative rods), the patient underwent a 6-week course of intravenous (IV) Ceftriaxone and IV Flagyl. Repeat MRI 16 weeks postoperatively revealed marked interval improvement in the cervical discitis and prevertebral phlegmonous change. Subsequently, the patient received adjuvant radiation (60 Gray in 33 fractions) 3 months after drainage of the epidural abscess. On his 3-month posttreatment CT and PET scans (6-month posttreatment of epidural abscess), he was without evidence of disease or recurrent infection. Few cases of spondylodiscitis with and without abscess after TORS radical tonsillectomy have been reported with high rates of mortality up to 43%.3, 4 Despite its rarity, it is of utmost relevance given the recent ORATOR 2 trial was stopped due of death from spondylodiscitis.5 A post-TORS patient presenting with fevers, neck pain (including point tenderness of cervical vertebrae), upper extremity weakness, or paresthesia should be evaluated for spinal or paraspinal infection. Risk factors identified in the literature include neoadjuvant or adjuvant radiation therapy, long operative time, severe blood loss, and extensive soft-tissue pharyngeal dissection.4 The latter may have been at play in the case presented due to the excision of the suspicious retropharyngeal lymph node, though the parapharyngeal space was not otherwise explored. Studies have suggested blood cultures or CT-guided diagnostic fine needle aspiration biopsy to guide antibiosis with surgical drainage or debridement of an epidural abscess only in the setting of clinical signs of neural compression.4 Given the high rate of neurologic deterioration and mortality with this complication, we propose consideration of therapeutic CT-guided drainage of epidural abscess even in the absence of clinical signs of compression, followed by culture-directed IV antibiosis. The use of CT guidance permits for safe navigation of the complex anatomy in this region. This allowed our patient to avoid revision open surgery with potential free flap reconstruction. Multi-institutional studies are necessary to further elucidate the prevalence and most appropriate treatment algorithm for this subset of infectious spinal lesions. Jacquelyn K. Callander, conception and drafting of the manuscript, data acquisition; Aaron J. Clark, conception and critical review of the manuscript, direct involvement in care of the patient; William Dillon, conception and critical review of the manuscript, direct involvement in care of the patient; William R. Ryan, conception and critical review of the manuscript, direct involvement in care of the patient; All authors provided final approval of this manuscript. William R. Ryan, MD, is on the Scientific Advisory Boards for Olympus and Rakuten Medical. The authors have no other funding or financial relationships to disclose.

BACKGROUND AND PURPOSE:& nbsp;The rate of abnormal intracranial MR imaging findings including subdural collections and dural enhancement after recent lumbar puncture is not known. The purpose of our study was to examine the intracranial MR imaging findings after recent image-guided lumbar puncture.& nbsp;MATERIALS AND METHODS: Patients who underwent contrast-enhanced MR imaging of the brain within 7?days of a CT-guided lumbar puncture between January 2014 and April 2021 were included. Contrast-enhanced MR images were reviewed for diffuse dural enhancement, morphologic findings of brain sag, dural venous sinus distension, and subdural collections.& nbsp;RESULTS: Of the 160 patients who met the inclusion criteria, only 6 patients (3.9%) had new diffuse dural enhancement, though none had dural enhancement when the MR imaging was within 2?days of lumbar puncture. All 6 patients with dural enhancement had small, concurrent subdural collections. Two additional patients had subdural collections, for a total of 5.2% of our population.& nbsp;CONCLUSIONS: Our study is the first to examine intracranial MR imaging after recent lumbar puncture and has 2 key findings: First, 5.2% of patients had small, bilateral subdural collections after recent lumbar puncture, suggesting that asymptomatic subdural collections after recent lumbar puncture are not atypical and do not require further work-up. Additionally, when MR imaging was performed within 2?days of lumbar puncture, none of our patients had diffuse dural enhancement. This argues against the commonly held practice of performing MR imaging before lumbar puncture to avoid findings of dural enhancement, and should not delay diagnostic work-up.

Purpose: To identify initial, preintervention magnetic resonance imaging (MRI) findings that are predictive of visual and mortality outcomes in acute invasive fungal rhinosinusitis (AIFRS). Design: Retrospective cohort study. Participants: Patients with histopathologically or microbiologically confirmed AIFRS cared for at a single, tertiary academic institution between January 2000 and February 2020. Methods: A retrospective review of MRI scans and clinical records of patients with confirmed diagnosis of AIFRS was performed. For each radiologic characteristic, a modified Poisson regression with robust standard errors was used to estimate the risk ratio for blindness. A multivariate Cox proportional hazards model was used to study AIFRS-specific risk factors associated with mortality. Main Outcome Measure: Identification of initial, preintervention MRI findings associated with visual and mortality outcomes. Results: The study comprised 78 patients (93 orbits, 63 with unilateral disease and 15 with bilateral disease) with AIFRS. The leading causes of immunosuppression were hematologic malignancy (38%) and diabetes mellitus (36%). Mucormycota constituted 56% of infections, and Ascomycota constituted 37%. The overall death rate resulting from infection was 38%. Risk factors for poor visual acuity outcomes on initial MRI included involvement of the orbital apex (relative risk [RR], 2.0; 95% confidence interval [CI], 1.1-3.8; P = 0.026) and cerebral arteries (RR, 1.8; 95% CI, 1.3-2.5; P < 0.001). Increased mortality was associated with involvement of the facial soft tissues (hazard ratio [HR], 4.9; 95% CI, 1.3-18.2; P = 0.017), nasolacrimal drainage apparatus (HR, 5.0; 95% CI, 1.5-16.1; P = 0.008), and intracranial space (HR, 3.5; 95% CI, 1.4-8.6; P = 0.006). Orbital soft tissue involvement was associated with decreased mortality (HR, 0.3; 95% CI, 0.1-0.6; P = 0.001). Conclusions: Extrasinonasal involvement in AIFRS typically signals advanced infection with the facial soft tissues most commonly affected. The initial, preintervention MRI is prognostic for a poor visual acuity outcome when orbital apex or cerebral arterial involvement, or both, are present. Facial soft tissues, nasolacrimal drainage apparatus, intracranial involvement, or a combination thereof is associated with increased mortality risk, whereas orbital soft tissue involvement is correlated with a reduced risk of mortality. (C) 2022 by the American Academy of Ophthalmology. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

BACKGROUND:Stenosis of a dural venous sinus is the most common cause of idiopathic intracranial hypertension (IIH) and can be classified as either intrinsic or extrinsic. Intrinsic stenoses are characterized by a focal filling defect within the sinus secondary to an enlarged arachnoid granulation or fibrous septa while extrinsic stenoses tend to be long and smooth-tapered and are most commonly secondary to external compression from the adjacent brain parenchyma. Brain herniations, or encephaloceles, into arachnoid granulations in dural venous sinuses have rarely been reported in the literature in patients with IIH. We propose that dural venous sinus stenting (VSS) may be a safe and effective treatment approach in patients with an encephalocele and IIH.METHODS:We retrospectively analyze three cases of patients with encephalocele who underwent VSS for treatment of medically refractory IIH at our institution.RESULTS:One patient underwent stenting ipsilateral and two patients underwent stenting contralateral to the side of their encephaloceles. No technical related issues or complications occurred during either of the three stenting procedures. Two out of the three patients had complete resolution in their IIH-related symptoms and normalization of cerebrospinal (CSF) pressures shortly after stenting. We await clinical follow-up in the third patient.CONCLUSIONS:Our results suggest that VSS is a technically feasible and effective approach in treating patients with medically refractory IIH and encephaloceles.

Spontaneous intracranial hypotension is an uncommon etiology of secondary headaches in children. We report a unique case of a girl with kaposiform lymphangiomatosis who developed postural headaches and imaging features of spontaneous intracranial hypotension without a spinal extradural collection. The girl underwent dynamic computed tomography myelography which revealed a cerebrospinal fluid (CSF)-lymphatic fistula related to a lymphatic malformation associated with the right T10 nerve. She underwent surgical ligation of the CSF-lymphatic fistula, resulting in resolution of the headaches. Spinal CSF-lymphatic fistulas are rare and have previously been reported in two patients with Gorham-Stout disease. The current report suggests that patients with systemic lymphatic anomalies who develop postural headaches should undergo evaluation for spontaneous intracranial hypotension and a CSF-lymphatic fistula. If discovered, surgical ligation is a potential treatment.

BACKGROUND AND PURPOSE: Craniospinal space compliance reflects the distensibility of the spinal and intracranial CSF spaces as a system. Craniospinal space compliance has been studied in intracranial pathologies, but data are limited in assessing it in spinal CSF leak. This study describes a method to estimate craniospinal space compliance using saline infusion during CT myelography and explores the use of craniospinal space compliance and pressure-volume curves in patients with suspected cerebrospinal-venous fistula. MATERIALS AND METHODS: Patients with suspected cerebrospinal-venous fistula underwent dynamic CT myelography. During the procedure, 1- to 5-mL boluses of saline were infused, and incremental changes in CSF pressure were recorded. These data were used to plot craniospinal space compliance curves. We calculated 3 quantitative craniospinal space compliance parameters: overall compliance, compliance at opening pressure, and the pressure volume index. These variables were compared between patients with confirmed cerebrospinal-venous fistula and those with no confirmed source of CSF leak. RESULTS: Thirty-four CT myelograms in 22 patients were analyzed. Eight of 22 (36.4%) patients had confirmed cerebrospinal-venous fistulas. Bolus infusion was well-tolerated with no complications and transient headache in 2/34 (5.8%). Patients with confirmed cerebrospinal-venous fistulas had higher compliance at opening pressure and overall compliance (2.6 versus 1.8?mL/cm H(2)0, P < .01). There was no difference in the pressure volume index (77.5 versus 54.3?mL, P?=?.13) between groups. CONCLUSIONS: A method of deriving craniospinal space compliance curves using saline intrathecal infusion is described. Preliminary analysis of craniospinal space compliance curves provides qualitative and quantitative information about pressure-volume dynamics and may serve as a diagnostic tool in patients with known or suspected cerebrospinal-venous fistulas.

Purpose: Radiology departments around the world have been faced with the challenge to adapt, and recover to the COVID-19 pandemic. This study is part of a worldwide survey of radiologists' responses to COVID-19 in 18 different countries in Africa, Asia, Europe, and Latin America. The purpose of this study is to analyze the changes made in international radiology departments and practices in response to the pandemic. Methods: The 18-item survey was sent via email from April to May 2020 to radiologists in Africa, Asia, Europe, and Latin America to assess their response to COVID-19. Our survey included questions regarding imaging, workforce adjustments, testing availability, staff and patient safety, research and education, and infrastructure availability. Results: Twenty-eight survey responses were reviewed. Of the 28 respondents, 42.9% have shortages of infrastructure and 78.6% responded that COVID-19 testing was available. Regarding the use of Chest CT in COVID-19 patients, 28.6% respondents used Chest CT as screening for COVID-19. For staff safety, interventions included encouraging use of masks in patient encounters, social distancing and PPE training. To cope with their education and research mission, radiology departments are doing online lectures, reducing the number of residents in rotations, and postponing any non-urgent activities. Conclusion: In conclusion, there are disparities in infrastructure, research, and educational initiatives during COVID-19 which also provides opportunity for the global radiology community to work together on these issues. (c) 2021 Elsevier Inc. All rights reserved.

Neurologic complications of imaging procedures are varied and largely related to either local complications of an invasive procedure or complications arising from the systemic use of intravenous contrast agents. This chapter provides a summary of neurologic complications related to those imaging procedures that are commonly performed in modern radiologic practices. Some historic perspective is presented as well, and the reader must be aware that changes in the practice of radiologic procedures affect the kinds of complications and their incidence over time.

Background Cerebrospinal fluid-venous fistulas (CVFs) are one of the less common etiologic causes of spontaneous intracranial hypotension. CVFs are most commonly treated with open surgical ligation and have reportedly not responded well to percutaneous treatments. Purpose To study treatment outcomes of CT-guided fibrin glue occlusion for CVFs. Materials and Methods Retrospective review of medical records from two institutions was performed for all patients with CVFs who underwent CT-guided percutaneous fibrin glue occlusion from March to October 2020. CVFs were assessed for resolution or persistence at posttreatment decubitus CT myelography (CTM). Pre- and posttreatment brain MRI scans were reviewed for principal signs of spontaneous intracranial hypotension. Clinical symptoms were documented before and immediately after therapy, and the current symptoms to date after fibrin glue occlusion were documented. Results CT-guided fibrin glue occlusion was performed in 13 patients (mean age, 62 years ± 14 [standard deviation]; eight women) with CVFs. Ten of 10 patients who underwent final posttreatment decubitus CTM examinations showed CVF resolution. All 13 patients showed improvement on posttreatment brain MRI scans. All 13 patients are currently asymptomatic, although three patients were asymptomatic before fibrin glue occlusion. Conclusion CT-guided fibrin glue occlusion is an effective treatment for patients with cerebrospinal fluid-venous fistulas (CVFs). Direct fibrin glue administration within the CVF may be one of the key factors for success. Further studies are needed to determine the long-term efficacy of this treatment. © RSNA, 2021.