VAPOUR Trial Results: Vertebroplasty Relieves Pain in Osteoporotic Fractures


The ASNR and ASSR are pleased to report breaking news from the Lancet. The Vertebroplasty for Acute Painful Osteoporotic fractURes (VAPOUR) trial has provided compelling evidence in support of the use of vertebroplasty as a treatment for painful acute (less than 6 weeks’ duration) vertebral compression fractures. Our own Drs. Hirsch and Chandra provided an invited commentary dubbed the Resurrection of Evidence for Vertebroplasty?

Vertebroplasty burst onto the American scene in 1997 when NeuroInterventional Radiologists Lee Jensen, Jacques Dion and colleagues published their initial experience with the treatment in the AJNR. That foundational manuscript remains one of the most cited articles in the Journal’s history.

In the decade that followed that initial publication, there was huge enthusiasm for vertebroplasty and a related procedure, kyphoplasty. In 2009, two blinded randomized controlled trials were published simultaneously in the New England Journal of Medicine that raised questions regarding the efficacy of vertebroplasty. These trials were subjected to intense scrutiny and extensive criticism. The challenge facing supporters of augmentation was that the vertebroplasty cohort performed in many ways as one might expect they would. It was the control group performing better than expected that, in large part, led to the question of unproven benefit for vertebroplasty.

VAPOUR randomized 120 patients with acute fractures and intense pain (at least 7 on a 10-point scale) to undergo either vertebroplasty (n=61) or a sham control procedure (n=59). A statistically significant different number of vertebroplasty patients achieved better pain relief (scores of 4 or less) at 14 days, compared with the sham cohort, and these observations were maintained through the 6-month post-treatment observation period.

Given the challenges of conducting randomized controlled trials related to pain, we believe it appropriate to pause and appreciate what Dr. Clark and colleagues have demonstrated. Vertebroplasty, which Neuro- and …

CT and MRI of the Whole Body, 2-Volume Set, 6th Edition

Haaga JR, Boll DT, eds. CT and MRI of the Whole Body. 6th ed. Elsevier; 2016; 2832 pp (including ill); $434.99

Haaga & Boll coverThe newest edition (6th) of CT and MRI of the Whole Body is a major publication in Diagnostic Radiology. Edited by Drs. John Haaga and Daniel Boll and co-authored by over 171 contributors, the book strives to be all-encompassing. Two volumes, with 2671 pages, cover the basic principles of CT and MR, neuroradiology (brain, spine, head/neck), chest, abdomen/pelvis, MSK, and image-guided procedures. The neuroradiology and abdomen/pelvis portions of the book compose nearly two-thirds of the material. While much of the information can be obtained from multiple other sources (books, review articles, imaging clinics, online information), it is beneficial to have this information under “one roof.” As is common in many publications these days, the book comes with a scratch-off code, allowing one to access the book/images on any device electronically.

From the neuroradiology aspect, the authors have done a good job in combining standard imaging with more advanced techniques. An example of the latter is the chapter on fMR where the fundamental concepts of fMR task involvement, image analysis, and clinical applications are described and shown. Likewise, the 36-page chapter on brain MRs is a thorough description of the technique involved and the value of adding this to routine imaging. The chapter benefits greatly from having a physicist (Dr. Kwock) as the senior author. Throughout multiple chapters, imaging other than standard sequences are shown, such as CT/pMR, permeability curves, PET/CT, and DTI maps. While most of these techniques are applied to the brain, some examples are part of other areas like neck masses. The book is abundantly illustrated with generally acceptable high-quality images (although the chapter on the orbit has some very dated and low-resolution images). Of course, …

T1 Signal-Intensity Increase in the Dentate Nucleus after Multiple Exposures to Gadodiamide: Intraindividual Comparison between 2 Commonly Used Sequences

Fellows’ Journal Club

The authors performed intraindividual qualitative and quantitative comparison between T1-weighted spin-echo and 3D MPRAGE images in 18 patients who had multiple exposures to gadodiamide. Differences in signal between the 2 sequences for both baseline and last examination dentate nucleus/middle cerebellar peduncle ratios were statistically significant. They conclude that T1-weighted spin-echo and MPRAGE sequences cannot be used interchangeably for qualitative or quantitative signal intensity analysis of the dentate nucleus in patients who received gadodiamide.


Figure 1 from paper
Axial MR images in a 40-year-old male patient with a right frontal low-grade astrocytoma. Unenhanced axial T1-weighted spin-echo (A and C) and 3D MPRAGE MR images (B and D) of the first (A and B) and fifth (2 years later, C and D) gadolinium-enhanced MR imaging examinations at the level of the dentate nuclei of the cerebellum. The images show progressively increased T1 signal of the dentate nuclei (white arrows, C and D). Note that the qualitative analysis was slightly different between the 2 sequences.


Different T1-weighted sequences have been used for qualitative and quantitative evaluation of T1 signal intensity related to gadolinium deposition in the dentate nucleus in patients who underwent several enhanced MR imaging studies. Our purpose was to perform an intraindividual qualitative and quantitative comparison between T1-weighted spin-echo and 3D magnetization-prepared rapid acquisition of gradient echo sequences in patients who had multiple exposures to gadodiamide.


Our retrospectively selected population included 18 patients who underwent at least 3 administrations of gadodiamide and had a baseline and a final MR imaging performed with both T1-weighted sequences. Qualitative and quantitative analyses were independently performed. Dentate nucleus/middle cerebellar peduncle signal-intensity ratios and signal changes between the baseline and final examinations were compared by using the Wilcoxon signed rank test. Correlation between quantitative and qualitative evaluations was assessed by

Cortical Perfusion Alteration in Normal-Appearing Gray Matter Is Most Sensitive to Disease Progression in Relapsing-Remitting Multiple Sclerosis

Editor’s Choice

Bookend perfusion was used to quantify parameters in normal-appearing and lesional tissue at different relapsing-remitting MS stages in 39 patients and 19 age-matched healthy controls. Perfusion parameters such as CBF, CBV, and MTT were compared along with cognitive performance. White matter lesion but not cortical lesion perfusion was significantly reduced in cognitively impaired patients with relapsing-remitting MS versus unimpaired patients with relapsing-remitting MS. Perfusion reduction with disease progression was greater in normal-appearing gray matter and normal-appearing white matter compared with cortical lesions and white matter lesions. The authors conclude that the greatest changes are present within NAGM and NAWM, necessitating absolute rather than relative lesion perfusion measurement.

Multimodal CT Imaging: Time to Treatment and Outcomes in the IMS III Trial

Fellows’ Journal Club

The authors explored the effect of multimodal imaging (CT perfusion and/or CT angiography) versus noncontrast CT alone on time to treatment and outcomes in the IMS III trial. Of 656 subjects enrolled in the trial, 90 (13.7%) received CTP and CTA, 216 (32.9%) received CTA (without CTP), and 342 (52.1%) received NCCT alone. Median times from stroke onset to IV tPA in the CTP+CTA, CTA, and NCCT groups were 120.5 vs 117.5 vs 120 minutes, respectively. They conclude that the use of CTA (with or without CTP) did not delay IV tPA or endovascular therapy compared with NCCT in the IMS III trial.


Figure 1 from paper
Time intervals of 3 imaging subgroups in the IV tPA treatment arm


The importance of time in acute stroke is well-established. Using the Interventional Management of Stroke III trial data, we explored the effect of multimodal imaging (CT perfusion and/or CT angiography) versus noncontrast CT alone on time to treatment and outcomes.


We examined 3 groups: 1) subjects with baseline CTP and CTA (CTP+CTA), 2) subjects with baseline CTA without CTP (CTA), and 3) subjects with noncontrast head CT alone. The demographics, treatment time intervals, and clinical outcomes in these groups were studied.


Of 656 subjects enrolled in the Interventional Management of Stroke III trial, 90 (13.7%) received CTP and CTA, 216 (32.9%) received CTA (without CTP), and 342 (52.1%) received NCCT alone. Median times for the CTP+CTA, CTA, and NCCT groups were as follows: stroke onset to IV tPA (120.5 versus 117.5 versus 120 minutes; P = .5762), IV tPA to groin puncture (77.5 versus 81 versus 91 minutes; P = .0043), groin puncture to endovascular therapy start (30 versus 38 versus 44 minutes; P = .0001), and endovascular therapy start to end (63 versus

Improved Leakage Correction for Single-Echo Dynamic Susceptibility Contrast Perfusion MRI Estimates of Relative Cerebral Blood Volume in High-Grade Gliomas by Accounting for Bidirectional Contrast Agent Exchange

Editor’s Choice

The authors’ hypothesis is that incorporating bidirectional contrast agent transport into the DSC MR imaging signal model will improve rCBV estimates in brain tumors. A unidirectional contrast agent extravasation model (Boxerman-Weisskoff) was compared with a bidirectional contrast agent exchange model. For both models, they compared the goodness of fit with the parent leakage-contaminated relaxation rate curves and the difference between modeled interstitial relaxation rate curves and dynamic contrast-enhanced MR imaging in 21 patients with glioblastoma. The authors conclude that the bidirectional model more accurately corrects for the T1 or T2* enhancement arising from contrast agent extravasation due to blood-brain barrier disruption in high-grade gliomas by incorporating interstitial washout rates into the DSC MR imaging relaxation rate model.

Specialty Imaging: Temporomandibular Joint, 1st Edition

Tamimi DF, Hatcher DC. Specialty Imaging: Temporomandibular Joint. 1st ed. Elsevier; 2016; 800 pp; 2000 ill; $299.99

Cover of Specialty Imaging by Tamimi & HatcherDo not be fooled by the title of this book: Temporomandibular Joint. The book is just under 900 pages in length, so one can immediately suspect that there is far more here than just the TMJ. Without actually counting the pages that directly address the joint itself, a conservative estimate is that there are 100 pages. That leaves 85% of the book for adjacent critical areas of the neck and spine. All this is said so that one can get a feeling for the encompassing nature of the book.

Done in the usual superb and inclusive manner of all of the books in this multi-year series from Amirsys/Elsevier, the two chief editors/authors, Drs. Tamimi and Hatcher, and 43 authors have put together a book which addresses areas we deal with on a nearly daily basis and other areas we less frequently encounter. The book comes (as do virtually all of the books in this series) with a code which allows access to the eBook version.

There are 7 sections: Understanding of the TMJ; Anatomy; Modalities Used for the TMJ Imaging: Diagnoses; Radiographic Differential Diagnosis; Clinical Differential Diagnosis; and Imaging of TMJ Procedures. These section titles belie the fact that there is much in such sections which are apart from the TMJ itself.

Virtually everyone in radiology knows the quality of these books, with their illustrations, graphics, imaging (CT/MR), and bullet points. This particular book is no exception. While some of the material is reproduced from their other publications, the bringing together of this material in anatomic regions adjacent to the TMJs has its advantages. Wide-ranging subjects are covered; for example, in Section 4 (400 pages) entitled Diagnoses, the beginning portion (150 …

Neuroradiology Imaging: Case Review Series, 1st Edition

Labruzzo SV, Loevner LA, Saraf-Lavi E, Yousem DM. Neuroradiology Imaging: Case Review Series. 1st ed. Elsevier; 2016; 416 pp; 530 ill; $69.99

Cover of Neuroradiology Imaging by Labruzzo et alMost radiologists love case-based books and for good reason. One gets to see and analyze images which might infrequently or rarely be seen in the course of a year’s practice. Further, it is an enjoyable way of challenging the depths of one’s knowledge.

Enter a new book (publication date 2017) entitled Neuroradiology Imaging: Case Review Series, written by Drs. Labruzzo and Yousem from John Hopkins, Dr. Loevner from the University of Pennsylvania, and Dr. Saraf-Lavi from the University of Miami. They have collected important and instructive cases encompassing material related to the brain, spine, and head/neck. In a familiar fashion, a case is presented with a few images and a brief history. Four questions follow (which often give away the diagnosis), and the over page features the answers to each question with an explanation and half page of comments related to the case. There are 200 cases mixed between brain/spine/H&N and bunched into categories which the authors consider relatively easy to more difficult. Under the answers to each question, the images shown on the prior page are repeated, albeit in a smaller format. Here the authors missed an opportunity to label the key findings, presuming that the findings were so obvious they did not have to be labeled. That may be true for most cases, but not for all. Take one example: the case of a TMJ with displacement of a disc without recapture. Here labeling the displaced disc would have been beneficial to those who do not have TMJ MR experience, as would labeling of inner ear abnormalities in Down syndrome. There are other examples where labeling the smaller images would have been worthwhile.

The …

Journal Scan – This Month in Other Journals, August 2016

Cavalcanti DD, Preul MC, Kalani MYS, Spetzler RF. Microsurgical anatomy of safe entry zones to the brainstem. J Neurosurg. 2016;124(5):1359–1376. doi:10.3171/2015.4.JNS141945.

In this image rich paper, the authors examined 13 safe entry zones on the brainstem (previously described in the literature) and used cadaveric dissections to evaluate the main surgical approaches currently employed to manage intrinsic brainstem lesions. Through dissection images of these approaches, they demonstrate what can be seen on the brainstem through each of these surgical corridors and delineate the safe entry zones provided by each approach.  The approaches described include three midbrain regions (anterior mesencephalic zone, lateral mesencephalic sulcus, intercollicular region), 6 pontine zones (peritrigeminal zone, supratrigeminal zone, lateral pontine zone, supracollicular zone, infracollicular zone, median sulcus of the fourth ventricle), and 4 medullary zones (anterolateral and posterior median sulci of the medulla, olivary zone, and lateral medullary zone). In addition to the surface anatomy, the paper describes the general surgical approaches to the regions, including Orbitozygomatic, Subtemporal, Subtemporal Transtentorial, Anterior Petrosectomy, Suboccipital Telovelar, Median Supracerebellar Infratentorial, Extreme Lateral Supracerebellar Infratentorial, Retrosigmoid, Far Lateral, and Retrolabyrinthine.

13 illustrations and 2 tables.

Close to all a Neuroradiologist needs to know about surgical approaches to the brainstem, and then some.

Drazin D, Nuño M, Patil CG, Yan K, Liu JC, Acosta FL. Emergency room resource utilization by patients with low-back pain. J Neurosurg Spine. 2016;24(5):686–693. doi:10.3171/2015.7.SPINE14133.

The authors conducted a retrospective analysis of patients with LBP discharged from hospitals according to the Nationwide Inpatient Sample (NIS) between 1998 and 2007. A majority (65%) of patients discharged from hospitals in the US from 1998 to 2007 with a primary diagnosis of LBP were admitted through the ER, with more patients being admitted via this route each year (183,151 patients). These patients were less likely to be discharged directly …

Atypical Presentations of Intracranial Hypotension: Comparison with Classic Spontaneous Intracranial Hypotension

Fellows’ Journal Club

The authors evaluated the clinical records and neuroimaging of patients with spontaneous intracranial hypotension from September 2005 to August 2014. Patients with classic spontaneous intracranial hypotension (n = 33) were compared with those with intracranial hypotension with atypical clinical presentation (n = 8). There was no significant difference in dural enhancement, subdural hematomas, or cerebellar tonsil herniation. Patients with atypical spontaneous intracranial hypotension had significantly more elongated anteroposterior midbrain diameter compared with those with classic spontaneous intracranial hypotension, and shortened pontomammillary distance. In this population, patients with atypical spontaneous intracranial hypotension showed a more chronic syndrome compared with classic spontaneous intracranial hypotension, more severe brain sagging, lower rates of clinical response, and frequent relapses.


Figure 1 from paper
Pontomammillary distance on sagittal T1 (A–C) and anteroposterior midbrain diameter on axial T2-weighted MRI (D–F) in a healthy control (A and D), and patients with classic SIH (B and E) and atypical SIH (C and F).


Atypical clinical presentations of spontaneous intracranial hypotension include obtundation, memory deficits, dementia with frontotemporal features, parkinsonism, and ataxia. The purpose of this study was to compare clinical and imaging features of spontaneous intracranial hypotension with typical-versus-atypical presentations.


Clinical records and neuroimaging of patients with spontaneous intracranial hypotension from September 2005 to August 2014 were retrospectively evaluated. Patients with classic spontaneous intracranial hypotension (n = 33; mean age, 41.7 ± 14.3 years) were compared with those with intracranial hypotension with atypical clinical presentation (n = 8; mean age, 55.9 ± 14.1 years) and 36 controls (mean age, 41.4 ± 11.2 years).


Patients with atypical spontaneous intracranial hypotension were older than those with classic spontaneous intracranial hypotension (55.9 ± 14.1 years versus 41.7 ± 14.3 years; P = .018). Symptom duration was shorter in classic compared with atypical spontaneous intracranial hypotension