2. U-King-Im JM, Fox AJ et al.    Characterization of Carotid Plaque Hemorrhage: A CT Angiography and MR Intraplaque Hemorrhage Study. Stroke 2010;41:1623-1629.  The authors did not find mean plaque density to be a useful factor for prediction of MR defined IPH. There was significant overlap between the mean plaque densities between the hemorrhagic and the nonhemorrhagic plaque groups. They did find a strong in vivo association between CTA plaque ulceration and IPH as defined by MR-IPH.

3. Raybaud C.  The corpus callosum, the other great forebrain commissures, and the septum pellucidum: anatomy, development, and malformation.  Neuroradiology (2010) 52:447–477.  This is a massive review.  I suggest a very large caffeinated drink prior to attempted reading.  Some things don’t change: the physiological role of the indusium griseum is still unknown.

4. Hassan AE, Zacharatos, H et al.  A Comparison of Computed Tomography Perfusion-Guided and Time-Guided Endovascular Treatments for Patients with Acute Ischemic Stroke. Stroke 2010; 41:1673-1678.  69 patients underwent CT-P-guided and 127 patients underwent time guided endovascular treatment.  CT-P guided endovascular treatment (compared with conventional time-guided endovascular treatment) was not associated with improved short-term outcomes.  Very interesting counterpoint to the utility of CTP, especially given the recent negative press concerning radiation dosage.

5. Ebinger M., et al. Clinical and Radiological Courses Do Not Differ Between Fluid-Attenuated Inversion Recovery-Positive and Negative Patients With Stroke After Thrombolysis.  Stroke 2010;41:1823-1825.  No significant difference was found in terms of lesion growth or neurological changes after thrombolysis between FLAIR-positive and FLAIR-negative patients. Thrombolysis should not be withheld solely based on FLAIR lesion visibility.

6. Soto-Pérez-de-Celis, E.  The Death of Leon Trotsky. Neurosurgery 67:417-423, 2010. In 1940, a Stalinist agent wounded Trotsky in the head with an ice axe in his house in Coyoacán, Mexico, where he was living in exile.  His assassin, Frank Jacson, after his release from prison, spent his time between Cuba and the Soviet Union, where he received the nation’s highest distinction, the Hero of the Soviet Union medal.  That Stalin, what  a guy.

7. Cloyd JM et al. En Bloc Resection for Primary and Metastatic Tumors of the Spine: A Systematic Review of the Literature. Neurosurgery 67:435-445, 2010. Median time to total recurrence for primary tumors was 113 months and for metastatic tumors was 24 months.  En bloc tumor excisions are highly complex and technically demanding procedure with average operating time of 12.1 hours, estimated blood loss of 3.7 L, and complication rate of 36.3%.  The comments are worth reading, and give a nice summary of current thinking regarding en bloc resection vs. lesion resection with chemo and radiation.

8. Scoccianti S., et al. Patterns of Care and Survival in a Retrospective Analysis of 1059 Patients with Glioblastoma Multiforme Treated Between 2002 and 2007.  Neurosurgery 67:446-458, 2010. Median survival was 9.5 months, and actuarial overall survival rates at 1, 2, and 5 years were 62.3%, 24.8%, and 3.9%, respectively.  Patient characteristics associated with a better prognosis included younger age at diagnosis, single lesion, absence of focal symptoms at diagnosis, and higher preoperative KPS score. One small glimmer of hope is the percentage of patients with long term survival (4-year 6.8%; 5-year 3.9%).

9. Pitt D., et al.  Imaging Cortical Lesions in Multiple Sclerosis with Ultra–High-Field Magnetic Resonance Imaging. Arch Neurol 2010; 67(7):812-818. This is a detailed assessment of the sensitivity of 3-D T2*GRE and 3-D inversion recovery WM attenuated turbo-field-echo (TFE) sequences at 7 T in formalin-fixed MS brains in three patients evaluating cortical demyelination. 46% (T2*GRE) and 42% (WHATTFE) of histologically confirmed lesions were seen on prospective scoring. These scores improved to 93% and 82%,respectively, on retrospective scoring. Lesion visibility was partially determined by size as all undetected lesions had a diameter of 1.1 mm or less.  Very impressive image quality.

10. Fisher CG, Vaccaro AR.  The Highest Level of Evidence in a High Impact Journal: Is This the Final Verdict? Spine 2010; 35 (15): E676-E677.  More fodder for the vertebroplasty debate.  They do make an interesting comparison to femur fractures: The natural history of femur fractures is healing by 6 to 12 months regardless of treatment. The goal of internal fixation is early mobilization and pain control.  The authors ask the question: Would anyone for go internal fixation of a femur fracture because of the equivocal long-term fracture healing?

11. Thompson PM, Martin MG, Wright MJ. Imaging genomics. Current Opinion in Neurology 2010, 23:368–373.  Nice reference list for an area of research to which I pay little (or no) attention.

12. Mirzayan MJ et al. Extended Long-Term (>5 Years) Outcome of  Cerebrospinal Fluid Shunting in Idiopathic Normal Pressure Hydrocephalus. Neurosurgery 67:295-301, 2010. Fifty-one patients (mean age of 70) were included after confirmation of the diagnosis by extensive clinical and diagnostic investigations. Surgery included ventriculoatrial or ventriculoperitoneal shunting with differential pressure valves. Shunt-related mortality was negligible and the main cause of death was vascular comorbidity. Nice table summarizing the literature regarding long-term follow-up studies after shunting in iNPH.

13. Langner S et al. Perfusion CT scanning and CT angiography in the evaluation of extracranial-intracranial bypass grafts. J Neurosurg July 9, 2010. Perfusion CT allows monitoring of hemodynamic changes after bypass surgery. The combination of both modalities enables noninvasive anatomical and functional analysis of superficial temporal artery–middle cerebral artery anastomoses using a single CT protocol.  Didn’t we know this already? We use both all the time in our by-pass population.

14. Barkovich AJ.  Current concepts of polymicrogyria.  Neuroradiology 52: 479-487, 2010.  Everything you need to know in one place….’nuff said.

15. Tubbs RS et al.  Retroclival Epidural Hematomas: A Clinical Series. Neurosurgery 67:404-407, 2010. As Dr. Heger noted in the comments section, 25% of their patients experience occipital cervical dissociation and required stabilization surgery underscores the need for a high index of suspicion for spinal instability in all cases of REDH. 5 of the 6 surviving patients had minimal to no neurologic deficit on long term follow-up indicates that the prognosis from this lesion may be good.

16. Rutherford MA, et al. Magnetic resonance imaging of white matter diseases of prematurity. Neuroradiology (2010) 52:505–521.  Excellent review article with loads of images.  Highly recommended.

Hirayama Disease (NXPowerLite)

2. Kim KH et al.  Adjacent Segment Disease After Interbody Fusion and Pedicle Screw Fixations for Isolated L4–L5 Spondylolisthesis. Spine 2010;35:625–634. A low postoperative segmental lordotic angle, especially less than 20°, at index level was related with development of clinical ASD in both isthmic and degenerative spondylolisthesis patients.

3. Ribas GC .The cerebral sulci and gyri. Neurosurg Focus 28 (2):E2, 2010.  Very detailed review of the literature regarding the historical, evolutionary, embryological, and anatomical aspects of the cerebral sulci and gyri to establish detailed descriptions of these structures, as well as their groupings in the brain lobes, for microneurosurgical purposes.

4. Diaz FL et al.  Cervical External Immobilization Devices: Evaluation of Magnetic Resonance Imaging Issues at 3.0 Tesla. Spine 2010;35:411–415. Generation 80 and V1 Halo devices exhibited substantial temperature rises with “sparking” evident for the Generation 80 during the MRI procedure. Artifacts were problematic for these devices. The 2 Resolve Ring-based cervical external immobilization devices showed little or no heating and the artifacts were acceptable.

5. Harrop JS et al.  Cervical Myelopathy: A Clinical and Radiographic Evaluation and Correlation to Cervical Spondylotic Myelopathy. Spine 2010;35:620–624.  Nice review of clinical signs.  No patients without cord compression showed myelopathy.  The likelihood of myelopathy increases with the presence of T2 cord signal hyperintensity.

6. Monti MM et al. Willful Modulation of Brain Activity in Disorders of Consciousness. N Engl J Med 2010;362:579-89. Of the 54 patients enrolled in the study, 5 were able to willfully modulate their brain activity demonstrated by fMRI.

7. Ropper AH. Cogito Ergo Sum by MRI. N Engl J Med 2010; Feb 18, 362;7. Editorial accompanying the N Engl J Med article above. (I think, therefore I am).The author reminds us of three important concepts: First, in this study, brain activation was detected in very few patients. Second, activation was found only in some patients with traumatic brain injury, not in patients with global ischemia and anoxia. Third, cortical activation does not provide evidence of an internal “stream of thought”, memory, self-awareness, reflection, synthesis of experience, symbolic representations, anxiety, despair, or awareness of one’s predicament.

8. Kase CS, Nguen TN.  The clinical conundrum of convexal subarachnoid hemorrhage. Neurology 2010;74:874–875.  Editorial. “Convexal” SAH is frequently encountered in clinical practice, and presents at times with acute headache suggestive of SAH, but often it is an unexpected finding on imaging in patients evaluated for a variety of symptoms, including change in mental status, transient focal neurologic deficits, or partial seizures.

9. Kumar S, Goddeau RP et al. Atraumatic convexal subarachnoid hemorrhage:  Clinical presentation, imaging patterns, and etiologies.  Neurology 2010;74:893–899. Reversible vasoconstriction syndrome appears to be a common cause in patients 60 years or younger whereas amyloid angiopathy is frequent in patients over 60.

10. Lovblad K, Baird AE.  Computed tomography in acute ischemic stroke. Neuroradiology (2010) 52:175–187.  Comprehensive review of use of CT imaging and perfusion.

11. Kleiser R, Staempfli P et al.  Impact of fMRI-guided advanced DTI fiber tracking techniques on their clinical applications in patients with brain tumors. Neuroradiology (2010) 52:37–46.  DTI scan can be acquired in a few more scan minutes in the same scan session in which all the other necessary images for the surgery are acquired (anatomical and fMRI data). The data processing is performed offline with dedicated software packages without involvement of the patient.

12. Bello L et al. Intraoperative use of diffusion tensor imaging fiber tractography and subcortical mapping for resection of gliomas: technical considerations. Neurosurg Focus 28 (2):E6, 2010.  Shows the potential usefulness of the routine combined use of DT imaging–FT and subcortical mapping, particularly in patients with low-grade gliomas. These tumors display an infiltrative modality of growth, along short and long connecting fibers, and visualizing the trajectory of the tracts is important for planning and performing surgery.

13. Verhoeven JS et al.  Neuroimaging of autism. Neuroradiology (2010) 52:3–14.  This is an area I have not paid much attention too, so it is convenient to have an all encompassing review available.

14. Chhabra V, Sung E et al.  Safety of magnetic resonance imaging of deep brain stimulator systems: a serial imaging and clinical retrospective study.  J Neurosurg 112:497–502, 2010.  This retrospective MR imaging–based study supports the safety of MR imaging in patients with implanted DBS systems.  Because the indications for DBS continue to expand, it is likely that postoperative MR imaging will remain an important clinical tool.

15. Richards PJ, George J et al. Spine Computed Tomography Doses and Cancer Induction. Spine Volume 35, Number 4, pp 430–433.  Risk ratio for inducing a cancer when CT scanning the whole lumbar spine was about 1 in 3200, which was much less than the risk of CTing the whole dorsal spine (about 1 in 1800) due to the longer coverage required and the anatomic implications of scanning in the region of the cervical dorsal junction.

16. Karppinen J, Solovieva S et al. Modic changes and interleukin 1 gene locus polymorphisms in occupational cohort of middle-aged men. Eur Spine J (2009) 18:1963–1970.  The pathomechanism of LBP due to Modic changes (MC) remains poorly understood. It has been hypothesized that MC is a result of a biomechanically induced inflammation around the intervertebral disc.  This inflammatory etiology is also supported by the finding of an increased number of tumor necrosis factor immunoreactive nerve cells and fibers in endplates with MC, especially in type I changes [30].   This paper shows an association between IL1A gene variation and type II MC replicates a previous finding from a different Finnish geographic area,  confirming the importance of the ILA gene in the pathophysiology of MC.

17. Kim D, Wadley R. Variability in Techniques and Patient Safety Protocols in Discography. Journal of Spinal Disorders & Techniques, 27 January 2010. To improve diagnostic validity and patient safety, the International Spine Intervention Society (ISIS) has published practice guidelines for performing discography (Bogduk N, ed. Practice Guidelines for Spinal Diagnostic and Treatment Procedures. San Francisco: International Spine Intervention Society; 2004:20–46).  The overall compliance with ISIS guidelines is fair to poor with the specialty rank order of compliance greatest to least as follows: Anesthesiology, PMR, and Radiology.

18. Kim HS, Chong HS et al. Vascular Injury in Thoracolumbar Spinal Surgeries and Role of Angiography in Early Diagnosis and Management. Journal of Spinal Disorders & Techniques, 27 January 2010. Of the total 8 arterial injury cases, only 1 of them occurred in the thoracic region and the rest all were seen in the lumbar spine.  Pseudoaneurysm formation in thoracic aorta was seen in 1 case of multiple vertebral fractures, segmental artery was found to be injured in 3 cases of osteotomy for deformities, 2 cases of aortic injury and 1 case of inferior mesenteric artery injury was seen in posterior lumbar interbody fusion. Common iliac artery and vein both were seen to be injured simultaneously in 1 case of lumbar discectomy.

Very nice review article with histopathology, imaging and helpful graphics

2.  Neuro-Behçet’s disease: epidemiology, clinical characteristics, and management.  Lancet Neurol 2009; 8: 192–204.

Behcet’s disease is a multisystem relapsing inflammatory disorder of unknown cause.  This review covers CNS parenchymal and nonparenchymal manifestations, as well as peripheral and uncommon variants.

3.  The protective status of subtotal obliteration of arteriovenous malformations after radiosurgery: significance and risk of hemorrhage.  Neurosurgery 65:709–718, 2009

Important paper evaluating the risk of AVM’s which show only early draining vein but no nidus following radiosurgery.  These “subtotally” obliterated AVM’s showed 0% rebleed rate.

4.  Microsurgical and endoscopic anatomy of the supratentorial arachnoidal membranes and cisterns.  Neurosurgery 65:644–665, 2009

More than I want to know about this topic, but nice to have as a reference.

5.  Hemispherotomy: efficacy and analysis of seizure recurrence.  J Neurosurg Pediatrics 4:000–000, 2009

Review of 49 patients who underwent functional hemispherotomy, with resultant freedom from seizures in 78%.

6.  Long term outcomes following surgical resection of myxopapillary ependymomas.  Neurosurg Rev (2009) 32:321–334

Retrospective review of 52 cases of spinal myxopapillary ependymomas.  Pediatric patients had much more aggressive tumors with recurrence and dissemination in 64%, vs. 32% in adults.  The role of radiotherapy and chemo is discussed.

7.  Neurosurgical implications of achondroplasia.  J Neurosurg Pediatrics 4:000–000, 2009

Review of treatment of pediatric patients with achondroplasia from Hospital for Sick Children, with focus on hydrocephalus and CV junction abnormalities.

8.  Occipital condyle fractures: clinical decision rule and surgical management.  J Neurosurg Spine 11:388–395, 2009

This is the kind of classification I like: presence or absence of craniocervical malalignment is the one important imaging parameter.  Malalignment was defined as C0-C1 interval on CT of >2mm.

9.  Comparison of clinical, familial, and MRI features of CADASIL and NOTCH3-negative patients.  Neurology  2010;74:57–63

Genetic analysis of 81 probands because CADASIL was suspected show no phenotypical differences between those with and without the mutation.

10.  Noninvasive testing, early surgery, and seizure freedom in tuberous sclerosis complex.  Neurology 2010;74:392–398

Evaluation of magnetic source imaing and PET/MRI coregistration techniques in 18 patients who underwent surgery.  Largest hypometabolic focus relative to the MR size seemed an important variable.

Here is a short and concise presentation on the etiology, imaging findings and treatment for subacute combined degeneration of the spinal cord.  It was prepared by one of our neuroradiology fellows, Dr. Ali Nasim, for our weekly interesting case conference.

1. How many people regularly do cervical nerve root blocks?
2. Are you using CT or conventional fluoro?
3. If you are using CT, do you use contrast to confirm needle position?

It would be great for people to comment on the blog, but you can also email me directly.

Thanks!
jenny.hoang@duke.edu

“Few would argue that percutaneous vertebroplasty announced its birth and found its voice on the pages of AJNR. No other publication has been more crucial to the discussion, dissection, and dissemination of technical and clinical research as it relates to this procedure,” said Collection editors Mary E. Jensen and Joshua A. Hirsch. “The sheer number of positive outcomes in patients debilitated by their disease, catalogued on these pages stand as testimony to the benefits of vertebroplasty over best medical therapy.”

“Little did all of us know that destiny would ‘throw us a curve ball’ on August 6 when the New England Journal published the now famous (or infamous?) articles that attempted to debunk vertebroplasty as treatment for painful osteoporotic spinal fractures,” explained AJNR’s Editor-in-Chief Mauricio Castillo. “These events make this compilation of articles even more pertinent. Now is the time for the reader to decide if the procedure is beneficial or not, and to act accordingly.”

AJNR Special Collections are released biannually on an open-access basis to provide a comprehensive source of imaging-related articles that are convenient, valuable, and quotable. Previous Collections include “Imaging Acute Stroke and its Consequences,” edited by Pamela W. Schaefer and R. Gilberto González, and “Acute Stroke Intervention” edited by Colin P. Derdeyn and Avi Mazumdar. All are available through AJNR’s print-on-demand service (Brightdoc), allowing readers to order a full-color hard copy for just US $50.00, plus shipping.

Be sure to bookmark the latest Special Collection link or connect through the AJNR homepage on your next visit.

Analysis of axial images showed that the mass involved the spinal canal but extended out into the paraspinal regions, including the right psoas muscle, via several neural foramina.  The diagnosis was reconsidered to include giant invasive spinal schwannoma (histologically confirmed later).

Schwannomas are the most common primary spinal tumor occurring predominantly in the cervical and thoracic regions.  Tumors of the cauda equina region represent only 6% of all spinal masses; most are schwannomas. “Giant” schwannomas are rare, long lesions that expand, remodel or destroy adjacent bones.  When they extend to extra-spinal myofascial planes, they are considered “invasive”.  Symptoms vary from severe to mild. Total excision is advocated but not always feasible.  Spinal fusion after tumor resection is needed in most patients.  Perhaps, fewer than 20 cases of giant schwannomas are found in the modern literature nearly all of them in the lumbosacral region. They are not associated with NF-2. The main differential diagnosis is that of myxopapillary ependymoma. Giant ependymomas are more common in younger individuals and despite attaining large size they do not tend to produce the focal bone scalloping and paraspinal involvement that giant schwannomas typically show (see illustration below). Mutiple schwannomas, as seen in NF-2 could also have a similar appearance.

References:

Sridhar K, Ramamurthi R, Vasudevan MC, Ramamurthi B. Giant invasive spinal schwannomas: definiation and surgical management. J Neurosurg (Spine) 2001; 94: 210-215

Hung CH, Tsai TH, Lin CL et al. Giant invasive schwannoma of the cauda equina with minimal neurologic deficit: a case report and literature review. Kaohsiung J Med Sci 2008; 24: 212-217

Guyotat J, Fishcer G, Remond J et al. Giant ependymoma of the cauda equine. Long-term development apropos of 7 cases. Neurochirurgie 1993; 39: 85-91

Does anyone know what this mass could be? It was biopsied 2 years ago and pathology reported it as  “normal brain tissue”.

As you can see, the lesion is hyperintense on T2, hypointense on T1 and does not enhance.  No calcifications are present and no there is no restricted diffusion .

The patient is 25  year old and has loss of short term memory and seizures.

Any input into the nature of the mass is welcome.