The loss of CSF volume explains the usual complaint of orthostatic headache, relieved by lying down, and the characteristic MRI findings: 1) thickening of the dura, enhancing after contrast medium administration, 2) subdural fluid collections, 3) sagging of the brain, 4) dilatation of the venous structures, which includes enlargement of the dural sinuses and veins, enlargement of the pituitary gland, and, in the spinal canal, engorgement of the epidural plexuses. All these features are explained by the Monro-Kellie doctrine: in a closed compartment, such as the intracranial cavity and spinal canal, which contains nervous tissue, blood, and CSF, the loss of one component is compensated by the equivalent increase of the other ones. Therefore, if a dural leakage causes a loss of CSF, an increase in nervous tissue or blood must compensate for that loss to re-establish the equilibrium. Obviously, the easiest compensation comes from an increase in blood, and specifically venous blood because the veins may dilate passively more than the arteries. In peculiar cases, the nervous tissue may participate in the compensation through swelling of the brain (Savoiardo et al. Brain 2007).

Most of the authors who have published papers on SIH, have shifted their emphasis from the loss of pressure in the closed system (intracranial hypotension) to the actual loss of volume of CSF. We agree that the loss of volume of CSF rather than its decreased pressure should be emphasized and pointed out in the denomination of this condition because it is more correct in terms of pathophysiology. However, the term “CSF hypovolemia”, that has been used by most authors, is wrong. We would like to point out again why this is so.

The suffix “emia” in “hypovolemia”, indicates blood, as in glycemia, uremia, and so on. Therefore, “CSF hypovolemia” means “decreased (hypo) volume (vol) of the blood (emia) of the CSF” which is a total nonsense. There is no “blood of the CSF”; moreover, we have seen that venous blood increases (“hypervolemia”) to compensate for the loss of CSF.

According to dictionaries, “hypovolia” exists and should be the correct term. However, since “hypovolia” has never been used and is unknown to most of us, we propose using “CSF loss of volume” or “decreased volume of CSF” rather than “CSF hypovolia”. In our opinion, “CSF hypovolemia” remains a misnomer and should be banned. This is probably a lost cause, but we think it’s worth using the precise terms.

We thank Dr. Neeraj Kumar and Dr. Mauricio Castillo for discussing this matter.

Mario Savoiardo and Marina Grisoli
Department of Neuroradiology
Foundation IRCCS Istituto Neurologico Carlo Besta
Milan, Italy

E-mail:
msavoiardo@istituto-besta.it
mgrisoli@istituto-besta.it

Savoiardo M, Minati L, Farina L, et al. Spontaneous intracranial hypotension with deep brain swelling. Brain 2007;130:1884-93.

Kumar N. Neuroimaging in superficial siderosis: an in-depth look. AJNR Am J Neuroradiol 2010;31:5-14.

Savoiardo M, Grisoli M. Further in-depth look at superficial siderosis (and intracranial hypotension). AJNR Am J Neuroradiol Published June 25, 2010 as DOI 103174/ajnr.A2172

Kumar N. Reply. AJNR Am J Neuroradiol Published June 25, 2010 as DOI 103174/ajnr.A2187

It has been about 2 – 3 years since COW was introduced by Dr Castillo. It has grown to be a tremendously popular site (sometimes receiving up to 10,000 views per month). With the hope of adding to the educational content of COW, Dr. Castillo and I have been thinking of introducing some changes to this popular site. These changes include:

1. Consider COW submissions from other faculty members (in addition to the Fellows). This would include submissions from residents (only when supported with an attending), and a junior attending (up to 3 years in practice).

2. Include Figure Legends.

3. Include 2 to 3 key diagnostic features in the discussion.

4. Include a list of relevant differential diagnosis. A discussion of the differential diagnosis will not be required.

5. Include all cases presented during that particular year as part of an electronic scientific exhibit for ASNR. In fact, such an electronic scientific exhibit was already presented at the recently concluded ASNR 2010 conference, where cases submitted during the year 2009 were compiled as an electronic scientific exhibit. This compilation is performed by me and Jason Gantenberg, Editorial/Web Assistant, AJNR and does not require any additional input from the contributing authors.

I do hope that the above mentioned changes will only add to the diagnostic armamentarium of us neuroradiologists. Do expect to see these changes taking effect from mid July/early August.

For those who are new to the submission process:

You can submit your cases directly to me at Girish.Fatterpekar@mssm.edu Cases need to be interesting and educational. They need not be rare. Case acceptance is entirely upon the discretion of the reviewer board. Upon receiving the case, a decision letter will be sent to you, usually within 2 -3 business days. If accepted, the acceptance letter will be followed by an email from Jason informing you about the possible publication date.

Case submission entails 3 power point slides:

Slide 1. Brief history, one to six high quality (color acceptable) illustrations. Name of the author (one per case) and institution.

Slide 2: With added Figure legends and appropriate annotations for the images (arrows, etc.).

Slide 3. Diagnosis, Succinct up-to-date discussion (1 to 2 lines each): background, relevant clinical information, key diagnostic features, list of differential diagnosis, treatment options, and up to 2 – 3 relevant current references (cite AJNR when possible, so as to allow link to the appropriate article).

I look forward to working with you all.

American Journal of Neuroradiology
DOI 10.3174/ajnr.A2189

American Society of Neuroradiology: Carolyn Cidis Meltzer
Our new ASNR President is Dr. Carolyn Cidis Meltzer and the society is honored to have an individual of her qualifications at its helm. She currently is Chair and Professor of Radiology, Neurology, and Psychiatry at Emory University in Atlanta, as well as faculty in the Department of Radiology of the University of Pittsburgh. As attested to by her accomplishments, supreme organizational and interpersonal abilities characterize her style. Apart from being a Chairperson, she is Associate Dean for Research and Director of Center of Systems Imaging at Emory. She holds or has held positions on more than 100 committees, 10 within ASNR, including Vice President. Dr. Meltzer reviews manuscripts for 25 journals, is an editorial board member for 2, has participated in 40 grant review panels, and is a member of 25 scientific organizations. If you are not impressed yet, the following facts will convince you of her incredible accomplishments: she is listed as a principal or co-investigator in 30 current grants (and 80 previously completed ones); has given 100 invited lectures; written more than 150 peer-reviewed articles, all published in high–impact factor journals; is an author of 17 book chapters and 2 books; and her cur¬riculum lists over 250 scientific abstracts presented at national and international meetings. She has supervised countless medical students and has been advisor to 23 postdoctoral fellows. There is no doubt her tremendous academic, research, and administrative background confers her respect and admiration from her colleagues in radiology and other subspecialties. ASNR is proud to have such an accomplished individual as its President.

American Society of Functional Neuroradiology: Scott Faro
Dr. Scott Faro is the new President of the ASFNR. After obtaining his MD from Rutgers University and completing his radiology residency at the Medical Center of Delaware, he went on to 2 fellowships: neuroradiology at Thomas Jefferson University and pediatric neuroradiology at the Children’s Hospital of Philadelphia. Currently he serves as Professor and Vice Chairman of Radiology at Temple University, where he is also a Professor of Electrical Engineering and Computer Science and Director of Functional Brain Imaging. In the ASFNR he has previously served as Treasurer, Secretary, and Vice President. He has been or is a principal or co-investigator in more than 20 grants. Dr. Faro is listed as an author in nearly 70 peer-reviewed articles and 17 book chapters, and is the author of 3 books. His latest text on functional neuroradiology will be published next year. His curriculum also lists 146 abstracts and nearly 100 presentations. He is a member of the editorial board of 2 prestigious journals: Brain Imaging and Behavior and Journal of Neuroimaging. ASFNR will certainly benefit from having such an accomplished individual as its new President.

American Society of Head and Neck Radiology: Laurie Loevner
Dr. Laurie Loevner, Professor of Radiology, Otorhinolaryngology, and Neurosurgery at the University of Pennsylvania, is the new President of ASHNR. She obtained her MD from the University of Penn¬sylvania and after completing her general radiology training at the University of Michigan, she returned to U Penn for her neuroradiol¬ogy fellowship. Her service appointments extend to many radiology organizations and she has been a member of 18 ASNR committees including serving as Chair of 3. In ASHNR she has served as Member-At-Large, Treasurer, Vice Presi¬dent, and Program Chair. Dr. Loevner is Past President of the Eastern Neuroradio-logical Society. An excellent speaker, she has given nearly 450 invited lectures and moderated 20 scientific sessions at inter¬national meetings. She has published more than 90 peer-reviewed articles, 70 abstracts, 31 editorials, and 4 books, and is currently the neuroradiology editor for RadioGraphics. Laurie is listed as a principal or coinvestigator in 7 current grants. ASHNR is in the hands of an enthusiastic and highly qualified individual and we congratulate her in her new position as its President.

American Society of Pediatric Neuroadiology: Tina Young Poussaint
Dr. Tina Young Poussaint is the ASPNR’s new President. Before this position, she held the offices of Treasurer, Secretary, and Vice President in the society. After obtaining her MD degree from Yale University, she completed both her general radiology and neuroradiology training at the Massachusetts General Hospital in Boston. She is currently Associate Professor of Radiology at the Children’s Hospital in Boston, where she also oversees the Pediatric Neuroradiology Fellowship Program and is a member of the Board of Directors of the Radiology Foundation. She is a manuscript reviewer for 10 journals and has given more than 100 presentations at regional, national, and international meeting and congresses. An author or co-author of nearly 80 peer-reviewed articles, she has also contributed to 11 book chapters and 2 books. Grantwise, her name is listed as a principal or co-investigator in 8 projects. Although she lists neuro-oncologic imaging as her area of excellence, the neuroradiology community knows of her modesty and that her excellence extends to many more areas. We welcome Dr. Young Poussaint as the new President of the ASPNR.

American Society of Spine Radiology: Gregory Petermann
Dr. Gregory Petermann is the new President of ASSR. He currently practices as a neuroradiologist at the Marshfield Clinic in Madison, Wisconsin, and is Associate Professor of Radiology and Nuclear Medicine at the Uniformed Services University of Health Sciences in Bethesda, Maryland. Greg recently retired from the US Army with the rank of Colonel after 24 years of service. He received his MD from the Uniformed Services University and completed his general radiology training at Tripler Army Medical Center in Hawaii and the Fitzsimons Army Medical Center in Colorado. His training in neuroradiology was at the Uni¬versity of Wisconsin in Madison, and shortly after completion he was named Chief of Neuroradiology, Director of MR Imaging, and Director of the Radiology Program at Tripler. His resumé lists 15 publications, more than 20 scientific exhibits and posters at national and international meetings, and 37 oral presentations. He has served ASNR in various positions, and has been Treasurer and Secretary as well as Vice President for ASSR.

2.  Is 80 the optimal kVp for the perfusion study?

Thanks

However, some of us propagate a more liberal use of intracranial stents because the stent should attribute to a more durable aneurysm occlusion on the long-term by diverting the flow and by creating a mesh at the level of the neck to be colonized and covered by endothelial cells. In view of these perceived advantages, some even place a stent after successful aneurysm occlusion by simple coiling. The key question in this issue is: Does the potential better long-term result with use of stents negate the higher expected rate of complications?

One answer to this question is provided by the recently published study by Piotin. Clinical and imaging results of 216 patients with aneurysms (181unruptured and 35 ruptured) that were treated with stent assistance were compared to results of 1109 aneurysms (549 ruptured and 560 unruptured) that were treated without stent. Permanent neurological procedure-related complications occurred in 7.4% (16 of 216) of the procedures with stents versus 3.8% (42 of 1109) in the procedures without stents. Procedure-induced mortality occurred in 4.6% (10 of 216) of the procedures with stents versus 1.2% (13 of 1109) in the procedures without stents. In other words, with stent assisted treatment, 12% of patients either died or had permanent neurological deficit as a direct consequence of the treatment. How about the angiographic results, are these better with stent than without stent? Aneurysms treated with a stent had a higher rate of initial incomplete occlusion (35% versus 18%). Only about half of the stented aneurysms had angiographic follow-up and there were less recurrences 15% (17 of 114) versus 34% (259 of 774).

Unfortunately, the authors did not further analyse the high rate of complications with stent assisted coiling (vessel perforations, aneurysm perforations, thrombo-embolic complications). They also did not provide a definition of a recurrence and more important, the rate of retreatment in both groups was not reported. Although there were fewer recurrences after stenting, the recurrence rate of 15% with stent assistance is within the normal range of 10-20% reported for coiling in general.

The results of the study by Piotin give a clear answer to our previous question: the complication rate of stent assisted coiling is alarmingly high in a population harboring mostly unruptured aneurysms located on sites that are easily accessible for surgery while the follow-up results are comparable to results of coiling in general.

In my opinion, the use of this dangerous stent-assisted coiling should be discouraged and restricted to those cases where a stent is absolutely necessary and no alternative treatment is available. For sure, placement of a stent after successful coiling should be deterred since by placing the stent the procedure is converted from low-risk to high-risk.

Finally, we should not blame the bad handling of the device for the increased complication rate; it is always the operator who decides what materials to use. The introduction of newer stents with safer handling is not an excuse for denying disappointing results.

With recent media coverage focusing on the risk of cancer from medical imaging, patients and physicians have become more concerned about the increased use of CT scans and x-rays. In response we have developed an educational website for patients and physicians to learn about radiation exposure from medical imaging. The site is available for free at www.xrayrisk.com. One of the site’s main features is a web-based calculator that allows users to track their imaging history and estimate their increased risk of cancer based on the studies they have had.

Exposure data was compiled from the National Academy of Sciences report on the Health Risks from Exposure to Low Levels of Ionizing Radiation, specifically the BEIR VII Phase 2 Report. Data is based on the incidence of all invasive cancer types with users entering their gender and age at the time of the study. Average doses were used, but if a user knows the Dose Length Product (mGy • cm), they can covert it to Effective Dose (mSv). Patients can find additional information in the Frequently Asked Questions section.

Great effort has been made throughout the medical community to ensure patient safety while providing quality diagnostic images. It is important to realize that in a properly performed individual exam, the potential health benefits almost always outweigh the potential risks of radiation exposure. The website aims to provide accurate information for patients and health care providers to facilitate well-informed discussions about the increased risk of cancer from low dose radiation exposure.

The American Board of Radiology is radically changing the initial certification and recertification examination process for radiology trainees. Beginning with residents entering training in 2010 the written ABR exam and the oral exam in Louisville will be history.  In their place will be two new computer based image rich exams. The first exam (“Core exam”) will be given after 36 months of training and will cover all aspects of radiology including radiation physics and radiation biology.  The second exam (“Initial Certifying exam”) will be given 15 month after the completion of residency training.  The Certifying Exam will have 5 parts.  There will be one part on non-diagnostic topics such as radiation safety, MR safety, contrast reactions, ethics etc. One section will concern diagnoses that all radiologists should be able to make with an emphasis on emergent conditions such as pneumothorax, free abdominal air aneurismal subarachnoid hemorrhage and acute infarction.  The radiologist determines the remaining three parts of the examination based on his or her practice pattern.  An individual may choose to be examined in 3 two or one area.  Therefore in theory an individual could choose to have all three self-determined exam sections in neuroradiology.  When the candidate takes the recertifying in 10 years he/she will once again choose areas that they wish to be examined in. These may be the same areas chosen on the initial certifying exam or they may be different if the radiologist’s practice pattern has changed.

So why is the ABR doing this now and why is it doing it in this manner?  Changing the exam structure has been “on the table” for years. We are all familiar with the arguments concerning the timing of the certifying exam. Board psychosis consumes 4^th year residents distracting them from the task of “finishing off” their training in preparation for entering practice. Radiology is the only specialty that gives its certifying exam during rather than after training.  So why not bite the bullet and just move the oral exam to one year after training?  Over the years there has been major push back to moving the exam from radiology residents the private practice community and even from academic departments.  All of these groups (basically everyone except radiology program directors who have had to deal with having their most experienced residents rendered clinically useless) liked the fact that having the exam at the end of training got certification “out of the way”.

The impetus to change the board has come from a different source. There has been a growing realization in the radiology community that our current training programs are not preparing our residents to function in the current medical environment. Care is increasingly supplied by physicians with subspecialty training and expertise.  The imaging needs of these referring doctors may not be met by radiologists trained to everything adequately but nothing well. In order to improve the training of radiologists we must allow residents to gain expertise in a few areas and in order to do this we must allow residents to have focused learning and clinical experiences during the 4^th year of the residency. The current ABR exam structure with its consequent effects on the 4^th year of training makes focused training impractical except in a few elite training programs.

The new ABR exam structure is meant to facilitate the process of increased practice specialization. The core exam at 36 month will cover all areas of radiology. Following passage of the exam the resident can devote his or her 4^th year to developing expertise in one or a few areas of radiology.  Following completion of residency and a year of practice or fellowship the candidate takes the certifying exam. 60% of the content of this exam will be chosen by the candidate to reflect their actual practice experience. This eliminates the need to study of all of radiology and encourages the candidate to study those things that have actual practical import for their own practice.  At the time of recertification the radiologist will once again choose to be examined in those aspects of radiology that pertain to his or her practice. Thus the radiologist may choose to be examined on the recertification exam in different areas if his or her practice changes.

How will these changes affect neuroradiology training and practice?  I have heard concerns that the institution of the 4^th year of focused training will eliminate the need (perceived or real) for a post graduate year of neuroradiology training thus seriously damaging the ACGME approved fellowship training of which we are so justly proud. Others believe that candidates who take all three of their test modules in neuroradiology will be able to claim that they are board certified neuroradiology destroying the value of the Subspecialty Certification (CAQ).

Let me deal with the “easy” questions first.

1)     Regardless of the areas a candidate chooses to be examined in, the ABR Diagnostic Radiology Certification will be in radiology with no indication of areas of specialized knowledge or skill. Therefore a candidate who chooses all of his/her modules in neuroradiology will not be able to claim to have documented expertise in neuroradiology.

2)     The CAQ (or Subspecialty Certification) exam will be given,as it is now, 15 months after completion of an ACGME fellowship. The exam will be a computer-based exam with the same general format of the current recertification exam. The exam will have fewer items than the recertification exam but the questions will have the same format and degree of difficulty.  It is likely that the ABR will replace the oral CAQ exam with computerized exam in 2011 or 2012.

3)     So what are the differences in the neuroradiology modules used for the Certifying exam for Diagnostic Radiology and those used for the initial or recertifying exams used for the CAQ exam? The modules will have different levels of difficulty. This may involve using different cases or asking more or less complex questions about the cases. An individual taking one or two modules as part of the Diagnostic Radiology Certifying (or recertifying)Exam will take “basic modules”.  If an individual chooses all three modules in one discipline he/she will be given at least one “advanced” module. All of the modules used for the initial or recertification CAQ exam will all be “advanced”.  Note that all of the modules used for the current recertification exam are “advanced”. What will be new are basic modules developed for the Diagnostic Radiology Initial certification and recertification exams.

4)     Once an individual passes the CAQ exam the first recertification exam is taken after 10 years and this exam will result in recertification in both Diagnostic Radiology and subspecialty certification in Neuroradiology.  Resetting” the recertification clock means that individuals will not have to take two different exams at two different 10 year cycles

And now for hard part:  How will this affect our training programs and the practice of neuroradiology?  First a caveat: Everything from here on out is speculation. Major changes often have unpredictable and/or unforeseen consequences and this is certainly a major change.  What follows is my opinion but believe it or not I have been wrong in the past.  We all need to think about these questions and try to figure out what will happen and what we will do about it.

It is certainly possible that the ability to obtained focus training during residency may decrease the number of residents seeking fellowships in all radiology specialties. Factors outside of our control including economic pressures and changes in health care will undoubtedly affect residents’ career decisions.  However there is every reason to believe that the changes in training will not have a significant impact on the number of residents entering neuroradiology fellowships. We all know that neuroradiology is the coolest specialty in the world and I am sure it will continue to attract our best residents. The practice of neuroradiology is changing and we need to train our fellows in advanced imaging techniques and invasive procedures such as spine interventions if we are to maintain our leadership in neuroimaging and intervention. Other groups are anxious to perform and interpret neuroimaging exams. Since we do not “control” patients (a truly abhorrent notion if one thinks about it) our only option is to take high road. We must maintain the highest levels of practice skill and in order to do this we must constantly improve and update our training programs.

I believe that the change in radiology residency programs can actually strengthen neuroradiology training. We all struggle to provide everything our fellows need to learn in the one year ACGME fellowship. Several years ago Dave Yousem lead an ASNR retreat that concluded that 18 months was the ideal amount of time for neuroradiology training. At the time there was no way to get a significant number of training programs to provide residents with dedicated time in the 4^th year to begin training in neuroradiology.   With the new structure of residency training dedicated time in neuroradiology should be available in many programs.  It might even be possible in the future to formally incorporate this time into the ACGME fellowship training program.

I hope that this blog will clear up confusion surrounding the changes in ABR exam structure and that it will stimulate discussion of how this will affect training and practice of neuroradiology

Bob Zimmerman

For Immediate Release
October 19, 2009

American Society of Head and Neck Radiology
Presents Gold Medal to Hugh D. Curtin, M.D. during 43^rd Annual Meeting

The American Society of Head and Neck Radiology (ASHNR) presented its 2009 Gold Medal to Dr. Hugh D. Curtin on October 8, 2009, during the ASHNR 43^rd Annual Meeting at the Sheraton New Orleans Hotel in New Orleans, Louisiana.

Dr. Hugh D. Curtin was born in Canton, New York.  He attended grade school and high school there before attending the University of Toronto, St. Michael’s College.  He then made a decision to become a physician and attended SUNY Upstate Medical University in Syracuse, New York.  Dr. Curtin next went to the University of Pittsburgh Medical Center where he was first an intern and then a Radiology Resident.  He also took a fellowship in Pediatric Radiology in Sweden and then he was a clinical fellow in radiology with Dr. Vignaud in Paris.

Dr. Curtin joined the radiology faculty in Pittsburgh where he rose to full Professor of Radiology in 1988.  Then about seven years later he moved to Boston in 1995 as the Chief of Radiology at the Massachusetts Eye and Ear Infirmary and was soon appointed as full Professor of radiology at the Harvard Medical School.

Dr. Curtin has lectured widely both nationally and internationally almost 350 times and he is well known as an excellent teacher.  In fact, he has received numerous awards for his teaching excellence.  He served as the Head and Neck Editor of the American Journal of Neuroradiology and has served on numerous committees for at least 14 societies, where he has been on the executive committees of many of these societies.  Dr. Curtin is a reviewer for at least 11 major journals and has received awards for the excellence of his reviewing.  He has participated in over 20 exhibits.  Last, but by far not the least, he has authored about 130 peer-reviewed articles and 71 chapters.  Many of these articles are considered sentinel articles as they have influenced the way images are interpreted in head and neck radiology.  He is the co-editor with Dr. Peter M. Som of Head and Neck Imaging, presently in preparation of the fifth edition.

Dr. Curtin has always been a calming resource to his family and colleagues and his good-natured persona has endeared him to all.  He is admired as a scholar and for his numerous contributions to the ASHNR.  Thus, the ASHNR is very proud to present its 2009 Gold Medal to Dr. Hugh D. Curtin, as a symbol of his outstanding achievements in head and neck radiology.

For more information on the ASHNR Gold Medal or on the Society in general, contact Business Manager Ken Cammarata at:

American Society of Head and Neck Radiology
2210 Midwest Road, Suite 207
Oak Brook, IL 60523-8205
Phone: 630/574-0220, ext. 226
FAX: 630/574-0661
Email: kcammarata@asnr.org

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