Fellows’ Journal Club Recap: Quantitative MRI for automated CSF measurements in hydrocephalus evaluation

Please check out the accompanying podcast of this blog post (discussion of this article begins at 15:07)

Current evaluation of idiopathic normal pressure hydrocephalus (NPH) depends predominantly on clinical examination, although there are some imaging features, including enlarged lateral ventricles, bowing of the corpus callosum, and enlargement of the sylvian fissures out of proportion to the other cerebrospinal fluid (CSF) spaces. However, these imaging features are largely subjective, depending heavily on the opinion of the interpreting physician.

In this paper, the authors sought to improve evaluation of idiopathic normal pressure hydrocephalus by developing an automated method for calculating CSF volumes within the calvarium, including volume in the lateral ventricles, total intracranial CSF volume, and brain parenchymal fraction. They compared this to manual segmentation and measured volumes in patients being evaluated for NPH both before and after a large volume lumbar puncture.

The results demonstrate that the method was useful for measuring CSF volumes, with good correlation between the automatic method and manual segmentation. Furthermore, the ventricular volume decreased after the large volume lumbar puncture, with the difference most pronounced 30 minutes after the procedure and gradually returning towards baseline over a 24 hour period. The method was also useful for calculating brain parenchymal fraction, which cannot be easily calculated manually.

These findings are interesting for several reasons. First, it is valuable to know that the automated method is reliable when compared to manual measurements and can be used to see how much change there is in the CSF volumes of patients being evaluated for normal pressure hydrocephalus. It is a natural extension of this study to see what the clinical outcomes were for these patients, and potentially know if there was a difference in patient that were ultimately diagnosed with NPH. Ideally, these values could potentially predict which …

Emergent Endovascular Management of Long-Segment and Flow-Limiting Carotid Artery Dissections in Acute Ischemic Stroke Intervention with Multiple Tandem Stents

Editor’s Choice

The authors investigated the role of emergent endovascular stenting of long-segment carotid dissections in the acute ischemic stroke setting in 15 patients. They specifically evaluated long-segment carotid dissections requiring stent reconstruction with multiple tandem stents (≥ 3 stents) and presenting with acute (<12 hours) ischemic stroke symptoms (NIHSS score, ≥ 4). Carotid stent reconstruction was successful in all patients with no residual stenosis or flow limitation. Nine patients (60%) harbored intracranial occlusions, and 6 patients (40%) required intra-arterial thrombolysis/thrombectomy, achieving 100% TICI 2b–3 reperfusion. They conclude that emergent stent reconstruction of long-segment and flow-limiting carotid dissections in acute ischemic stroke intervention is safe and effective, with favorable clinical outcomes.

Broken Bones: The Radiological Atlas of Fractures and Dislocations, 2nd Edition

Chew FS, Maldijan C, Mulcahy H. Broken Bones: The Radiological Atlas of Fractures and Dislocations. 2nd ed. Cambridge University Press; 2016; 406 pp; 1101 ill; $89.99

Chew et al cover

This is an atlas showing fractures and dislocations of many areas of the body. Two chapters (54 pages) deal with cervical and thoracolumbar spine injuries. It seems a bit unusual to have an atlas entitled Broken Bones and not include fractures of the skull, skull base, temporal bones, and facial bones. Are these not bones? Anyway, the spine imaging and the descriptions are adequate for the intended purpose of the book; however, when the authors describe entities such as atlantooccipital dislocations and mention associated tectorial membrane disruption, they fail to show that “disruption” with MR imaging. One recognizes that in modern-day spine trauma imaging, an analysis of the ligaments, in addition to bone imaging, is crucial. A neuroradiologist might consider the analysis in this book of spine trauma and acute fractures incomplete, even though some MRs are illustrated. There is not a sufficiently detailed analysis of ligamentous injuries associated with those fractures/dislocations to significantly advance our ability to precisely image these patients.

This book would be of limited interest to a neuroradiologist.…

Intracranial Arteriovenous Shunting: Detection with Arterial Spin-Labeling and Susceptibility-Weighted Imaging Combined

Fellows’ Journal Club

Ninety-two consecutive patients with a known (n = 24) or suspected arteriovenous shunting (n = 68) underwent DSA and brain MR imaging, including arterial spin-labeling/SWI and conventional angiographic MR imaging. DSA showed arteriovenous shunting in 63 of the 92 patients. Interobserver agreement was excellent. In 5 patients, arterial spin-labeling/SWI correctly detected arteriovenous shunting, while the conventional angiographic MR imaging did not. The authors conclude that the combined use of arterial spin-labeling and SWI may be an alternative to contrast-enhanced MRA for the detection of intracranial arteriovenous shunting.


Figure 3 from paper
A 60-year-old patient with a right paracentral AVM. ASL raw data (A) demonstrates a strong hypersignal at the anterior part of the right paracentral region (A, arrow). The slight venous hypersignal related to AVS was initially missed by the blinded readers by using SWI alone (B, arrowhead) but was correctly identified by using ASL and SWI combined (C, ASL/SWI merged image, arrow). Findings of time-resolved 4D contrast-enhanced MRA (D) were considered negative by the blinded readers. DSA reveals a small pial AVM in the right paracentral region (E, arrow).


Arterial spin-labeling and susceptibility-weighted imaging are 2 MR imaging techniques that do not require gadolinium. The study aimed to assess the accuracy of arterial spin-labeling and SWI combined for detecting intracranial arteriovenous shunting in comparison with conventional MR imaging.


Ninety-two consecutive patients with a known (n = 24) or suspected arteriovenous shunting (n = 68) underwent digital subtraction angiography and brain MR imaging, including arterial spin-labeling/SWI and conventional angiographic MR imaging (3D TOF, 4D time-resolved, and 3D contrast-enhanced MRA). Arterial spin-labeling/SWI and conventional MR imaging were reviewed separately in a randomized order by 2 blinded radiologists who judged the presence or absence of arteriovenous shunting. The accuracy of arterial spin-labeling/SWI for the detection of

AOSpine Masters Series, Volume 7: Spinal Cord Injury and Regeneration

Vialle LR, ed. Fehlings MG, Weidner N, guest eds. AOSpine Masters Series: Spinal Cord Injury and Regeneration. Vol 7. Thieme; 2016; 225 pp; 50 ill; $119.99

Vialle cover

The latest volume in the AOSpine Masters Series deals with spinal cord injury and regeneration. It should be a publication of interest to all neuroradiologists because it contains information that is not dealt with in common textbooks about spine radiology. The guest editors, Drs. Fehlings and Weidner, along with 25 contributors, address issues at the core of short-term and long-term care of patients with spinal cord injuries. The chapter on MR imaging covers important clinical/imaging correlates such as predicting outcomes based on MR and describing and annotating with technical factors the utility of advanced imaging protocol and more routinely employed MR protocols. The following chapters address topics other than pure imaging—such as the timing of surgery in acute spinal cord injury, the value of medical treatment, the potential role of neuroprotective schemes, materials used in attempts at neural repair and regeneration, the potential role of stem cell transplantation in SCI, and rehabilitative strategies for patients with spinal injuries—but are nonetheless of interest. Besides, the concepts of primary and secondary injury and the means of cord reconstitution are related to the very real, everyday issue of timing of possible surgery in acute SCI. The emphasis on the diminished effect of secondary injury (like vascular comprise/interruption) when decompressive surgery is performed within 24 hours posttrauma on a severely injured cord is summarized and discussed. Spinal Cord Injury and Regeneration is an important volume in this Spine Masters Series. It should appeal to all those who work closely with spine trauma surgeons, particularly in facilities where there is a sizeable rehab facility.…

Journal Scan – This Month in Other Journals, January 2017

Akoudad S, Wolters FJ, Viswanathan A, et al. Association of Cerebral Microbleeds With Cognitive Decline and Dementia. JAMA Neurol. 2016;73(8):934. doi:10.1001/jamaneurol.2016.1017.

The authors wanted to determine whether microbleed count and location were associated with an increased risk for cognitive impairment and dementia. They evaluated a prospective population-based study set in the general community, and assessed the presence, number, and location of microbleeds at baseline (August 2005 to December 2011) on brain MRI in 4841 participants 45 years or older. Trained research physicians, blinded to clinical data, reviewed the MRs. Cerebral microbleeds were defined as small, round to ovoid areas of focal signal loss on T2- weighted images. Participants underwent neuropsychological testing at 2 time points approximately 6 years apart, and were also followed up for incident dementia. 3257 participants underwent baseline and follow-up cognitive testing. Microbleed prevalence was 15.3%. The presence of more than 4 microbleeds was associated with cognitive decline. The presence of microbleeds was associated with an increased risk for dementia after adjustment for age, sex, and educational level, including Alzheimer dementia.

The strengths of this study, according to the authors, is the longitudinal population based design with a large sample size, the use of an extensive neuropsychological test battery, and the virtually complete screening for incident dementia. Limitations include multiple statistical tests, increasing the chance of type I errors. Second, selection bias may have influenced the results, because healthier people without subjective memory complaints were more likely to receive follow-up cognitive testing. Most importantly perhaps, the microbleed number may not reflect the true biological number because microbleed detection strongly depends on technical imaging methods used. T2W images were used, and as we know, SWI is far superior for the detection of these lesions.

4 Tables

Manoso MW, Moore TA, Agel J, Bellabarba C, Bransford RJ. Floating

ASNR and Radiopaedia.org Seek Entries for Annual Meeting Case of the Day Brain Category

radiopaedia logo

ASNR and Radiopaedia.org are again collaborating to give you the opportunity to submit an adult brain case to ASNR 2017 Case of the Day.

Each day during the ASNR 55th Annual Meeting (April 22 – 27) in Long Beach, California, a brain case is part of the official Case of the Day program. This has traditionally been by invitation only, but like last year, one of the cases will be chosen from cases you submit to Radiopaedia.org.

In addition to one ASNR 2017 case of the day winner, Radiopaedia.org will also be showcasing a number of the best submissions as Radiopaedia.org ‘cases of the day’ on its home page and through social media!


There are a number of prizes available:


The winner gets two awesome prizes:

  • Standard Room for two (2) nights at the Hyatt Regency Long Beach or Westin Long Beach Hotel (based on availability) – total value is $522 with taxes; complimentary daily standard in-room WiFi and daily health club access. The prize is courtesy of the American Society of Neuroradiology (ASNR). The provided complimentary housing reservation can be used at any point during the ASNR 55th Annual Meeting dates from Friday, Apr. 20 through Friday, Apr. 27. If you are not planning to attend the conference, then you can transfer this prize to another colleague attending the meeting in Long Beach.) If you have questions, please contact, Ashley Boser at 630-574-0220, ext. 231, or email aboser@asnr.org.


The Radiopaedia.org editorial team will also be selecting a runner-up who will receive 12-month online access to our two hugely popular neuroradiology …

Applications Available for the 2017 Women in Neuroradiology Leadership Award: Deadline March 1


In 2012, the Foundation of the American Society of Neuroradiology (Foundation), American College of Radiology (ACR), and American Association for Women Radiologists (AAWR) established an award to provide leadership opportunities for women in neuroradiology and/or radiology overall. Since neuroradiologists must be leaders in the field, this award is for mid-career women with demonstrated experience and promise for leadership in neuroradiology and/or radiology overall. The objectives are to provide the award recipient with additional skills and insights to enhance opportunities for advancement.

The award recipient will receive funding to cover tuition and transportation costs to attend the ACR 2017 Radiology Leadership Institute Summit in conjunction with Babson College in Wellesley, Massachusetts, to be held at the Babson Executive Conference Center, Sept. 7-10, 2017. All other expenditures will be at the expense of the award recipient.

Eligible applicants must have a MD degree or DO degree, plus subspecialty certification in neuroradiology, or its equivalent for international candidates. Applicants must have demonstrated experience and promise for leadership in neuroradiology/radiology, and must be a member of ASNR, ACR, and AAWR prior to Jan. 1, 2017. Strong consideration will be given to applicants from practices and institutions that show a commitment to the applicant’s career development.

The deadline for receipt of applications and required attachments is March 1, 2017; late applications will not be accepted. Applications must be sent electronically, as indicated in the instructions.

Click here for the Prospectus.

Click here for the Application.

ASNR 55th Annual Meeting, April 22-27, 2017

2017 meeting logo

ASNR 55th Annual Meeting, April 22 – 27, 2017
Long Beach Convention and Entertainment Center
Long Beach, California

Join us for The Foundation of the ASNR Symposium 2017 and the ASNR 55th Annual Meeting! Learn about the clinical, scientific, academic, socioeconomic and other practice-related issues challenging neuroradiologists today and anticipated ahead.

ASNR Advance Registration and Housing deadline: Friday, March 10, 2017

Register today and book your housing!

Highlights of The Foundation of the ASNR Symposium 2017 and the ASNR 55th Annual Meeting:

The Foundation of the ASNR Symposium 2017, beginning at 10:30AM Saturday and 8:00AM Sunday, will focus on Discovery and Didactics, featuring “What’s New” and “What’s Next?” for neuroradiology.  Immediately following the Symposium, join us for the closing reception (included in your registration fee) on Sunday, April 23 from 6:00pm – 7:15pm.  Enjoy beach background music featuring Woodie and the Longboards – performing hit music from the 50s to the 80s.

The annual meeting will continue from Monday, April 24 – Thursday, April 27, focusing on Diagnosis and Delivery, how to keep up with the challenges and changes of healthcare reform, maintaining quality, considering cost, and teaching best practices.  The heart of the meeting will include invited lectures, original presentations, scientific posters, parallel paper sessions, and educational exhibits. Two special sessions this year – “Taking the Lead!” with CEO perspectives and “Meet the Pres”.  More exciting information to follow.  Don’t miss the Annual Meeting Reception with Technical Exhibitors, including a night of mingling and jazz music from 6:30pm – 8:00pm on Monday, April 24.

  • Twelve (12) Self-Assessment Module (SAM) Sessions Programming throughout the week
  • Earn up to 43.50 AMA PRA Category 1 Credits™.
  • Need to complete evaluations in order to receive CME credits but don’t have time to stop by the CME Pavilion?  You

Complications in Vascular Interventional Therapy: Case-Based Solutions

Mueller-Huelsbeck S, Jahnke T. Complications in Vascular Interventional Therapy: Case-Based Solutions. Thieme; 2016; 280 pp; 540 ill; $159.99

Mueller-Huelsbeck and Jahnke cover

Steve Harvey, the entertainer who mistakenly crowned the wrong woman as Miss Universe 2015, once said, “Failure is a great teacher, and I think when you make mistakes and you recover from them and you treat them as valuable learning experiences, then you’ve got something to share.” While mistakes in medicine are never as laughable as his, this quote underscores one of the most powerful teachers in medicine: mistakes. Winston Churchill said, “All men make mistakes, but only wise men learn from their mistakes.” While local morbidity and mortality conferences allow groups to learn from one individual’s mistakes, fear of legal action or professional embarrassment engenders reticence to present and publish our own mistakes on a national or international stage. However, physicians everywhere know the value of learning from complications. For example, by popular demand, a local morbidity and mortality conference in Austria has morphed into a major international conference (International Conference on Complications in Interventional Radiology sponsored by the Cardiovascular and Interventional Radiology Society of Europe, or CIRSE).

This book presents a total of 106 cases (illustrated with 540 images). Each case provides patient history, initial/intended treatment, problems encountered, a list of possible bailouts of the complication, an explanation of which route was chosen and how it was carried out, and finally, an analysis of the complication. What makes the cases such good learning experiences is the fact that, despite many awful-looking initial complications, only one of the patients died (but likely because of his underlying condition rather than the complication). Therefore, in reading this book, one can learn of the plethora of endovascular complications that exist, and hopefully learn how to prevent their occurrence, or at the very least, …