A Spinal Cavernous Malformation in Multiple Cerebral Cavernous Venous Malformations Syndrome.

Teaching Point: In patients with familial multiple cavernous malformation syndrome with acute focal neurological deficit, a symptomatic spinal cavernous malformation must be included in the differential diagnosis.

MRI of Nitrous Oxide-Related Subacute Cervical Myelopathy.

Teaching point: Myelopathy may occur following nitrous oxide (N2O) misuse, even if vitamin B12-levels are normal. The typical appearance on magnetic resonance imaging (MRI), is an inverted V-shaped T2-weighted hypersignal in the dorsal columns of the cervicothoracic spinal cord.

Multislice cardiac computed tomography in symptomatic middle-aged women.

OBJECTIVE: To assess the accuracy of multislice cardiac computed tomography (MSCT) for detection of significant coronary artery disease (CAD) in middle-aged symptomatic women. METHODS: We included 70 women (51+/-8 years) with complaints of chest pain or dyspnea, and an abnormal maximum exercise electrocardiogram (ECG) (8.6+/-1.4 metabolic equivalents). All had a MSCT using a 16 detector rows scanner, and coronary arteriography (CA). Blinded results of the two modalities were compared using a segment, vessel, and patient-based analysis. RESULTS: On MSCT 36% had normal coronaries, 24% had significant CAD requiring revascularization, and the remainder had mild CAD. MSCT had reasonably high diagnostic accuracy at segment level (negative predictive value of 95%, positive predictive value 81%, specificity 99%, and sensitivity 50%), regarding single or multivessel CAD when both nonassessable and assessable segments were included in the analysis. The agreement between the segments comparing MSCT and CA for significant CAD was excellent at 98% (kappa value 0.89). CONCLUSIONS: In this cohort of middle-aged symptomatic women with an abnormal stress test, 24% had significant CAD requiring intervention. MSCT was highly accurate in diagnosing significant CAD with an excellent negative predictive value.

Imaging in spinal trauma.

Because it may cause paralysis, injury to the spine is one of the most feared traumas, and spinal cord injury is a major cause of disability. In the USA approximately 10,000 traumatic cervical spine fractures and 4000 traumatic thoracolumbar fractures are diagnosed each year. Although the number of individuals sustaining paralysis is far less than those with moderate or severe brain injury, the socioeconomic costs are significant. Since most of the spinal trauma patients survive their injuries, almost one out of 1000 inhabitants in the USA are currently being cared for partial or complete paralysis. Little controversy exists regarding the need for accurate and emergent imaging assessment of the traumatized spine in order to evaluate spinal stability and integrity of neural elements. Because clinicians fear missing occult spine injuries, they obtain radiographs for nearly all patients who present with blunt trauma. We are influenced on one side by fear of litigation and the possible devastating medical, psychologic and financial consequences of cervical spine injury, and on the other side by pressure to reduce health care costs. A set of clinical and/or anamnestic criteria, however, can be very useful in identifying patients who have an extremely low probability of injury and who consequently have no need for imaging studies. Multidetector (or multislice) computed tomography (MDCT) is the preferred primary imaging modality in blunt spinal trauma patients who do need imaging. Not only is CT more accurate in diagnosing spinal injury, it also reduces imaging time and patient manipulation. Evidence-based research has established that MDCT improves patient outcome and saves money in comparison to plain film. This review discusses the use, advantages and disadvantages of the different imaging techniques used in spinal trauma patients and the criteria used in selecting patients who do not need imaging. Finally an overview of different types of spinal injuries is given.

MR angiography of the intracranial vessels: technical aspects and clinical applications.

Evaluation of the intracranial circulation provides valuable information in the diagnosis and prognosis of various intracranial abnormalities and may influence patient management. Technical advances in magnetic resonance angiography (MRA) have improved the accuracy of this technique in various clinical situations, such as aneurysms, arterial and venous steno-occlusive diseases, vascular malformations, inflammatory arterial diseases, preoperative assessment of the patency of dural sinuses, and congenital vascular abnormalities. In many centers, MRA has replaced conventional digital subtraction angiography in screening for intracranial vascular disease, because of its non-invasive and non-ionizing character. Several MRA techniques have been developed for the imaging of the intracranial vascular system, such as time-of-flight MRA (TOF MRA), phase-contrast MRA (PC MRA), and more recently contrast-enhanced MRA (CE MRA). In the evaluation of steno-occlusive disease, the three-dimensional (3D) TOF-MRA technique is recommended for arterial evaluation, and the 2D TOF or 2D PC-MRA technique for venous evaluation. For the evaluation of aneurysms and arteriovenous malformations (AVMs), we recommend the 3D CE-MRA technique, especially dynamic sequences in case of AVM. In this review, the technical aspects, limitations, and optimization of these MRA techniques will be discussed together with their indications in intracranial disease.

Cortical hypoxic-ischemic brain damage in shaken-baby (shaken impact) syndrome: value of diffusion-weighted MRI.

Shaken-baby syndrome (SBS) is a type of child abuse caused by violent shaking of an infant, with or without impact, and characterized by subdural hematomas, retinal hemorrhages, and occult bone fractures. Parenchymal brain lesions in SBS may be missed or underestimated on CT scans, but can be detected at an earlier stage with diffusion-weighted MRI (DW-MRI) as areas of restricted diffusion. We demonstrate the value of DW-MRI in a 2-month-old baby boy with suspected SBS. The pattern of diffusion abnormalities indicates that the neuropathology of parenchymal lesions in SBS is due to hypoxic-ischemic brain injuries, and not to diffuse axonal injury.

A brief review of parallel magnetic resonance imaging.

Since the 1980s, the implementation of fast imaging methods and dedicated hardware for MRI scanners has reduced the image acquisition time from nearly an hour down to several seconds and has therefore enabled a widespread use of MRI in clinical diagnosis. Since this development, the greatest incremental gain in imaging speed has been provided by the development of parallel MRI (pMRI) techniques in late 1990s. Within the past 2 years, parallel imaging methods have become commercially available, which means that pMRI is now available for broad clinical use. In the clinical routine, virtually any MRI method can be enhanced by pMRI, allowing faster image acquisitions without any increased gradient system performance. In some cases pMRI can even result in a significant gain in image quality due to this faster acquisition. In this review article, the advantages and the disadvantages of pMRI in clinical applications are discussed and examples from many different daily applications are given.

Brainstem hemorrhage in descending transtentorial herniation (Duret hemorrhage).

OBJECTIVES: To review clinical and radiological findings in patients with Duret hemorrhages and to discuss the pathophysiology and differential diagnosis of these lesions. PATIENTS AND METHODS: We reviewed the case records of four patients with Duret hemorrhages who had been admitted to the neurological intensive care unit with supratentorial mass lesions. RESULTS: Descending transtentorial and subfalcine herniations were present in all cases. Three patients were admitted with acute subdural hematoma and one with intraparenchymal hemorrhage. Computed tomography revealed the presence of blood in the mesencephalon and upper pons. Three patients died; one survived with severe disabilities. DISCUSSION: Duret hemorrhages are typically located in the ventral and paramedian aspects of the upper brainstem (mesencephalon and pons). The pathophysiology of Duret hemorrhage remains under debate: arterial origin (stretching and laceration of pontine perforating branches of the basilar artery), versus venous origin (thrombosis and venous infarction). Multifactorial causation seems likely. CONCLUSION: Duret hemorrhages are delayed, secondary brainstem hemorrhages. They occur in craniocerebral trauma victims with rapidly evolving descending transtentorial herniation. Diagnosis is made on computed tomography of the brain. In most cases the outcome is fatal. On the basis of our observations we believe that arterial hypertension and advanced age are risk factors for the development of Duret hemorrhage.