Arteriovenous shunts of the cervical spine: patient demographics, presentation, patterns of high-risk venous drainage, and updated classification.

BACKGROUND: Intracranial dural arteriovenous (AV) fistula classifications focus on presence/absence of retrograde flow in the cortical veins of the brain as this angiographic finding portends a worse prognosis. However, prior categorization systems of AV shunts in the spine do not incorporate these features. We propose an updated classification for spinal shunting lesions that terms any shunting lesion with retrograde flow in any cortical vein of the brain or spinal cord medullary vein as "high risk". To present this classification, we analyzed our center's most recent experience with cervical spine shunting lesions. METHODS: The electronic medical record at our institution was reviewed to identify shunting lesions of the cervical spine and patient demographics/presentation. Comprehensive craniospinal digital subtraction angiograms were evaluated to classify shunt location, type (arteriovenous malformation (AVM) vs arteriovenous fistula (AVF)), and presence of high-risk venous drainage. RESULTS: Some 52 lesions were identified and categorized as pial/dural/epidural/paravertebral AVFs and intramedullary/extraspinal AVMs. Lesions were classified as high risk or not depending on the presence of retrograde flow into at least one vein that directly drains the spinal cord or brain. All patients who presented with either hemorrhage or infarct had underlying high-risk lesions. Additionally, 50% (17/34) of symptomatic patients with high-risk lesions presented with neurological extremity symptoms (OR=10.0, p=0.037) most of which fit a myelopathic pattern. CONCLUSION: We present an updated classification system for shunting lesions of the spine that focuses on high-risk retrograde flow to the brain or spine in addition to anatomical location in order to better inform patient management.

Communication of Incidental Imaging Findings on Inpatient Discharge Summaries After Implementation of Electronic Health Record Notification System.

OBJECTIVES: Inadequate follow-up of incidental imaging findings (IIFs) can result in poor patient outcomes, patient dissatisfaction, and provider malpractice. At our institution, radiologists flag IIFs during report dictation to trigger electronic health record (EHR) notifications to providers and patients. Nurse coordinators directly contact patients or their primary care physicians (PCPs) regarding IIFs if follow-up is not completed within the recommended time frame. Despite these interventions, many patients and their PCPs remain unaware of IIFs. In an effort to improve awareness of IIFs, we aim to investigate communication of IIFs on inpatient discharge summaries after implementation of our EHR notification system. METHODS: Inpatient records with IIFs from 2018 to 2021 were retrospectively reviewed to determine type of IIFs, follow-up recommendations, and mention of IIFs on discharge summaries. Nurse coordinators spoke to patients and providers to determine their awareness of IIFs. RESULTS: Incidental imaging findings were reported in 51% of discharge summaries (711/1383). When nurse coordinators called patients and PCPs regarding IIFs at the time follow-up was due, the patients and PCPs were aware of 79% of IIFs (1096/1383). CONCLUSIONS: With implementation of EHR notifications to providers regarding IIFs, IIFs were included in 51% of discharge summaries. Lack of inclusion of IIFs on discharge summaries could be related to transitions of care within hospitalization, provider alert fatigue, and many diagnostic testing results to distill. These findings demonstrate the need to improve communication of IIFs, possibly via automating mention of IIFs on discharge summaries, and the need for care coordinators to follow up on IIFs.

MR Thermometry during Transcranial MR Imaging-Guided Focused Ultrasound Procedures: A Review.

Interest in transcranial MR imaging-guided focused ultrasound procedures has recently grown. These incisionless procedures enable precise focal ablation of brain tissue using real-time monitoring by MR thermometry. This article will provide an updated review on clinically applicable technical underpinnings and considerations of proton resonance frequency MR thermometry, the most common clinically used MR thermometry sequence.

Middle meningeal artery embolization with polyvinyl alcohol particles in a patient with ophthalmic artery origin from middle meningeal artery: Case report and technical note.

This is a case report of an adult with chronic subdural hematoma (cSDH) who underwent endovascular treatment for middle meningeal artery (MMA) embolization. There was a prominent meningo-ophthalmic branch with an absence of an ophthalmic artery from the internal carotid artery. MMA embolization was performed utilizing particles with no complications and the resolution of the cSDH was within 4 months. This case report demonstrates that despite extreme variant anatomy, MMA embolization with particles is feasible, effective, and safe when appropriate techniques are used.

Automating Structured Results Communication to Expedite Imaging-Directed Care in Spine Oncology.

Cancers frequently metastasize to the spine, where they can cause severe morbidity, including pain, vertebral collapse, and paralysis. Accurate assessment and timely communication of actionable imaging findings are critical. We developed a scoring mechanism to capture the key imaging features of examinations performed to detect and characterize spinal metastases in patients with cancer. An automated system was developed to relay those findings to the institution's spine oncology team to expedite treatment. This report describes the scoring scheme, the automated results communication platform, and initial clinical experience with the system. The scoring system and communication platform enable prompt, imaging-directed care of patients with spinal metastases.

More than just noise: Association of pulsatile tinnitus with anxiety, depression, and reduction of quality of life.

BACKGROUND: While many of the causes of pulsatile tinnitus (PT) are treatable with endovascular approaches, the risks of treatment must be balanced with the risks of the underlying cause and the psychological impact of symptoms on patients. While many physicians have anecdotal experience, the comorbid relationship of depression and anxiety with PT is unknown. The objectives of this study are to quantify the prevalence of depression and anxiety, and, to identify the demographic risk factors for impactful depression and anxiety in patients with PT. METHODS: Subjects recruited from online PT groups filled out secure online questionnaires that included demographic questions, validated Tinnitus Functional Index (TFI) as well as PHQ-9 and GAD-7 questionnaires to assess the prevalence of concurrent depression and anxiety, respectively. RESULTS: Sample included 515 surveys (84% female, 65% unemployed, mean(sd) age = 46.4 years (14.2)). Median symptom duration was 1.9 years. Data showed 46% and 37% of patients with moderate to severe depression and anxiety, respectively. Higher TFI scores were associated with moderate to severe depression (OR 1.07; 95% CI 1.06-1.09, p < 0.001) and anxiety (OR 1.05, 95% CI 1.04-1.06, p < 0.001), with TFI subscores also independently being associated in a univariate analysis. CONCLUSIONS: The prevalence of moderate to severe depression and anxiety in the PT population, which was previously unknown, is estimated in our study to be 46% and 37%, respectively. Significant association of TFI score with increased depression and anxiety scales adds further evidence of the impact of PT on the psychological health of these patients.

Unruptured Arteriovenous Malformations in the Multidetector Computed Tomography Era: Frequency of Detection and Predictable Failures.

OBJECTIVES: While hemorrhage arising from ruptured arteriovenous malformations (AVMs) is usually evident on multidetector non-contrast computed tomography (NCCT), unruptured AVMs can be below the limits of detection. We performed a retrospective review of NCCT of patients with a proven diagnosis of unruptured AVM to determine if advances in CT technology have made them more apparent and what features predict their detection. MATERIAL AND METHODS: Twenty-five NCCTs met inclusion criteria of having angiography or MR proven AVM without hemorrhage, prior surgery, or other CNS disease. Demographic variables, clinical symptoms at presentation, abnormal CT imaging findings, attenuation of the superior sagittal sinus (SSS), and Spetzler-Martin grade of each AVM were recorded. We examined the relationship between AVM detection and SSS attenuation through Kruskal-Wallis test. Exploratory serial logistic principal components analysis was performed including demographics, symptoms, and CT features in the multivariate model. RESULTS: About 80% of the NCCTs showed an abnormality while 20% were normal. All those with an identifiable abnormality showed hyperdensity (80%). Logistic regression models indicate that clustered associations between several CT features, primarily calcifications, hyperdensity, and vascular prominence significantly predicted Spetzler-Martin grade (likelihood ratio 7.7, P = 0.006). SSS attenuation was significantly lower in subjects with occult AVMs when compared to those with CT abnormalities (median 47 vs. 55 HU, P < 0.04). CONCLUSION: Abnormal hyperdensity was evident in all detectable cases (80%) and multiple CT features were predictive of a higher Spetzler-Martin AVM grade. Moreover, SSS attenuation less than 50 HU was significantly correlated with a false-negative NCCT.

Economic impact of selective use of contrast for routine follow-up MRI of patients with multiple sclerosis.

BACKGROUND AND PURPOSE: Imaging and autopsy studies show intracranial gadolinium deposition in patients who have undergone serial contrast-enhanced MRIs. This observation has raised concerns when using contrast administration in patients who receive frequent MRIs. To address this, we implemented a contrast-conditional protocol wherein gadolinium is administered only for multiple sclerosis (MS) patients with imaging evidence of new disease activity on precontrast imaging. In this study, we explore the economic impact of our new MRI protocol. METHODS: We compared scanner time and Medicare reimbursement using our contrast-conditional methodology versus that of prior protocols where all patients received gadolinium. RESULTS: For 422 patients over 4 months, the contrast-conditional protocol amounted to 60% decrease in contrast injection and savings of approximately 20% of MRI scanner time. If the extra scanner time was used for performing MS follow-up MRIs in additional patients, the contrast-conditional protocol would amount to net revenue loss of $21,707 (∼3.7%). CONCLUSIONS: Implementation of a new protocol to limit contrast in MS follow-up MRIs led to a minimal decrease in revenue when controlled for scanner time utilized and is outweighed by other benefits, including substantial decreased gadolinium administration, increased patient comfort, and increased availability of scanner time, which depending on type of studies performed could result in additional financial benefit.

Current Clinical Applications of Intracranial Vessel Wall MR Imaging.

Intracranial vessel wall MR imaging (VWI) is increasingly being used as a valuable adjunct to conventional angiographic imaging techniques. This article will provide an updated review on intracranial VWI protocols and image interpretation. We review VWI technical considerations, describe common VWI imaging features of different intracranial vasculopathies and show illustrative cases. We review the role of VWI for differentiating among steno-occlusive vasculopathies, such as intracranial atherosclerotic plaque, dissections and Moyamoya disease. We also highlight how VWI may be used for the diagnostic work-up and surveillance of patients with vasculitis of the central nervous system and cerebral aneurysms.

Brain MRI Deep Learning and Bayesian Inference System Augments Radiology Resident Performance.

Automated quantitative and probabilistic medical image analysis has the potential to improve the accuracy and efficiency of the radiology workflow. We sought to determine whether AI systems for brain MRI diagnosis could be used as a clinical decision support tool to augment radiologist performance. We utilized previously developed AI systems that combine convolutional neural networks and expert-derived Bayesian networks to distinguish among 50 diagnostic entities on multimodal brain MRIs. We tested whether these systems could augment radiologist performance through an interactive clinical decision support tool known as Adaptive Radiology Interpretation and Education System (ARIES) in 194 test cases. Four radiology residents and three academic neuroradiologists viewed half of the cases unassisted and half with the results of the AI system displayed on ARIES. Diagnostic accuracy of radiologists for top diagnosis (TDx) and top three differential diagnosis (T3DDx) was compared with and without ARIES. Radiology resident performance was significantly better with ARIES for both TDx (55% vs 30%; P < .001) and T3DDx (79% vs 52%; P = 0.002), with the largest improvement for rare diseases (39% increase for T3DDx; P < 0.001). There was no significant difference between attending performance with and without ARIES for TDx (72% vs 69%; P = 0.48) or T3DDx (86% vs 89%; P = 0.39). These findings suggest that a hybrid deep learning and Bayesian inference clinical decision support system has the potential to augment diagnostic accuracy of non-specialists to approach the level of subspecialists for a large array of diseases on brain MRI.

Recurrent massive hemoptysis in a patient with cystic fibrosis: balloon assisted Onyx embolization after bronchial artery coil recanalization.

BACKGROUND: Although not standard of care, Cystic Fibrosis patients with recurrent hemoptysis occasionally have coil embolization of bronchial arteries. In the event of recanalization of these arteries in this specific subset of patients, the presence of indwelling coils makes the prospect of conventional particle embolization more difficult, preventing both adequate catheterization of the coiled segment and reflux of the particles. CASE PRESENTATION: In this report, we describe a case of bronchial artery embolization of a complex Cystic Fibrosis patient with massive hemoptysis from recanalized coiled bronchial arteries utilizing a Scepter Balloon Catheter® (Microvention Terumo, USA) in administration of the liquid embolic agent Onyx® (Medtronic, USA). CONCLUSIONS: The Scepter occlusion balloon catheter allowed for careful placement of the tip within the interstices of the pre-existing coils, allowing for Onyx injection directly into the coil mass without reflux, reconfirming the benefits of Onyx embolization in bronchial artery embolization and providing evidence that the Scepter occlusion balloon catheter should be added to the armamentarium of devices used in complex bronchial artery embolization for Cystic Fibrosis patients with massive hemoptysis.

An Initiative to Reduce Unnecessary Gadolinium-Based Contrast in Multiple Sclerosis Patients.

OBJECTIVE: Patients with multiple sclerosis (MS) routinely undergo serial contrast-enhanced MRIs. Given concerns regarding tissue deposition of gadolinium-based contrast agents (GBCAs) and evidence that enhancement of lesions is only seen in patients with new disease activity on noncontrast imaging, we set out to implement a prospective quality improvement project whereby intravenous contrast would be reserved only for patients with evidence of new disease activity on noncontrast images. METHODS: To prospectively implement such a protocol, we leveraged our in-house computer-assisted detection (CAD) software and 3-D laboratory radiology technologists to perform real-time preliminary assessments of the CAD-processed T2 fluid attenuated inversion recovery (FLAIR) noncontrast images as a basis for deciding whether to inject contrast. Before implementation, we held multidisciplinary meetings with neurology, neuroradiology, and MR technologists and distributed surveys to objectively assess opinions and obstacles to clinical implementation. We evaluated reduction in GBCA utilization and technologist performance relative to final neuroradiologist interpretations. RESULTS: During a 2-month trial period, 153 patients were imaged under the new protocol. Technologists using the CAD software were able to identify patients with new or enlarging lesions on FLAIR images with 95% accuracy and 97% negative predictive value relative to final neuroradiologist interpretations, which allowed us to avoid the use of contrast and additional imaging sequences in 87% of patients. DISCUSSION: A multidisciplinary effort to implement a quality improvement project to limit contrast in MS patients receiving follow-up MRIs allowed for improved safety and cost by targeting patients that would benefit from the use of intravenous contrast in real-time.

BDNF Val66Met polymorphism tunes frontolimbic circuitry during affective contextual learning.

Adaptive learning impairments are common in cognitive and behavioral disorders, but the neurogenetic mechanisms supporting human affective learning are poorly understood. We designed a higher-order contextual learning task in which healthy participants genotyped for the Val66Met polymorphism of the brain derived neurotropic factor gene (BDNF) were required to choose the member of a picture pair most congruent with the emotion in a previously-viewed facial expression video in order to produce an advantageous monetary outcome. Functional magnetic resonance imaging (fMRI) identified frontolimbic blood oxygenation level dependent (BOLD) reactivity that was associated with BDNF Val66Met genotype during all three phases of the learning task: aversive and reward-predictive learning, contextually-challenging decision-making, and choice-related monetary loss-avoidance and gain outcomes. Relative to Val homozygotes, Met carriers showed attenuated ventromedial prefrontal response to predictive affective cues, dorsolateral prefrontal signaling that depended on decision difficulty, and enhanced ventromedial prefrontal reactivity that was specific to loss-avoidance. These findings indicate that the BDNF Val66Met polymorphism is associated with functional tuning of behaviorally-relevant frontolimbic circuitry, particularly involving the ventromedial prefrontal cortex, during higher-order learning.

Comparison of non-invasive MRI measurements of cerebral blood flow in a large multisite cohort.

UNLABELLED: Arterial spin labeling and phase contrast magnetic resonance imaging provide independent non-invasive methods for measuring cerebral blood flow. We compared global cerebral blood flow measurements obtained using pseudo-continuous arterial spin labeling and phase contrast in 436 middle-aged subjects acquired at two sites in the NHLBI CARDIA multisite study. Cerebral blood flow measured by phase contrast (CBFPC: 55.76 ± 12.05 ml/100 g/min) was systematically higher (p < 0.001) and more variable than cerebral blood flow measured by pseudo-continuous arterial spin labeling (CBFPCASL: 47.70 ± 9.75). The correlation between global cerebral blood flow values obtained from the two modalities was 0.59 (p < 0.001), explaining less than half of the observed variance in cerebral blood flow estimates. Well-established correlations of global cerebral blood flow with age and sex were similarly observed in both CBFPCASL and CBFPC CBFPC also demonstrated statistically significant site differences, whereas no such differences were observed in CBFPCASL No consistent velocity-dependent effects on pseudo-continuous arterial spin labeling were observed, suggesting that pseudo-continuous labeling efficiency does not vary substantially across typical adult carotid and vertebral velocities, as has previously been suggested. CONCLUSIONS: Although CBFPCASL and CBFPC values show substantial similarity across the entire cohort, these data do not support calibration of CBFPCASL using CBFPC in individual subjects. The wide-ranging cerebral blood flow values obtained by both methods suggest that cerebral blood flow values are highly variable in the general population.