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Background and Purpose: Spontaneous intracranial hypotension (SIH) is caused by spinal cerebrospinal fluid (CSF) leaks. This study assessed whether the certainty and/or multifocality of CSF leaks is associated with the severity of intracranial sequelae of SIH. Materials and Methods: A retrospective review was completed of patients with suspected SIH that underwent digital subtraction myelogram (DSM) preceded by brain MRI. DSMs were evaluated for the presence or absence of a CSF leak, categorized both as positive/negative/indeterminate and single versus multifocal. Brain MRIs were assessed for intracranial sequelae of SIH based on two probabilistic scoring systems (Dobrocky and Mayo methods). For each system, both an absolute "numerical" score (based on tabulation of findings) and "categorized" score (classification of probability) were tabulated. Results: 174 patients were included; 113 (64.9%) were female, average age 52.0 ± 14.3 years. One or more definite leaks were noted in 76 (43.7%) patients; an indeterminate leak was noted in 22 (12.6%) patients. 16 (16.3%) had multiple leaks. There was no significant difference in the severity of intracranial findings between patients with a single versus multiple leaks (p values ranged from.36 to.70 using categorized scores and 0.22–0.99 for numerical scores). Definite leaks were more likely to have both higher categorized intracranial scores (Mayo p =.0008, Dobrocky p =.006) and numerical scores (p =.0002 for Mayo and p =.006 for Dobrocky). Conclusions: Certainty of a CSF leak on diagnostic imaging is associated with severity of intracranial sequelae of SIH, with definite leaks having significantly more intracranial findings than indeterminate leaks. Multifocal leaks do not cause greater intracranial abnormalities. [ABSTRACT FROM AUTHOR]

CT myelography has been traditionally used to evaluate post-operative paraspinal fluid collections to discern CSF leaking into a pseudomeningocele versus a contained seroma. Rather than performing a lumbar puncture and injecting intrathecal contrast for myelography, we present the first report of direct contrast injection into a post-operative paraspinal pseudomeningocele for CSF leak confirmation and localization. This is a simple procedure that has several advantages over a conventional CT myelogram for the evaluation of post-operative paraspinal fluid collections. [ABSTRACT FROM AUTHOR]

Purpose: Imaging changes in the pituitary volume during pregnancy remains scantly researched. This study set out to assess the differences in total, anterior, and posterior pituitary volume in pregnant women compared to nulliparous and post-partum women. Materials and Methods: A retrospective review was completed of women that had undergone MRI imaging of the brain. Patients were divided into three cohorts: pregnant, nulliparous, and post-partum (defined as being within 12 months of delivery). Anterior and posterior pituitary volumes were manually measured. Results: 171 patients were included, of which 68 were pregnant, 52 were post-partum, and 51 were nulliparous. The average anterior (621.0 ± 171.6 mm3) and total (705.4 ± 172.2 mm3) pituitary volumes were significantly larger in pregnant patients than nulliparous women (522.6 ± 159.8 mm3 and 624.5 ± 163.7 mm3, respectively) (p =.002 and p =.01, respectively). The posterior pituitary volume was significantly smaller in pregnant women (84.4 ± 32.9 mm3) compared to both post-partum (101.2 ± 42.0 mm3) and nulliparous (102.0 ± 46.1 mm3) women (p =.02 for both). Conclusions: The anterior and total pituitary volumes are significantly larger during pregnancy persisting into the post-partum period. The posterior pituitary volume, conversely, decreases during pregnancy, and returns to its normal size in the post-partum period. [ABSTRACT FROM AUTHOR]

Cauda Equina Neuroendocrine Tumors (CE-NET), previously referred to as paragangliomas are a rare subset of spinal tumors, with limited data on imaging. Herein, we present a retrospective review of clinical and imaging findings of CE-NETs in ten patients who were evaluated at our institution over the past two decades. All patients had well-defined intradural lesions in the lumbar spine which demonstrated slow growth. A review of imaging findings revealed the presence of an eccentric vascular pedicle along the dorsal aspect of the tumor in 8 of the 10 patients (eccentric vessel sign), a distinctive finding that has not previously been reported with this tumor and may help improve the accuracy of imaging-based diagnosis. In all cases, a gross-total resection was performed, with resolution of symptoms in most of the cases. [ABSTRACT FROM AUTHOR]

Introduction: Spontaneous intracranial hypotension (SIH) caused by a spinal cerebrospinal fluid (CSF) leak classically presents with orthostatic headache. Digital subtraction myelography (DSM) has a well-established diagnostic yield in the absence of extradural spinal collection. At our institution, DSM is followed by lateral decubitus CT myelogram (LDCTM) in the same decubitus position to increase diagnostic yield of the combined study. We evaluated the incremental diagnostic yield of LDCTM following negative DSM and reviewed patient outcomes. Methods: Retrospective review of consecutive DSMs with subsequent LDCTM from April 2019 to March 2021 was performed. Combined reports were reviewed, and studies with positive DSMs were excluded. Of the exams with negative DSM, only studies with LDCTM reports identifying potential leak site were included. Interventions and follow-up clinical notes were reviewed to assess symptoms improvement following treatment. Results: Of the 83 patients with negative DSMs, 11 (13.2%) had positive leak findings on LDCTMs, and 21 (25.3%) were equivocal. Of 11 positive LDCTMs, 6 leaks were nerve sheath tears (NSTs) and 5 were CSF-venous fistulas (CVFs). 10/11 (90.9%) had intervention and follow-up, with 9/10 (90%) having positive clinical outcome. Of the 21 equivocal LDCTM patients (19 CVFs and 2 NSTs), 15 (71.4%) had interventions and follow-up, with 3/15 (20.0%) with positive clinical outcomes. Conclusion: LDCTM following negative DSM has an incremental diagnostic yield up to 38.6%, with up to 14.5% of positive patient outcomes following treatment. LDCTM should be considered after DSM to maximize diagnostic yield of the combined exam. [ABSTRACT FROM AUTHOR]

Background and purpose: Radiation therapy is an important component of treatment in patients with malignancies of the head, neck, and spine. However, radiation to these regions has well-known potential side effects, many of which can be encountered on imaging. In this manuscript, we review selected radiographic manifestations of therapeutic radiation to the head, neck, and spine that may be encountered in the practice of radiology. Methods: We conducted an extensive literature review of known complications of radiation therapy in the head, neck, and spine. We excluded intracranial and pulmonary radiation effects from our search. We selected complications that had salient, recognizable imaging findings. We searched our imaging database for illustrative examples of these complications. Results: Based on our initial literature search and imaging database review, we selected cases of radiation-induced tumors, radiation tissue necrosis (osteoradionecrosis and soft tissue necrosis), carotid stenosis and blowout secondary to radiation, enlarging thyroglossal duct cysts, radiation myelopathy, and radiation-induced vertebral compression fractures. Conclusions: We describe the clinical and imaging features of selected sequelae of radiation therapy to the head, neck, and spine, with a focus on those with characteristic imaging findings that can be instrumental in helping to make the diagnosis. Knowledge of these entities and their imaging findings is crucial for accurate diagnosis. Not only do radiologists play a key role in early detection of these entities, but many of these entities can be misinterpreted if one is not familiar with them. [ABSTRACT FROM AUTHOR]

Superficial siderosis refers to hemosiderin deposition along the pial surface of the brain and spinal cord. It results from chronic and repetitive low-grade bleeding into the subarachnoid space. Dural tears are a common cause of superficial siderosis. Although such tears typically occur in the spine, dural tears can also occur in the posterior fossa. In many cases, posterior fossa dural tears are iatrogenic, and patients may present with neuroimaging evidence of postoperative pseudomeningoceles. We present a case of superficial siderosis caused by a persistent posterior fossa dural leak. The patient presented with superficial siderosis 30 years after a Chiari I malformation repair. A pinhole-sized dural tear was identified preoperatively using computed tomography cisternography. The dural defect was successfully repaired. An additional small tear that was not seen on imaging was also identified at surgery and successfully repaired. [ABSTRACT FROM AUTHOR]

Peripheral neuropathies are a recognized complication of labor in the post-partum period. Herein, we describe an uncommon presentation of sciatic mononeuropathy due to ischiofemoral impingement during labor. A 29-year-old, gravida 4 para 2, female presented post-partum with acute left lower limb paresthesia and left foot drop, following spontaneous vaginal delivery of twins. Neurological examination demonstrated no activation of the left sciatic-innervated muscles and sensory loss in the same distribution. Electromyography (EMG) demonstrated an acute complete left sciatic mononeuropathy. MRI of the lumbosacral plexus and sciatic nerve showed a narrowed quadratus femoris space with mild edema of the muscle, consistent with ischiofemoral impingement syndrome. In addition, there was flattening of the sciatic nerve as it passed through the ischiofemoral space. She was treated conservatively, and at 7-month follow-up, there was marked improvement in muscle strength with ongoing sensory impairment. Repeat EMG demonstrated reinnervation in all sciatic-innervated muscles. This case highlights the risk of a sciatic mononeuropathy secondary to ischiofemoral impingement in the peripartum setting. Future studies are needed to determine if women with a narrow ischiofemoral space at baseline are at increased risk for peripheral nerve injury during labor. [ABSTRACT FROM AUTHOR]

Torus mandibularis is a benign osseous overgrowth arising from the lingual surface of the mandible. It is a common, incidental finding on imaging due to its relatively high prevalence. In the majority of cases, mandibular tori are asymptomatic. We report a novel presentation of a giant torus mandibularis causing bilateral obstruction of the submandibular ducts and consequent sialadenitis. Our patient presented with progressive pain centered in the floor of his mouth and had bilateral submandibular glandular enlargement on exam. Computed tomography showed a giant right torus mandibularis, which was causing obstruction and dilation of the bilateral submandibular ducts. Although conservative management was attempted, he ultimately underwent surgical resection of his torus with symptomatic improvement. This patient highlights a novel complication of torus mandibularis and illustrates successful treatment. Though not previously described, this complication may be underreported and should be considered in the appropriate clinical setting. [ABSTRACT FROM AUTHOR]

Tolosa–Hunt syndrome is characterized by unilateral retro-orbital headaches and cranial nerve palsies, usually involving cranial nerves III–VI. It is rare for other cranial nerves to be involved, although this has previously been reported. We report a 19-year-old woman presenting with typical features of Tolosa–Hunt syndrome but ultimately developing bilateral facial nerve palsies and enhancement of both facial nerves on magnetic resonance imaging. The patient presented with unilateral retro-orbital headaches and palsies of cranial nerves III–VI. She was diagnosed with Tolosa–Hunt syndrome but was non-compliant with her corticosteroid treatment due to side effects. She returned with progressive left followed by right facial nerve palsy. Her corresponding follow-up magnetic resonance imaging scans showed sequential enhancement of the left and right facial nerves. She ultimately had clinical improvement with IV methylprednisolone. To our knowledge, Tolosa–Hunt syndrome associated with bilateral facial nerve palsy and corroborative facial nerve enhancement on magnetic resonance imaging has not previously been described. Moreover, our patient's clinical course is instructive, as it demonstrates that this atypical presentation of Tolosa–Hunt syndrome can indeed respond to corticosteroid treatment and should not be mistaken for other entities such as Bell's palsy. [ABSTRACT FROM AUTHOR]

A 69-year-old female presented with subacute onset ascending weakness and paraesthesias. She was initially diagnosed with Guillain–Barré syndrome (GBS) based on her clinical presentation and cerebrospinal fluid (CSF) analysis showing albuminocytological dissociation. However, she was later found to have anti-neuronal nuclear antibody 1 (ANNA-1/anti-Hu)-positive CSF and was subsequently diagnosed with small-cell lung cancer. Her neurological symptoms were ultimately attributed to ANNA-1/anti-Hu-associated paraneoplastic polyneuropathy. During the course of her evaluation, she had magnetic resonance imaging findings of dorsal predominant cauda equina nerve root enhancement, which has not been previously described. The only previously reported case of cauda equina enhancement due to ANNA-1-associated polyneuropathy described ventral predominant findings. The distinction between ventral and dorsal enhancement is important, since it suggests that different patterns of nerve root involvement may be associated with this paraneoplastic syndrome. Therefore, ANNA-1-associated paraneoplastic inflammatory polyneuropathy can be considered in the differential diagnosis of cauda equina nerve root enhancement with ventral and/or dorsal predominance. This can potentially be helpful in differentiating ANNA-1 polyneuropathy from GBS, which classically has ventral predominant enhancement. [ABSTRACT FROM AUTHOR]

Stem cell treatment outside of studied and approved medical indications can have unforeseen adverse consequences. Here, we present a 74-year-old male that underwent such therapy. The patient presented to our institution with progressive lower extremity weakness and urinary incontinence. He had previously undergone intrathecal stem cell therapy in Moscow, Russia for weakness and fatigue. Magnetic resonance imaging of his thoracic and lumbar spine showed marked enlargement of the cauda equina nerve roots and abnormal mass-like soft tissue involving the thoracolumbar thecal sac. Surgical biopsy of the intrathecal soft tissue showed polyclonal lymphocytic and glial cell proliferation. The patient's symptoms did not improve with medical treatment or radiation, and he is currently under observation after multidisciplinary evaluation. Our patient's experience illustrates one of the potential risks of "stem cell tourism" and exemplifies the imaging and histopathologic features of this rare entity. We also compare our patient's treatment with other similar examples of stem cell treatments in our institution and others. These have had a wide spectrum of results. In some instances, intrathecal stem cells have caused abnormal imaging findings without any associated patient symptoms. In extreme examples, however, stem cell treatments have resulted in central nervous system neoplasms. Our patient's lesion is quite unique, with only one similar lesion having been previously published. [ABSTRACT FROM AUTHOR]