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Plexopathy may be caused by diverse pathologies, including trauma, nerve entrapment, neoplasm, inflammation, infection, autoimmune disease, hereditary disease, and idiopathic etiologies. For patients presenting with brachial or lumbosacral plexopathy, dedicated plexus MRI is the most appropriate initial imaging modality for all clinical scenarios and can identify processes both intrinsic and extrinsic to the nerves. Other imaging tests may be appropriate for initial imaging depending on the clinical scenario. This document addresses initial imaging strategies for brachial and lumbosacral plexopathy in the following clinical situations: nontraumatic plexopathy with no known malignancy, traumatic plexopathy (not perinatal), and plexopathy occurring in the context of a known malignancy or posttreatment syndrome. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Spine infection is both a clinical and diagnostic imaging challenge due to its relatively indolent and nonspecific clinical presentation. The diagnosis of spine infection is based upon a combination of clinical suspicion, imaging evaluation and, when possible, microbiologic confirmation performed from blood cultures or image-guided percutaneous or open spine biopsy. With respect to the imaging evaluation of suspected spine infection, MRI without and with contrast of the affected spine segment is the initial diagnostic test of choice. As noncontrast MRI of the spine is often used in the evaluation of back or neck pain not responding to conservative medical management, it may show findings that are suggestive of infection, hence this procedure may also be considered in the evaluation of suspected spine infection. Nuclear medicine studies, including skeletal scintigraphy, gallium scan, and FDG-PET/CT, may be helpful in equivocal or select cases. Similarly, radiography and CT may be appropriate for assessing overall spinal stability, spine alignment, osseous integrity and, when present, the status of spine instrumentation or spine implants. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

In the United States, acute low back pain, with or without radiculopathy, is the leading cause of years lived with disability and the third ranking cause of disability-adjusted life-years. Uncomplicated acute low back pain and/or radiculopathy is a benign, self-limited condition that does not warrant any imaging studies. Imaging is considered in those patients who have had up to 6 weeks of medical management and physical therapy that resulted in little or no improvement in their back pain. It is also considered for those patients presenting with red flags, raising suspicion for a serious underlying condition, such as cauda equina syndrome, malignancy, fracture, or infection. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Coronavirus disease 2019 (COVID-19) myelitis is a rare condition, most commonly presenting with nonenhancing central expansile cord T2 signal changes. A single case report has also described longitudinal involvement of the dorsal columns. We present 5 cases of COVID-19-associated myelitis with tract-specific involvement of the dorsal and lateral columns and discuss potential pathophysiologic pathways for this unique pattern.

Myelopathy is a clinical diagnosis with localization of the neurological findings to the spinal cord, rather than the brain or the peripheral nervous system, and then to a particular segment of the spinal cord. Myelopathy can be the result of primary intrinsic disorders of the spinal cord or from secondary conditions, which result in extrinsic compression of the spinal cord. While the causes of myelopathy may be multiple, the acuity of presentation and symptom onset frame a practical approach to the differential diagnosis. Imaging plays a crucial role in the evaluation of myelopathy with MRI the preferred modality. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Thoracic outlet syndrome (TOS) is the clinical entity that occurs with compression of the brachial plexus, subclavian artery, and/or subclavian vein at the superior thoracic outlet. Compression of each of these structures results in characteristic symptoms divided into three variants: neurogenic TOS, venous TOS, and arterial TOS, each arising from the specific structure that is compressed. The constellation of symptoms in each patient may vary, and patients may have more than one symptom simultaneously. Understanding the various anatomic spaces, causes of narrowing, and resulting neurovascular changes is important in choosing and interpreting radiological imaging performed to help diagnose TOS and plan for intervention. This publication has separated imaging appropriateness based on neurogenic, venous, or arterial symptoms, acknowledging that some patients may present with combined symptoms that may require more than one study to fully resolve. Additionally, in the postoperative setting, new symptoms may arise altering the need for specific imaging as compared to preoperative evaluation. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Acute changes in mental status represent a broad collection of symptoms used to describe disorders in mentation and level of arousal, including the more narrowly defined diagnoses of delirium and psychosis. A wide range of precipitating factors may be responsible for symptom onset including infection, intoxication, and metabolic disorders. Neurologic causes that may be detected on neuroimaging include stroke, traumatic brain injury, nonconvulsive seizure, central nervous system infection, tumors, hydrocephalus, and inflammatory disorders. Not infrequently, two or more precipitating factors may be found. Neuroimaging with CT or MRI is usually appropriate if the clinical suspicion for an acute neurological cause is high, where the cause of symptoms is not found on initial assessment, and for patients whose symptoms do not respond appropriately to management. There was disagreement regarding the appropriateness of neuroimaging in cases where a suspected, nonneurologic cause is found on initial assessment. Neuroimaging with CT is usually appropriate for patients presenting with delirium, although the yield may be low in the absence of trauma or a focal neurological deficit. Neuroimaging with CT or MRI may be appropriate in the evaluation of new onset psychosis, although the yield may be low in the absence of a neurologic deficit. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

A palpable neck mass may be the result of neoplastic, congenital, or inflammatory disease. Older age suggests neoplasia, and a congenital etiology is more prevalent in the pediatric population. The imaging approach is based on the patient age, mass location, and clinical pulsatility. Underlying human papillomavirus-related malignancy should be considered in all age groups. Although the imaging appearance of some processes in the head and neck overlap, choosing the appropriate imaging examination may allow a specific diagnosis, or a limited differential diagnosis. Tissue sampling is indicated to confirm suspected malignancy. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Nontraumatic neck pain is a leading cause of disability, with nearly 50% of individuals experiencing ongoing or recurrent symptoms. Radiographs are appropriate as initial imaging for cervical or neck pain in the absence of "red flag" symptoms or if there are unchanging chronic symptoms; however, spondylotic changes are commonly identified and may result in both false-positive and false-negative findings. Noncontrast CT can be complementary to radiographs for evaluation of new or changing symptoms in the setting of prior cervical spine surgery or in the assessment of extent of ossification in the posterior longitudinal ligament. Noncontrast MRI is usually appropriate for assessment of new or increasing radiculopathy due to improved nerve root definition. MRI without and with contrast is usually appropriate in patients with new or increasing cervical or neck pain or radiculopathy in the setting of suspected infection or known malignancy. Imaging may be appropriate; however, it is not always indicated for evaluation of cervicogenic headache without neurologic deficit. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

PURPOSE To perform a quantitative evaluation of myelination on WT and myelin-deficient (shiverer) mouse spinal cords using ultrahigh-b diffusion-weighted imaging (UHb-DWI). METHODS UHb-DWI of ex vivo on spinal cord specimens of two shiverer (C3HeB/FeJ-shiverer, homozygous genotype for MbPshi ) and six WT (Black Six, C3HeB/FeJ) mice were acquired using 3D multishot diffusion-weighted stimulated-echo EPI, a homemade RF coil, and a small-bore 7T MRI system. Imaging was performed in transaxial plane with 75 × 75 μm2 in-plane resolution, 1-mm-slice thickness, and radial DWI using bmax = 42,890 s/mm2 . Histological evaluation was performed on upper thoracic sections using optical and transmission electron microscopy. Numerical Monte Carlo simulations (MCSs) of water diffusion were performed to facilitate interpretation of UHb-DWI signal-b curves. RESULTS The white matter ultrahigh-b radial DWI (UHb-rDWI) signal-b curves of WT mouse cords behaved biexponentially with high-b diffusion coefficient DH < 0.020 × 10-3 mm2 /s. However, as expected with less myelination, the signal-b of shiverer mouse cords behaved monoexponentially with significantly greater DH = 0.162 × 10-3 , 0.142 × 10-3 , and 0.164 × 10-3 mm2 /s at anterodorsal, posterodorsal, and lateral columns, respectively. The axial DWI signals of all mouse cords behaved monoexponentially with D = (0.718-1.124) × 10-3 mm2 /s. MCS suggests that these elevated DH are mainly induced by increased water exchange at the myelin sheath. Microscopic results were consistent with the UHb-rDWI findings. CONCLUSION UHb-DWI provides quantitative differences in myelination of spinal cords from myelin-deficit shiverer and WT mice. UHb-DWI may become a powerful tool to evaluate myelination in demyelinating disease models that may translate to human diseases, including multiple sclerosis.

BACKGROUND AND PURPOSE: The National Institute of Neurological Disorders and Stroke common data elements initiative was created to provide a consistent method for recording and reporting observations related to neurologic diseases in clinical trials. The purpose of this study is to validate the subset of common data elements related to MR imaging evaluation of acute spinal cord injury. MATERIALS AND METHODS: Thirty-five cervical and thoracic MR imaging studies of patients with acute spinal cord injury were evaluated independently in 2 rounds by 5 expert reviewers. Intra- and interrater agreement were calculated for 17 distinct MR imaging observations related to spinal cord injury. These included ordinal, categoric, and continuous measures related to the length and location of spinal cord hemorrhage and edema as well as spinal canal and cord measurements. Level of agreement was calculated using the interclass correlation coefficient and kappa. RESULTS: The ordinal common data elements spinal cord injury elements for lesion center and rostral or caudal extent of edema or hemorrhage demonstrated agreement ranging from interclass correlation coefficient 0.68 to 0.99. Reproducibility ranged from 0.95 to 1.00. Moderate agreement was observed for absolute length of hemorrhage and edema (0.54 to 0.60) with good reproducibility (0.78 to 0.83). Agreement for the Brain and Spinal Injury Center score showed the lowest interrater agreement with an overall kappa of 0.27 (0.20, 0.34). For 7 of the 8 variables related to spinal cord injury, agreement improved between the first and second evaluation. Continuous diameter measures of the spinal cord and spinal canal using interclass correlation coefficient varied substantially (0.23 to 0.83). CONCLUSIONS: Agreement was more consistent for the ordinal measures of spinal cord injury than continuous measures. Good to excellent agreement on length and location of spinal cord hemorrhage and edema can be achieved with ordinal measures alone.

Purpose To determine optimal timing of biopsy for suspected discitis-osteomyelitis (DOM) with respect to preliminary blood culture results and the effect of biopsy timing on hospital length of stay (LOS). Materials and Methods This retrospective study reviewed disc/vertebral biopsies for suspected DOM performed between 2010 and 2018. A total of 107 disc/vertebral biopsies were performed on 96 inpatients (mean ± SD age 57.9 ± 14.5 years, 68 men/28 women) for suspected DOM, and 100 cases of DOM were clinically confirmed and treated. Descriptive and regression statistics were performed with LOS as the primary outcome. Results Of disc biopsies in clinically confirmed cases, 68% were positive; 20% of all biopsies had preliminary positive blood cultures after 2 hospital days. There was no difference in LOS between cases with biopsy performed ≤ 2 days after blood culture and cases with biopsy performed > 2 days after blood culture (P = .40). Regression analysis showed no association between positive biopsy results and sepsis, white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), or C-reactive protein (CRP). Biopsy yield was not significantly decreased in patients previously taking antibiotics (P = .09). Conclusions Waiting 2 days for preliminary blood culture results could avoid disc/vertebral biopsy in 20% of patients and does not significantly impact hospital LOS. Additionally, clinical factors (sepsis, WBC count, CRP, and ESR) do not have predictive value for positive disc biopsy results.

Sinonasal imaging is performed in 2 major clinical scenarios: inflammatory rhinosinusitis or suspected mass lesion. Rhinosinusitis affects more than 16% of the US population annually. It poses an immense economic burden, accounting for more than 26 million outpatient visits annually and costing more than $4.3 billion annually in direct medical expenses. Most cases of uncomplicated acute and subacute rhinosinusitis are diagnosed clinically and should not require any imaging procedure. CT of the sinuses without contrast is the imaging method of choice in patients with recurrent acute sinusitis or chronic sinusitis. Sinusitis cannot be diagnosed on the basis of imaging findings alone. CT scan findings should be interpreted in conjunction with clinical and endoscopic findings. MRI is currently used for evaluation of sinus disease as a complementary study in cases of aggressive sinus infection with ocular/intracranial complications, potential invasive fungal sinusitis in immunocompromised patients or in the evaluation of a sinonasal mass. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

There is a paucity of evidence-based literature regarding the advantages and disadvantages of the interlaminar approach and needle bevel orientation for performing a lumbar interlaminar epidural steroid injection (ESI). The purpose of this study was to determine if superior versus inferior lamina approach, needle bevel tip orientation, or both may predispose to inadvertent nonepidural penetration during lumbar interlaminar ESI.A prospective study was performed of patients with low back pain with or without radicular pain or neurogenic claudication referred for lumbar interlaminar ESI. Two hundred eleven patients were randomized by interlaminar approach (superior vs inferior) and bevel tip orientation (cranial vs caudal). Lumbar interlaminar ESI was performed by six interventionalists of varying levels of experience using fluoroscopic guidance with curved tip epidural needles, using loss-of-resistance technique and confirmation with contrast opacification. Exact Poisson regression was used to model the study outcome.Two hundred twenty-one lumbar interlaminar ESIs were performed on 211 patients, randomized to a superior (n = 121) or inferior lamina approach (n = 100) and to a cranial (n = 103) or caudal (n = 118) orientation of the bevel tip. Epidural needle placement was confirmed in 96.4% (n = 213) of cases. Nonepidural needle placement was most commonly associated with superior lamina approach and caudal bevel tip orientation, which was marginally significant (adjusted risk ratio, 6.88; 95% CI, 0.93-∞; p = 0.059).Inadvertent nonepidural needle penetration during fluoroscopically guided lumbar interlaminar ESI appears to be affected by approach, with superior lamina approach and caudal bevel tip orientation being the least favorable technique.

High-resolution vessel wall MRI (vwMRI) of the intracranial arteries is an emerging diagnostic imaging technique with the goal of evaluating vascular pathology. vwMRI sequences have high spatial resolution and directly image the vessel wall by suppressing blood signal. With vwMRI, it is possible to identify distinct morphologic and enhancement patterns of atherosclerosis that can provide important information about stroke etiology and recurrence risk. We present a review of vwMRI research in relation to intracranial atherosclerosis, with a focus on the relationship between ischemic stroke and atherosclerotic plaque T1 post-contrast enhancement or plaque/vessel wall morphology. The goal of this review is to provide readers with the most current understanding of the reliability, incidence, and importance of specific vwMRI findings in intracranial atherosclerosis, to guide their interpretation of vwMRI research, and help inform clinical interpretation of vwMRI. We will also provide a translational perspective on the existing vwMRI literature and insight into future vwMRI research questions and objectives. With increased use of high field strength MRI, powerful gradients, and improved pulse sequences, vwMRI will become standard-of-care in the diagnosis and prognosis of patients with cerebrovascular disease, making a firm grasp of its strengths and weakness important for neuroimagers.

We present 5 cases of demyelination in patients diagnosed with multiple sclerosis that are closely associated with a developmental venous anomaly. Although the presence of a central vein is a known phenomenon with multiple sclerosis plaques, demyelination occurring around developmental venous anomalies is an underreported phenomenon. Tumefactive demyelination can cause a diagnostic dilemma because of its overlapping imaging findings with central nervous system neoplasm. The relationship of a tumefactive plaque with a central vein can be diagnostically useful, and we suggest that if such a lesion is closely associated with a developmental venous anomaly, an inflammatory or demyelinating etiology should be a leading consideration.

Rationale and Objectives Emergency department (ED) patients with acute low back pain (LBP) may present with ambiguous clinical findings that pose diagnostic challenges to exclude cauda equina syndrome (CES). As a proof of concept, we aimed to determine the efficacy of a rapid lumbar spine (LS) magnetic resonance imaging (MRI) screening protocol consisting of a single 3D-T2 SPACE FS (3D-T2 Sampling Perfection with Application optimized Contrasts using different flip angle Evolution fat saturated) sequence relative to conventional LS MRI to exclude emergently treatable pathologies in this complex patient population. Materials and Methods LS MRI protocol including a sagittal 3D-T2 SPACE FS pulse sequence was added to the routine for ED patients presenting with acute atypical LBP over a 12-month period. Imaging findings were categorically scored on the 3D-T2 SPACE FS sequence and separately on the reference standard conventional LS MRI sequences. Patients' symptoms were obtained from review of the electronic medical record. Descriptive test statistics were performed. Results Of the 206 ED patients who obtained MRI for acute atypical LBP, 118 (43.3 ± 13.5 years of age; 61 female) were included. Specific pathologies detected on reference standard conventional MRI included disc herniation ( n = 30), acute fracture ( n = 3), synovial cyst ( n = 3), epidural hematoma ( n = 2), cerebrospinal fluid leak ( n = 1), and leptomeningeal metastases ( n = 1), and on multiple occasions these pathologies resulted in nerve root impingement ( n = 36), severe spinal canal stenosis ( n = 13), cord/conus compression ( n = 2), and cord signal abnormality ( n = 2). The 3D-T2 SPACE FS sequence was an effective screen for fracture (sensitivity [sens] = 100%, specificity [spec] = 100%), cord signal abnormality (sens = 100%, spec = 99%), and severe spinal canal stenosis (sens = 100%, spec = 96%), and identified cord compression not seen on reference standard. Motion artifact was not seen on the 3D-T2 SPACE FS but noted on 8.5% of conventional LS MRI. Conclusions The 3D-T2 SPACE FS sequence MRI is a rapid, effective screen for emergently actionable pathologies that might be a cause of CES in ED patients presenting with acute atypical LBP. As this abbreviated, highly sensitive sequence requires a fraction of the acquisition time of conventional LS MRI, it has the potential of contributing to increased efficiencies in the radiology department and improved ED throughput.

Interpreting imaging studies of peripheral nerve diseases and especially the brachial plexus (BP) and lumbosacral plexus (LSP) can be challenging. It requires a firm knowledge of the anatomy. It is just as important to be familiar with the end-organ innervations and the surrounding structures, the latter serving as important landmarks.

Unknown spinal lesions are commonly encountered either in the presence of symptoms or incidentally. In addition to tumors, the differential diagnosis should consider nonneoplastic spine tumor mimics, which may be differentiated based on history, physical, and imaging. Treatment strategies diverge considerably from neoplastic counterparts, and care is optimized by considering these entities. General classes include infectious, metabolic, degenerative, inflammatory, hemorrhagic, and other rare entities.

Acute low back pain, defined as less than 6 weeks in duration, does not require imaging in the absence of "red flags" that may indicate a cause, such as fracture, infection, or malignancy. When imaging is indicated, it is important to rule out a host of abnormalities that may be responsible for the pain and any associated symptoms. A common mnemonic VINDICATE can help ensure a thorough consideration of the possible causes.

Computed tomography (CT) and MRI are complementary imaging modalities for the evaluation of the traumatic spine. Osseous delineation is best assessed with CT, whereas MRI gives superb soft tissue description. Awareness of the strengths and pitfalls of each modality is critical in the accurate interpretation of images. Advances in MR imaging of the spine, particularly of the spinal cord, provide glimpses into to the pathobiological mechanism of spinal cord injury. Innovative techniques relay microstructural information about the integrity of the axons and myelin sheaths. In addition to clinical status, imaging features may be helpful in prognostication and in monitoring therapeutic interventions.

Background Pediatric bipolar disorder (PBD) (occurring prior to 18 years of age) is a developmental brain disorder that is among the most severe and disabling psychiatric conditions affecting youth. Despite increasing evidence that brain connectivity is atypical in adults with bipolar disorder, it is not clear how brain connectivity may be altered in youths with PBD. Methods This cross-sectional resting-state functional magnetic resonance imaging study included 80 participants recruited over 4 years: 32 youths with PBD, currently euthymic (13 males; 15.1 years old), and 48 healthy control (HC) subjects (27 males; 14.5 years old). Functional connectivity between eight major intrinsic connectivity networks, along with connectivity measurements between 333 brain regions, was compared between PBD and HC subjects. Additionally, connectivity differences were evaluated between PBD and HC samples in negatively correlated connections, as defined by 839 subjects of the Human Connectome Project dataset. Results We found increased inter- but not intranetwork functional connectivity in PBD between the default mode and salience networks (p = .0017). Throughout the brain, atypical connections showed failure to develop anticorrelation with age during adolescence in PBD but not HC samples among connections that exhibit negative correlation in adulthood. Conclusions Youths with PBD demonstrate reduced anticorrelation between default mode and salience networks. Further evaluation of the interaction between these networks is needed in development and with other mood states such as depression and mania to clarify if this atypical connectivity is a PBD trait biomarker.

Background After a far-lateral transcondylar approach, patients may maintain neutral alignment in the immediate postoperative period, but severe occipitoatlantal subluxation may occur gradually with cranial settling and possible neurological injury. Previous research is based on assumptions regarding the extent of condylar resection and the change in biomechanics that produces instability. Objective To quantify the extent of bone removal during a far-lateral transcondylar approach, determine the changes in range of motion (ROM) and stiffness that occur after condylar resection, and identify the threshold of condylar resection that predicts alterations in occipitocervical biomechanics. Methods Nine human cadaveric specimens were biomechanically tested before and after far-lateral transcondylar resection extending into the hypoglossal canal (HC). The extent of condylar resection was quantified using volumetric comparison between pre- and postresection computed tomography scans. ROM and stiffness testing were performed in intact and resected states. The extent of resection that produced alterations in occipitocervical biomechanics was assessed with sensitivity analysis. Results Bone removal during condylar resection into the HC was 15.4%-63.7% (mean 35.7%). Sensitivity analysis demonstrated that changes in biomechanics may occur when just 29% of the occipital condyle was resected (area under the curve 0.80-1.00). Conclusion Changes in occipitocervical biomechanics may be observed if one-third of the occipital condyle is resected. During surgery, the HC may not be a reliable landmark to guide the extent of resection. Patients who undergo condylar resections extending into or beyond the HC require close surveillance for occipitocervical instability.

Despite the popularity of flow-diverting stents for the treatment of cerebral aneurysms, there is no widely accepted scale for the characterization of results. We present an outcomes-based grading scale that considers factors related to failure of flow diversion.The grading scale was developed using the results from consecutive patients at two institutions who were treated with flow diversion for a cerebral aneurysm. The initial treatment results were graded on patient, aneurysm, and treatment characteristics. A 6-point grading scale was developed based on these data.One hundred and seventy-one patients were included in the patient cohort. When compared by multivariate analysis with patients without residuals, patients with aneurysm residuals were found to be older (age ≥60 years, p=0.01, OR 1.17, 95% CI 1.03 to 1.33), to have larger aneurysms (size ≥15 mm, p0.01, OR 1.38, 95% CI 1.17 to 1.62), to have aneurysms with associated side branches (p=0.02, OR 1.17, 95% CI 1.03 to 1.33), and to have a post-treatment Raymond score of 2 or 3 (p=0.01, OR 1.28, 95% CI 1.06 to 1.56). Using the Raymond score (1-3) as the foundation for the grading scale, additional points (0 or 1) were given for the other three identified factors, creating a 6-point scale. We found that patients with residual aneurysms had statistically higher final tabulated scores (p0.01).We propose a novel straightforward outcomes-based scale to characterize results after flow diversion treatment of cerebral aneurysms. This scale may provide the basis for the common reporting of results in future studies.

UNLABELLED : Imaging is important in the evaluation of patients with degenerative disease and infectious processes. There are numerous conditions that can manifest as low back pain (LBP) or neck pain in a patient, and in many cases, the cause may be multifactorial. Clinical history and physical examination are key components in the evaluation of such patients; however, physical examination has variable sensitivity and specificity. Although studies have demonstrated that uncomplicated acute LBP and/or radiculopathy are self-limited conditions that do not warrant any imaging, neuroimaging can provide clear anatomic delineation of potential causes of the patient's clinical presentation. Various professional organizations have recommendations for imaging of LBP, which generally agree that an imaging study is not indicated for patients with uncomplicated LBP or radiculopathy without a red flag (eg, neurological deficit such as major weakness or numbness in lower extremities, bowel or bladder dysfunction, saddle anesthesia, fever, history of cancer, intravenous drug use, immunosuppression, trauma, or worsening symptoms). Different imaging modalities have a complementary role in the diagnosis of pathologies affecting the spine. In this review, we discuss the standard nomenclature for lumbar disk pathology and the utility of various clinical imaging techniques in the evaluation of LBP/neck pain for potential neurosurgical management. The imaging appearance of spinal infections and potential mimics also is reviewed. Finally, we discuss advanced neuroradiological techniques that offer greater microstructural and functional information. ABBREVIATIONS ADC, apparent diffusion coefficientDTI, diffusion tensor imagingDWI, diffusion-weighted imagingDOM, diskitis-osteomyelitisLBP, low back painMRM, magnetic resonance myelographySNA, spinal neuroarthropathySPECT, single-positron emission computed tomographySTIR, short tau inversion recovery.

Spinal neuroarthropathy (SNA), or Charcot spine, is a progressive destructive arthropathy occurring after loss of neuroprotective sensation and proprioceptive reflexes. Clinical diagnosis is difficult because of the variable length to presentation after initial neurologic damage and the limited symptoms given preexisting neurologic deficits. SNA is also a diagnostic challenge because its imaging features are similar to those of spinal conditions such as discitis-osteomyelitis, osseous tuberculosis, hemodialysis-related spondyloarthropathy, and pseudarthrosis. The most important imaging clues for diagnosis of SNA are involvement of both anterior and posterior elements at the thoracolumbar and lumbosacral junctions. Additional imaging clues include vacuum phenomenon within the disk (indicating excessive motion), malalignment, and paraspinal soft-tissue masses or fluid collections containing bone debris. Despite these imaging signs, findings may overlap in some cases with those of infection, or SNA can be superinfected, and biopsy may be necessary. Development of SNA requires a preexisting neurologic condition, most commonly traumatic spinal cord injury. Areas of greatest mobility and weight bearing within the desensate spine experience repetitive microtrauma and unregulated hyperemia, leading to destruction of the intervertebral articulations. The progressive and destructive nature of SNA causes substantial deformity, loss of function, and often further neurologic deficits. Patients present with deformity, back pain, audible noises during movement, or new neurologic symptoms. The mainstay of treatment is surgical débridement, reduction, and fusion. The radiologist can help initiate early intervention by using key imaging features to distinguish SNA from imaging mimics and prevent further neurologic deterioration. (©)RSNA, 2016.

Graphical abstract, Highlights • Ultrahigh-b DWI (UHb-DWI) method applied to MS spinal cords. • UHb-DWI provides quantitative measures of the MS lesions in the spinal cord. • High-b diffusion coefficient (DH) is theoretically sensitive for demyelination. • DH in MS lesion is significantly elevated compared to that of normal spinal cords., Purpose The purpose of this study was to investigate UHb-rDWI signal in white matter tracts of the cervical spinal cord (CSC) and compare quantitative values between healthy control WM with both MS NAWM and MS WM lesions. Methods UHb-rDWI experiments were performed on (a) 7 MS patients with recently active or chronic lesions in CSC and on (b) 7 healthy control of similar age range and gender distribution to MS subjects. All MRI data were acquired using clinical 3T MRI system. Axial high-b diffusion images were acquired using 2D single-shot DW stimulated EPI with reduced FOV and a CSC-dedicated 8 channel array coil. High-b diffusion coefficient DH was estimated by fitting the signal-b curve to a double or single-exponential function. Results The high-b diffusivity DH values were measured as (0.767 ± 0.297) × 10−3 mm2/s in the posterior column lesions, averaged over 6 MS patients, and 0.587 × 10−3 mm2/s in the corticospinal tract for another patient. The averaged DH values of the 7 healthy volunteers from the posterior and lateral column were (0.0312 ± 0.0306) × 10−3 and (0.0505 ± 0.0205) × 10−3 mm2/s, respectively. UHb-rDWI signal-b curves of the MS patients revealed to noticeably behave differently to that of the healthy controls. The patient signal-b curves decayed with greater high-b decay constants to reach lower signal intensities relative to signal-b curves of the healthy controls. Conclusion UHb-DWI of the CSC reveals a marked difference in signal-b-curves and DH values in MS lesions compared to NAWM and healthy control WM. Based on physical principles, we interpret these altered observations of quantitative diffusion values to be indicative of demyelination. Further studies in animal models will be required to fully interpret UHb-DWI quantitative diffusion values during demyelination and remyelination.

Posterior fossa hemorrhage (PFH) of the cerebellum is managed by decompressive craniectomy when there is clinical deterioration. There is no current consensus on an objective imaging method to determine which patients need surgery before clinical deterioration. We developed an imaging scoring tool by assessing initial hemorrhage diameter and posterior fossa (PF) measurements to determine which patients will benefit from early surgical intervention.For this case-control study, we reviewed the electronic medical record to identify adults who presented with PFH over a 10-year period at our institution. Chart review for clinical findings and inciting factors were documented. The average diameter of PFH and the surrogate PF volume on initial imaging studies were measured. These measurements were correlated with surgical intervention. A scoring tool was developed based on radiographic and clinical data.Fifty-one patients met the inclusion criteria. The average hemorrhage diameter and the surrogate PF volume measurements were statistically different between surgical and nonsurgical cases (P0.001 and P = 0.019, respectively). The scoring system was created by dividing average hemorrhage diameter by surrogate PF volume and multiplying by 1000. The median score of nonsurgical patients was 9.1, and the median score of surgical patients was 15.6.Patients presenting with PFH with smaller PF volumes may be more likely to require surgery as determined by clinical standards. The proposed scoring system based on simple measurements on initial computed tomography and magnetic resonance imaging may help surgeons consider early surgical intervention in those patients with PFH with smaller PF volumes.

BACKGROUND AND PURPOSE: Demyelination is a recently recognized cause of FLAIR hyperintensities associated with developmental venous anomalies. Our purpose was to quantify the prevalence of white matter signal abnormalities associated with developmental venous anomalies in patients with multiple sclerosis compared with controls. MATERIALS AND METHODS: A retrospective, blinded, multireader study compared the prevalence of FLAIR hyperintense signal abnormalities adjacent to developmental venous anomalies in patients with MS compared with controls (patients with developmental venous anomalies without MS). Study findings were positive if a central vein was demonstrated using FLAIR and contrast-enhanced fat-saturated T1 sequences. Imaging parameters also included developmental venous anomaly location, developmental venous anomaly drainage, white matter lesion size, and depth of white matter lesions. Clinical parameters included age, sex, and the presence of confounding variables (hypertension, diabetes, migraines, and/or vasculopathy). RESULTS: FLAIR signal abnormality was present around 47.3% (35/74) of developmental venous anomalies in patients with MS, and 13.5% (10/74) of developmental venous anomalies in the control group (P < .001). The multivariate logistic regression model controlling for covariates (including migraines, hypertension, diabetes mellitus, vasculopathy, age, sex, and drainage direction of developmental venous anomalies) showed that the odds of FLAIR hyperintensity around developmental venous anomalies was 6.7-fold higher in patients with MS (relative risk MS = 6.68; 95% CI, 2.79–15.97; P < .001). CONCLUSIONS: The association of developmental venous anomalies and FLAIR hyperintensities was more common in patients with MS, which suggests that the underlying demyelinating pathologic process of MS may be the cause of this propensity in patients with MS. Impaired venous drainage in the territory of developmental venous anomalies may predispose to development of these lesions, and an associated central vein is helpful in understanding an atypical location of MS plaques.

BackgroundWith increasing use of flow-diverting stents for the treatment of intracranial aneurysms, standardized methods and a common language to evaluate angiographic outcomes are needed. Multiple grading scales have been developed for this purpose but none has been widely adopted.ObjectiveTo analyze these scales to determine interobserver reliability.MethodsFour independent assessors scored the intraprocedural angiograms of patients who underwent flow-diverting stent deployment for an intracranial saccular or fusiform aneurysm at our institution between October 2012 and June 2015. Angiographic outcome immediately after flow-diverting stent deployment was scored using three grading scales (Kamran–Byrne (KB), Simple Measurement of Aneurysm Residual after Treatment (SMART), and O'Kelley, Krings, Marotta (OKM)). Statistical analysis was performed using Light's κ for multiple raters (κ), Kendall's coefficient of concordance (W), and intraclass correlation (ICC).ResultsWe included the angiograms of 50 consecutive patients (mean age 58 years, range 30–79) who underwent flow-diverting stent deployment for an intracranial aneurysm (40 saccular, 10 fusiform). Six aneurysms were located in the posterior circulation. The inter-rater reliability was typically poor or fair: SMART aneurysm filling (κ=0.30, W=0.36, ICC=0.12), SMART parent vessel stenosis (κ=0.07, W=0.33, ICC=0.12), KB axis I (κ=0.24, W=0.50, ICC=0.25), KB axis II (κ=0.07, W=0.30, ICC=0.06), OKM aneurysm filling (κ=0.23, W=0.45, ICC=0.13), OKM contrast stasis (κ=0.36,W=0.71, ICC=0.54).ConclusionsExisting flow-diverting stent grading scales have low inter-rater reliability for most categories.

OBJECT Posterior odontoid process inclination has been demonstrated as a factor associated with Chiari malformation Type I (CM-I) in the pediatric population; however, no studies to date have examined this measurement in the adult CM-I population. The purpose of this study was to evaluate craniocervical junction (CCJ) measurements in adult CM-I versus a control group. METHODS The odontoid retroflexion, odontoid retroversion, odontoid height, posterior basion to C-2 line measured to the dural margin (pB-C2 line), posterior basion to C-2 line measured to the dorsal odontoid cortical margin (pB-C2* line), and clivus-canal angle measurements were retrospectively analyzed in adult patients with CM-I using MRI. These measurements were compared with normative values established from CT scans of the cervical spine in adults without CM-I. RESULTS A statistically significant difference was found between 55 adults with CM-I and 150 sex-matched controls (125 used for analysis) in the mean clivus-canal angle and the mean pB-C2 line. CONCLUSIONS These data suggest that there are sex-specific differences with respect to measurements at the CCJ between men and women, with women showing a more posteriorly inclined odontoid process. There were also differences between the CM-I and control groups: a more acute clivus-canal angle was associated with CM-I in the adult population. These CCJ findings could have an influence on presurgical planning.

In the imaging evaluation of hearing loss, the radiologic examination is complementary to the physical examination. The clinical evaluation includes not only an accurate history of the hearing loss itself (unilateral or bilateral, slow onset or fast onset, etc.) but also the patient's medical history (possible trauma, ototoxic drugs, associated facial nerve palsies, etc.). Hearing loss can be described as sensorineural, conductive, or mixed, and this will guide the choice of imaging modality to correlate with the clinical history and symptoms. In this chapter, we will review the more common hearing loss entities and divide these pathologies into those presenting with sensorineural hearing loss (SNHL), conductive hearing loss (CHL), and mixed hearing loss (MHL). The pathologies for SNHL and CHL will be further grouped and discussed as either congenital or acquired entities. In very simplistic terms, CHL is frequently initially evaluated with CT, whereas SNHL is most frequently initially evaluated with MRI. When reviewing the imaging studies, a systematic “outside-in” approach along the hearing pathway is helpful, from the external anatomic structures to the internal structures.

BACKGROUND AND PURPOSE: Calcified cerebral emboli are a rarely reported but devastating cause of stroke and may be the first manifestation of vascular or cardiac disease. Our aim was to evaluate the diagnosis, prevalence, imaging appearance, presumed embolic source, treatment, and outcome of patients with calcified cerebral emboli. MATERIALS AND METHODS: Our radiology information system was searched for all CT scans by using keywords “calcified,” “emboli,” and their permutations. The radiology information system was also searched to identify all “stroke” CT reports to calculate the prevalence of calcified cerebral emboli. We also performed a MEDLINE search to identify all published case reports. RESULTS: Twenty-two cases were identified from our database, and 48 were cases reported from the literature. The middle cerebral artery was the site of 83% of calcified emboli. Presumed sources were calcific aortic stenosis (36%), carotid atherosclerotic plaque (30%), and mitral annular calcification (11%). Spontaneous embolism occurred in 86%. Surgical treatment was performed in 34% of patients. Sixty-four percent of the patients with calcified aortic stenosis underwent aortic valve replacement. Among those with identifiable arterial disease, 53% underwent endarterectomy. Forty-one percent of patients experienced at least 1 recurrent stroke. The prevalence of calcified cerebral emboli identified on stroke CT scans at our institution was 2.7%. Seventy-three percent of cases were correctly identified. Twenty-seven percent were misdiagnosed on initial interpretation, while 9% were overlooked on preliminary interpretation. CONCLUSIONS: Calcified cerebral emboli are more common than previously assumed, are frequently overlooked or misinterpreted, affect clinical course when diagnosed, and carry substantial risk for recurrent stroke.

Background: Malignant peripheral nerve sheath tumors (MPNSTs) of the brachial plexus have unique radiographic and clinical findings. Patients often present with progressive upper extremity paresthesias, weakness, and pain. On magnetic resonance (MR) imaging, lesions are isointense on T1-weighted and hyperintense on T2-weighted sequences, while also demonstrating marked enhancement on MR studies with gadolinium diethylenetriamine pentaacetic acid. On the basis of their characteristic MR imaging features and rapid clinical progression, two brachial plexus lesions proved to be organizing hematomas rather than MPNST. Methods: A 51-year-old male and a 31-year-old female were both assessed for persistent and worsened left-sided upper extremity pain, paresthesias, and weakness. In both cases, the MR imaging of the brachial plexus demonstrated an extraspinal enhancing lesion located within the left C7–T1 neuroforamina. Results: Although the clinical and radiographic MR features for these 2 patients were consistent with MPNSTs, both lesions proved to be benign organizing hematomas. Conclusions: These two case studies emphasize that brachial plexus hematomas may mimic MPNSTs on MR studies. Accurate diagnosis of these lesions is critical for determining the appropriate management options and treatment plans. Delaying the treatment of a highly aggressive nerve sheath tumor can have devastating consequences, whereas many hematomas resolve without surgery. Therefore, if the patient has stable findings on neurological examination and a history of trauma, surgical intervention may be delayed in favor of repeat MR imaging in 2–3 months to re-evaluate the size of the mass.

In the setting of posterior fossa dural venous sinus thrombosis, mastoid findings can potentially be mistaken as the cause rather than a secondary effect. Obstruction of the mastoid venous drainage can lead to transudation of fluid into the mastoid air cells. We hypothesize that a continuum of the mastoid manifestations secondary to dural venous sinus thrombosis can be seen on MRI and that the difference in venous drainage between the mastoid and middle ears can assist with this important imaging differential.A retrospective review of acute dural venous sinus thrombosis cases and their follow-up imaging were graded as follows: no involvement; grade 1 mucosal congestion; grade 2, film of fluid; or grade 3, complete opacification. Presence of middle ear fluid was also documented.Of 22 posterior fossa dural venous sinus thrombosis cases without clinical infectious mastoiditis, 19 had mastoid findings: eight with grade 1, eight with grade 2, and three with grade 3. Middle ear fluid was seen in only one case. There was a statistically significant association between posterior fossa dural venous sinus thrombosis and mastoid findings (chisquare test (n = 22), p0.04). Fifteen of 18 cases with follow-up MRI examinations showed lessening of the mastoid findings with resolving dural venous sinus thrombosis.Acute posterior fossa dural venous sinus thrombosis may present with a spectrum of mastoid findings that should not be misdiagnosed as the cause of the thrombosis. This study illustrates that in the absence of clinical findings of mastoiditis, mastoid fluid with a clear middle ear argues that the mastoid changes are the effect of the dural venous sinus thrombosis rather than the cause.

Imaging with computed tomography and magnetic resonance imaging is fundamental to the evaluation of traumatic spinal injury. Specifically, neuroradiologic techniques show the exact location of injury, evaluate the stability of the spine, and determine neural element compromise. This review focuses on the complementary role of different radiologic modalities in the diagnosis of patients with traumatic injuries of the spine. The role of imaging in spinal trauma classifications will be addressed. The importance of magnetic resonance imaging in the assessment of soft tissue injury, particularly of the spinal cord, will be discussed. Last, the increasing role of advanced imaging techniques for prognostication of the traumatic spine will be explored. Abbreviations ADC, apparent diffusion coefficientALL, anterior longitudinal ligamentAS, ankylosing spondylitisASIA, American Spine Injury AssociationCTA, computed tomography angiographyCVJ, craniovertebral junctionDISH, diffuse idiopathic skeletal hyperostosisDTI, diffusion tensor imagingFA, fractional anisotropyMDCT, multidetector computed tomographyMRA, magnetic resonance angiographySCI, spinal cord injurySTIR, short tau inversion recoveryVAI, vertebral artery injury.

Background The adult spinal cord is typically resistant to hypoxic-ischemic injury because of collateral blood supply; however, congenital or acquired stenosis may result in baseline maximal vasodilation, such as superimposed hemodynamic stresses, that cannot be accommodated, leaving the spinal cord vulnerable to ischemic injury. We present a rare case of spinal cord hypoxic-ischemic injury in an adult with underlying cervical spinal stenosis. Case Description A 37-year-old man with a history of morbid obesity, diabetes mellitus, hypertension, and obstructive sleep apnea presented after developing progressive weakness in the extremities. Preoperative computed tomography myelography demonstrated ossification of the posterior longitudinal ligament and severe spinal canal narrowing. Approximately 1 week after posterior decompression, the patient experienced spinal hypoxic-ischemic injury. Imaging revealed cord expansion and abnormal T2 signal intensity. Axial diffusion tensor images of the brain revealed delayed ischemic leukoencephalopathy with restricted diffusion in the cerebral cortex and deep white matter; this led to the decision to withdraw care, and the patient died. Conclusions We hypothesize that vascular dysregulation due to cervical stenosis made the cord parenchyma vulnerable to hypoxic and/or hypoperfusion stresses.

The intraosseous fluid sign (IFS) in chronic osteoporotic vertebral fractures is attributed to fluid accumulation within non-healing intervertebral clefts. IFS can also be seen in acute traumatic fractures, not previously described. We hypothesize a pathophysiological mechanism for the acute traumatic intraosseous fluid sign (ATIFS) and its predisposition to dynamic fracture mobility with axial loading on upright radiographs. Retrospective analysis was performed of 41 acute thoracic and lumbar compression or stable burst fractures with both supine CT and upright plain films completed within 1 week of each other. The presence of an intravertebral cleft with fluid attenuation and vertebral body height loss was assessed on CT scans. Changes in the fractured vertebral body height and angulation were measured on upright radiographs. The ATIFS was identified in 18 (44%) of the 41 acute fractures. Mean kyphotic angle increase was significantly greater (p = 0.000) for ATIFS fractures (8.2°, SD ±4.2) than fractures without ATIFS (1.6°, SD ±3.4). There was significantly greater mean anterior (p = 0.0009) and central (p = 0.026) height loss in ATIFS fractures (4.3 mm, SD ±3.76 and 1.89 mm, SD ±4.44, respectively) compared to fractures without ATIFS (0.59 mm, SD ±2.24 and −0.52 mm, SD ±2.01, respectively). The IFS can be seen in acute traumatic vertebral fractures and show dynamic mobility. These ATIFS fractures show statistically significant greater mean height loss ratio differences and have significantly greater changes in kyphotic angulation on upright imaging when compared to fractures without ATIFS.

Background: Differentiating between posterior ethmoid and sphenoid sinuses can be difficult endoscopically. Anatomic relationships should guide surgery, irrespective of the ability to verify them with image guidance. The authors sought to verify an anatomic landmark found to be useful during endoscopic sinus surgery: the ability to see the sphenoid floor with a 0-degree nasal endoscope. Methods: The angle formed by a nasal endoscope placed at the sphenoid ostium and the mucosa of the sphenoid floor was measured in 93 consecutive sphenoid sinuses radiologically. Angles of view of 3 common endoscopes were directly measured and compared to the radiologic measurements. Results: The angle to the most inferior aerated portion of the sphenoid sinus averaged 113.6 degrees with a range of 77 to 145 degrees. The angle of view of the 3 endoscopes was found to be 38.1 degrees, 46.7 degrees, and 44.4 degrees. With these angles of view, the most inferior aerated portion of 100% of the radiologically assessed sinuses could not be seen with these endoscopes. Conclusion: Inability to see the mucosa of the floor of the sphenoid sinus with a 0-degree nasal endoscope appears to be a reliable finding. Individual variations that may affect this finding such as hypoplasia or severe mucosal edema should be identified preoperatively on imaging. In their absence, the inability to see the floor of an entered sinus with a 0-degree nasal endoscope provides another reliable clue to the position of the sphenoid sinus during endoscopic sinus surgery. © 2011 ARS-AAOA, LLC.

Sarcoidosis can involve the central nervous system in approximately 5-15% of cases. Any part of the nervous system can be involved, so presentation can be quite varied. Isolated disease of the spinal cord is even less common and reports are limited to single cases and small series. Although in the setting of systemic disease the diagnosis can be made with skin or lymph node biopsy, isolated disease of the spinal cord presents a diagnostic challenge. We present a case of isolated intramedullary neurosarcoidosis of the distal thoracic spinal cord presenting with posterior column dysfunction. Imaging demonstrated T2 changes in the patient's lower thoracic cord adjacent to disc herniation. Over time, however, his symptoms progressed despite decompression, and the abnormal region began to exhibit focal contrast enhancement. The persistence of symptoms as well as the new enhancement led us to perform a spinal cord biopsy, which demonstrated histopathological findings consistent with sarcoidosis. Further workup failed to reveal any evidence of systemic disease. Intramedullary sarcoidosis without systemic sarcoidosis is extremely rare. With its variable imaging appearance and inconsistent clinical manifestations, it can be difficult to diagnose. It should be considered in the differential diagnosis of a mass-like intramedullary lesion with progressive symptoms. Biopsy with histopathological correlation may be the only definite management option.

Tailgut cysts are developmental cysts that arise from remnants of the embryonic postanal gut and are typically located within the presacral, retrorectal space. Isolated cases of aberrant locations, including prerectal, perirenal, perianal, retrovesical, and subcutaneous locations, have been reported. Malignant transformations with the presence of adenocarcinomas or carcinoids have been recognized within these entities. It is well recognized that anterior sacrococcygeal abnormalities are present and are frequently caused by the slow-growing nature of the tailgut cysts and related mass effect; however, the authors are aware of no reports in the literature of isolated tailgut cysts within the thecal sac in direct contact with neural elements, without extension into the peritoneal cavity. In this case, a 28-year-old woman presented with progressive back pain, frequent urinary tract infections, and bowel dysfunction. She was found to have a purely intradural tailgut cyst with malignant transformation consistent with carcinoid. No peritoneal extension of her disease was found. The authors hypothesize that this is a rare developmental aberration that has not been commonly recognized and potentially has implications for embryological development.

Though the incidence of cervical spine injuries in the pediatric population is relatively low at 1.2% of trauma patients, these injuries are often associated with severe neurologic deficits [1]. Upper cervical spine injuries are more common in children less than 11 years old [1–3]. This may be explained by the unique biomechanics of the pediatric cervical spine [4] as well as the anatomy [3, 5–8]. Furthermore, the craniocervical junction (CCJ) has a dynamic complex anatomic relationship between the occiput and the atlantoaxial structures. Congenitally anomalous CCJ can lead to an acute or chronic disability related to spinal cord compression [1, 9]. Most anomalies of the CCJ are asymptomatic and occult without the presence of an underlying syndrome that may herald its presence such as Klippel-Feil, Goldenhar syndrome, or numerous additional skeletal dysplasias [10]. We present a case of spinal cord injury without radiographic abnormality (SCIWORA) secondary to minor trauma in a pediatric patient with a congenital left atlanto-occipital assimilation joint.

In this article, we review the common entities causing the hearing loss and divide these pathologies into conductive hearing loss, sensorineural hearing loss, and mixed hearing loss. With this format, congenital pathologies are addressed first followed by the acquired entities. We review the common pathologies and the imaging findings affecting the hearing pathways from outside to inside, starting at the external auditory canal and moving inward toward the midbrain.

Pigmented villonodular synovitis (PVNS) is an uncommon, benign, but locally aggressive lesion characterized most commonly by synovial proliferation of the appendicular large joints, but occasionally involving a bursa or the tendon sheath. PVNS of the spine is rare, typically involving the posterior elements. The lytic radiographic appearance and fludeoxyglucose avidity of PVNS may mimic malignant bone lesions, including metastatic disease or myeloma. On T 1 and T 2 weighted, and gradient recalled echo MRI sequences, the low signal intensity may mimic giant cell tumour of the bone, gout or synovial amyloid deposits, thus posing a diagnostic dilemma for the imagers and the treating clinicians. We present a pathologically confirmed case of PVNS of the cervical spine in a 49-year-old female, detailing her imaging work-up, describing histopathological correlation and highlighting the lesion location and involvement of the joint space as useful imaging discriminators for diagnosing PVNS of the cervical spine.

This case report illustrates the neuroanatomy and neurovascular anatomy of the cervical spinal cord by exploring the pathophysiology of cervical cord infarction secondary to vertebral artery injury. The spinal cord is made up of several important tracts, including the dorsal column medial lemniscus system, corticospinal tracts, and the anterolateral system. Injury to one or more of these pathways can result in localizing neurological symptoms. Also contributing to the complexity of spinal vascular pathophysiology is the considerable variation to the cervical cord vascular anatomy. Understanding spinal cord function and neuroanatomy can aid in prompt diagnosis and management of ischemic cord lesions. In combination with a thorough clinical exam, advanced imaging techniques, such as diffusion tensor imaging, can not only localize the injury but also potentially help predict functional outcome.

Introduction: Patients with age-related degenerative changes in the cervical spine leading to cervical spondylosis may be symptomatic or asymptomatic. Older patients with radicular pain tend to have a better response to epidural steroid injections, but it is often difficult to predict which patients will have a positive response to selective nerve root block (SNRB). We analyzed whether the cervical neuroforaminal area measured on MRI predicts immediate therapeutic responses to SNRB in patients who have cervical radiculopathy. Methods: We retrospectively reviewed all patients who had cervical SNRBs treated at a single tertiary referral center. We recorded patient demographics, the neuroforaminal area of the symptomatic and contralateral sides, Visual Analog Scale (VAS) score pre- and post-injection, history of previous cervical surgery, comorbidities, and history of tobacco use. Results: Sixty-four patients with symptoms of cervical radiculopathy treated with neuroforaminal nerve root injections had appropriate imaging and VAS scores recorded. The average foraminal area of the symptomatic side before treatment was significantly smaller than the contralateral asymptomatic neuroforamen (p

Background S2-alar-iliac (S2AI) screws are 1 technique for lumbopelvic fixation to improve fusion rates across the lumbosacral junction that has gained wider acceptance. The S2AI screw crosses the cortical surfaces of the sacroiliac joint (SIJ), which may improve the biomechanical strength of the instrumentation. Objective To report preliminary radiographic outcomes of patients who underwent lumbopelvic fixation with S2AI screws with a minimum 12-month follow-up. Methods We retrospectively reviewed adult patients who underwent lumbopelvic fixation with S2AI screws. Patients with computed tomography (CT) scans obtained preoperatively and ≥12 months postoperatively were reviewed to determine whether there was S2AI screw backout or breakage, periscrew lucency, or SIJ degeneration, and to assess L5-S1 fusion status. Results Twenty-six S2AI screws in 13 patients were evaluated (mean follow-up 24.8 months [14-52 months]). Nine patients had L5-S1 interbody grafts. Partial periscrew lucency was identified in 7 S2AI screws (27%) in 5 patients (38%), and L5-S1 fusion occurred in 92% of patients. L5-S1 nonunion was seen in 1 patient (8%), who had evidence of bilateral screw loosening in the sacral portion. Four patients with screw loosening had an osseous L5-S1 fusion. No patients had radiographic evidence of progression of SIJ degeneration, experienced screw backout or breakage, required reoperation for L5-S1 nonunion, or had S2AI screw-related complication. Conclusion S2AI screws maintained their integrity without causing SIJ degeneration or major screw-related complications in this small retrospective series with short follow-up. Long-term results are needed to evaluate the durability of S2AI screws over time.

To prospectively evaluate the effect of preoperative functional magnetic resonance (MR) imaging localization of language and motor areas on therapeutic decision making in patients with potentially resectable brain tumors.The Institutional Review Board approved this HIPAA-compliant study, and each patient gave written informed consent. Thirty-nine consecutive patients (19 male, 20 female; mean age, 42.2 years) referred for functional MR imaging for possible tumor resection were prospectively evaluated. A preoperative diagnosis of brain tumor was made in all patients. Sentence completion and bilateral hand squeeze tasks were used to map language and sensory motor areas. Neurosurgeons completed questionnaires regarding the proposed treatment plan before and after functional MR imaging and after surgery. They also gave confidence ratings for functional MR imaging results and estimated the effect on surgical time, extent of resection, and surgical approach. The effect of functional MR imaging on changes in treatment plan was assessed with the Wilcoxon signed rank test. Differences in confidence ratings between altered and unaltered treatment plans were assessed with the Mann-Whitney U test. The estimated influence of functional MR imaging on surgical time, extent of resection, and surgical approach was denoted with summary statistics.Treatment plans before and after functional MR imaging differed in 19 patients (P.05), with a more aggressive approach recommended after imaging in 18 patients. There were no significant differences in confidence ratings for functional MR imaging between altered and unaltered plans. Functional MR imaging resulted in reduced surgical time (estimated reduction, 15-60 minutes) in 22 patients who underwent surgery, a more aggressive resection in six, and a smaller craniotomy in two.Functional MR imaging enables the selection of a more aggressive therapeutic approach than might otherwise be considered because of functional risk. In certain patients, surgical time may be shortened, the extent of resection increased, and craniotomy size decreased.

Objective: To characterize a cohort of patients with the signs and symptoms of posterior reversible encephalopathy syndrome (PRES), but with clinical and radiologic involvement of the spinal cord. Methods: We report 2 cases of PRES with spinal cord involvement and identified an additional 6 cases in the Medline database using various search terms related to “spinal PRES,” “spinal reversible posterior leukoencephalopathy syndrome,” and “spinal hypertensive encephalopathy.” We analyzed the clinical and imaging characteristics of the 8 cases. Results: Average age was 31 years, with 5 male and 3 female patients. All patients had severe acute hypertension and a confluent, expansile central spinal cord T2 hyperintensity spanning at least 4 spinal segments, originating at the cervicomedullary junction. Of 8 patients, 7 had hypertensive retinopathy, a favorable clinical course with only antihypertensive treatment, and resolution of the spinal cord lesions on follow-up imaging. A total of 4 of 8 patients had symptoms referable to the spinal cord lesions and only 1 of 8 had a seizure. Conclusion: In light of the already wide definition of PRES, we propose a new syndrome named PRES with spinal cord involvement (PRES-SCI). Clinicians should suspect PRES-SCI when patients with PRES have neurologic signs referable to the spinal cord, extreme elevation in blood pressure, MRI lesions that extend to the cervicomedullary junction, or grade IV hypertensive retinopathy. These clinical scenarios should prompt a cervical spine MRI to help guide patient management decisions and prognostication. When clinicians evaluate longitudinally extensive spinal T2 hyperintensities, they should consider PRES-SCI, which, if diagnosed, would spare patients the morbidity of a standard myelitis workup and empiric treatment.