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Multimodal CT scans, including non-contrast CT, CT perfusion, and CT angiography, are widely used in acute stroke diagnosis and therapeutic planning. While each imaging modality has its advantage in brain cross-sectional feature visualizations, the varying image resolution of different modalities hinders the ability of the radiologist to discern consistent but subtle suspicious findings. Besides, higher image quality requires a high radiation dose, leading to increases in health risks such as cataract formation and cancer induction. In this work, we propose a deep learning-based method Transfer-GAN that utilizes generative adversarial networks and transfer learning to improve multimodal CT image resolution and to lower the necessary radiation exposure. Through extensive experiments, we demonstrate that transfer learning from multimodal CT provides substantial visualization and quantity enhancement compare to the training without learning the prior knowledge.

There is no standard treatment algorithm for patients who present to the emergency department (ED) with acute traumatic brain injury (TBI). This is in part because of the heterogeneity of the injury pattern and the patient profile, and the lack of evidence-based guidelines, especially for mild TBI in adults. As TBI is seen more and more frequently in the ED, a standardized assessment would be beneficial in terms of efficiency. The authors present their ED approach to mild TBI evaluation in the ED, along with results to date. These data represent a prospective observational cohort study, where each patient provided individual, written informed consent.

OBJECTIVE The objective of this study was to compare the variability of computed tomography perfusion (CTP) results in identical data sets of middle cerebral artery (MCA) acute ischemic stroke (AIS) generated by standard singular value decomposition (sSVD) deconvolution and tracer delay-insensitive singular value decomposition (SVD+) algorithm analyses. METHODS Whole-brain 320-detector-row CTP data sets from 9 unilateral MCA AIS cases and 9 controls were retrospectively analyzed. Computed tomography perfusion values for the combined core/penumbra, contralateral hemispheres and arterial territories were measured and compared with literature values. Simple linear regression models are provided to predict corresponding SVD+ value and sSVD CTP values. RESULTS In the core/penumbra, sSVD generated lower cerebral blood flow (CBF) values, higher mean transit time (MTT) values, and a broader range of CBF and MTT values as compared with SVD+. Mean transit time value differences between the core/penumbra and contralateral hemispheres were statistically significant using sSVD, whereas those of SVD+ were not. Goodness of fit between algorithms for the core/penumbra was lower for CBF (0.483) and MTT (0.494), as compared with time to peak (0.891) and cerebral blood volume (0.997). CONCLUSIONS In this study using identical source data for patients with MCA AIS, use of either sSVD or SVD+ analyses created statistically significant differences in the CTP value results. Tracer delay-sensitive and -insensitive algorithms impact CTP results in AIS and controls, highlighting the need to pursue additional studies that assess the variability, accuracy, and clinical implications of CTP results generated when using heterogeneous deconvolution algorithms.

OBJECTIVE: Whole-brain computed tomography perfusion (CTP) data sets generated by tracer delay-insensitive singular value decomposition plus (SVD+) and standard singular value decomposition (sSVD) deconvolution algorithms were evaluated to quantify relatedness and discrepancies in CTP results. METHODS: Twenty females with symmetrical hemispheric CTP maps indicative of brain tissue without apparent abnormalities were studied. Tissue-specific CTP values were analyzed. RESULTS: Standard SVD values were higher than SVD+ for cerebral blood flow. Other CTP values had minimal differences across brain regions. All simple linear regression models were statistically significant (P < 0.05) except for cerebral blood flow in white matter (P = 0.06). Cerebral blood volume had a good model fit, and mean transit time, a poor fit. CONCLUSIONS: Corresponding fitted CTP values for sSVD and SVD+ based on regression equations for brain-tissue types are presented. Additional research is required to compare SVD+ and sSVD in disease states when significant hemodynamic brain alterations are present.

Objective. To study the impact of helmet use on outcomes after recreational vehicle accidents.Methods. This is an observational cohort of adult and pediatric patients who sustained a TBI while riding a recreational vehicle. Recreational vehicles included bicycles, motorcycles, and all-terrain vehicles (ATVs), as well as a category for other vehicles such as skateboards and scooters.Results. Lack of helmet use was significantly associated with having a more severe traumatic brain injury and being admitted to the hospital. Similarly, 25% of those who did wearing a helmet were admitted to the ICU versus 36% of those who did not (P=0.0489). The hospital length of stay was significantly greater for patients who did not use helmets.Conclusion. Lack of helmet use is significantly correlated with abnormal neuroimaging and admission to the hospital and ICU; these data support a call for action to implement more widespread injury prevention and helmet safety education and advocacy.

Papaverine has been associated with transient cranial nerve dysfunction after topical application during craniotomy. The authors report similar dysfunction after the use of papaverine affected brainstem structures. Two patients undergoing craniotomy for clipping of an aneurysm experienced bilateral depression of cortical somatosensory evoked potentials to both median and tibial nerve stimulation after administration of papaverine. Arterial blood gas analysis, hemodynamic parameters, and anesthetic levels remained constant throughout these somatosensory evoked potential changes. In addition, intraoperative angiography and immediate postoperative CT imaging showed intact blood flow with complete exclusion of the aneurysm. Both patients recovered within 1–2 hours and had normal neurological examination findings after extubation. Topical papaverine use may be associated with direct effects on brainstem structures. The transient nature of those changes suggests that aggressive intervention may not be needed. Maneuvers to limit the spread of papaverine to basal cisterns should be considered.

Review of the University of Florida experience in treating advanced squamous cell carcinomas of the head and neck with concurrent intraarterial cisplatin and radiotherapy (RADPLAT).Thirty-five patients with Stage III or IV head and neck squamous cell carcinomas were treated between November 2000 and October 2001 with 3 to 4 cycles of weekly intraarterial cisplatin (150 mg/m2) and a rapid infusion of the neutralizing agent sodium thiosulfate (9 g/m2), followed by a continuous infusion of sodium thiosulfate (12 g/m2), with concomitant radiotherapy (RT). The primary site was treated with 70 Gy in 35 fractions with 6 MV photons, and the low neck received 50 to 70 Gy depending on nodal involvement. Median follow-up for all patients was 4.06 years; median follow-up for living patients was 4.34 years.The 4-year outcomes were: local-regional control, 78%; distant metastasis-free survival, 83%; cause-specific survival, 65%; and survival, 57%. The majority of patients with recurrent disease failed at the primary site (73%); the remaining 27% of patients with recurrent disease failed only in distant sites. Nine patients required a neck dissection after chemoradiation because of suspected residual disease; 2 of 9 patients had residual tumor in the neck nodes. Severe osteoradionecrosis occurred in 26% of patients, and 9 of 35 patients (26%) required a permanent gastrostomy.RADPLAT results in excellent local-regional control and survival in patients with advanced squamous cell carcinomas of the head and neck. Outcomes from the University of Florida are comparable to those reported by other institutions. However, in our limited experience, the likelihood of osteoradionecrosis and permanent gastrostomy may be higher than what might be anticipated after RT alone or combined with intravenous chemotherapy.

A 72-year-old woman with a painful left third cranial nerve palsy due to a basilar artery aneurysm situated between the superior cerebellar and posterior cerebral arteries was treated with Guglielmi detachable coils (GDCs). Despite a good initial angiographic result with a small residual neck and improvement in the ocular motility and pain, the patient experienced worsening of the third cranial nerve palsy 15 months later. Cerebral angiography confirmed coil compaction with aneurysmal regrowth. A second endovascular coil embolization resulted in complete obliteration of the aneurysm. The patient experienced complete resolution of the pain and partial resolution of the third cranial nerve palsy. In some patients, a small residual aneurysm neck after endovascular embolization therapy with GDCs can result in delayed aneurysmal regrowth due to coil compaction. Clinical manifestations may herald this dangerous regrowth.

Introduction: Although there are approximately 1.1 million case presentations of mild traumatic brain injury (mTBI) in the emergency department (ED) each year, little data is available to clinicians to identify patients who are at risk for poor outcomes, including 72-hour ED return after discharge. An understanding of patients at risk for ED return visits during the hyperacute phase following head injury would allow ED providers to develop clinical interventions that reduce its occurrence and improve outcomes. Methods: This institutional review board-approved consecutive cohort study collected injury and outcome variables on adults with the purpose of identifying positive predictors for 72-hour ED return visits in mTBI patients. Results: Of 2,787 mTBI patients, 145 (5%) returned unexpectedly to the ED within 72 hours of hospital discharge. Positive predictors for ED return visits included being male (p=0.0298), being black (p=0.0456), having a lower prehospital Glasgow Coma Score (p=0.0335), suffering the injury due to a motor vehicle collision (p=0.0065), or having a bleed on head computed tomography (CT) (p=0.0334). ED return visits were not significantly associated with age, fracture on head CT, or symptomology following head trauma. Patients with return visits most commonly reported post-concussion syndrome (43.1%), pain (18.7%), and recall for further clinical evaluation (14.6%) as the reason for return. Of the 124 patients who returned to the ED within 72 hours, one out of five were admitted to the hospital for further care, with five requiring intensive care unit stays and four undergoing neurosurgery. Conclusion: Approximately 5% of adult patients who present to the ED for mTBI will return within 72 hours of discharge for further care. Clinicians should identify at-risk individuals during their initial visits and attempt to provide anticipatory guidance when possible. [West J Emerg Med. 2015;16(2):481–485.]

PERCUTANEOUS VERTEBROPLASTY WAS developed in France by Deramond et al., who provided initial reports of the procedure in 1987. This minimally invasive procedure uses a large-bore bone-cutting needle to percutaneously access a vertebral body, inject bone cement, and thereby stabilize and reinforce the remaining bone structure. The procedure was used initially to treat aggressive hemangiomas, but it then was extended to the treatment of osteolytic metastases and myeloma and currently osteoporotic compression fractures refractory to medical therapy. In this article, we review the current technique and its indications along with emerging devices and areas of current research.

Background.Improper positioning of central venous catheters (CVCs) can lead to erosion through the superior vena cava (SVC) or right atrium (RA) and pericardial tamponade. It is widely recommended that the tip of CVCs be placed above the heart or the pericardial reflection. The purpose of this study was to identify an easily recognized landmark to allow identification of the proximal extent of the pericardial reflection on a routine chest radiograph (CXR). Methods.We analyzed the computerized tomograms of the chest from 97 adults to evaluate the relationship between the pericardial reflection, SVC, carina, and right mainstem bronchus. Correlations between demographic data and length of SVC or pericardial reflection were sought. Results.The mean length of the SVC was 6.5 cm. The pericardial reflection covered an average of 3.6 cm of the distal SVC. The carina was a mean of 1.3 cm below the mid-point of the SVC and 0.7 cm below the pericardial reflection. There was no significant correlation between SVC or pericardial length and either age, height, or weight. Conclusions.The distal half of the SVC lies within the pericardial reflection, and the upper limit of the pericardial reflection is slightly above the level of the carina. These landmarks are useful for determining proper position of the tip of a CVC on CXR.

Background The objective of this study was to determine who gets post-concussion syndrome (PCS) after mild traumatic brain injury or head injury. Methods Patients presented within an hour of mild traumatic brain injury (mTBI). Written informed consent was obtained from all patients, who then provided detailed answers to surveys at the time of injury as well as at 1 week and 1 month follow-up. Statistical analyses were performed using JMP 11.0 for the Macintosh. Results The most commonly reported symptoms of PCS at first follow-up were headache (27%), trouble falling asleep (18%), fatigue (17%), difficulty remembering (16%), and dizziness (16%). Furthermore, only 61% of the cohort was driving at 1 week follow-up, compared to 100% prior to the injury. Linear regression analysis revealed the consumption of alcohol prior to head injury, the mechanism of head injury being a result of motor vehicle collision (MVC) or fall, and the presence of a post-injury headache to be significantly associated with developing PCS at 1 week follow-up, while the occurrence of a seizure post-injury or having an alteration in consciousness post-injury was significantly associated with developing PCS at 1 month follow-up. On multivariate regression analysis, the presence of a headache post-injury was the most robust predictor, retaining statistical significance even after controlling for age, gender, and presence of loss of consciousness (LOC), alteration of consciousness (AOC), post-traumatic amnesia (PTA), seizure, or vomiting. Conclusions The results of this prospective study suggest that headache right after the head injury, an alteration of consciousness after the head injury, and alcohol consumption prior to the head injury are significant predictors of developing PCS, which occurs with equal frequency in men and women. Early identification of those who are at risk of developing PCS would diminish the burden of the injury and could potentially reduce the number of missed work and school days.

To assess the clinical performance and usefulness of an on-line patient exposure meter installed on a neuroradiologic biplane imaging system.A commercial on-line patient exposure meter was installed on each plane of a biplane neuroradiologic imaging system. The meter computed skin exposures on the basis of selected technique factors (tube potential and current) and information about patient location relative to the x-ray tube. Simulations were performed to measure the system accuracy with an angiographic anthropomorphic head phantom with the skin exposures measured with an ionization chamber. Skin doses were computed for 114 consecutive patients who underwent diagnostic and interventional neuroradiologic procedures.Agreement between measured and computed skin exposures in fluoroscopy, plain radiography, and digital imaging was generally within 5% of the true skin dose. For all fluoroscopic and radiographic procedures, total median skin doses were 1.20 and 0.64 Gy for the frontal and lateral planes, respectively. In both planes, patient skin doses resulted primarily from digital subtraction angiographic acquisitions. In 29 (25%) patients, the skin dose exceeded 2.00 Gy, but no radiation-induced deterministic effects were observed.An on-line patient exposure meter can provide accurate radiation skin dose data in patients undergoing diagnostic and therapeutic neuroradiologic procedures.

Infection is a well-known cause of cerebral vasculopathy and vasculitis. We report a 36-year-old woman with cerebral vasculitis and ischemic stroke secondary to herpes simplex virus (HSV). MRI studies revealed a pontine stroke with basilar artery stenosis and vessel wall gadolinium enhancement. This case demonstrates the ability of HSV to cause a focal brainstem vasculitis and the utility of enhanced MRI in the diagnosis of stroke related to HSV central nervous system vasculitis.

A 50-year-old woman presented with 4 weeks of ascending paralysis associated with nausea, vomiting, hypophonia, and dyspnea. Examination revealed hypophonia, diminished strength in the upper and lower extremities, increased reflexes throughout, and a T10 sensory level. Imaging ([figures 1][1] and [2

A case of an anterior third ventricular meningioma in a 17-year-old girl is presented. Gross total resection of this tumor with minimal morbidity was accomplished by transcallosal exposure through a frontal craniotomy. A review of the literature implies that surgical morbidity and mortality for the removal of third ventricular meningiomas markedly improved with the use of the operating microscope. Despite advanced imaging capabilities, radiographic analysis of a solid third ventricular mass may not always determine tissue diagnosis. In addition, preoperative placement of a ventriculoperitoneal shunt will treat hydrocephalus, but may limit the surgical options for tumor exposure. The differential diagnosis for this solid anterior third ventricular mass is presented, and the method of treatment for this case is discussed.

A preterm male infant developed a rapidly growing, treatment-resistant orbital hemangioma. Despite aggressive management, the patient required enucleation of his right eye and image-guided ethanol sclerosis to limit tumor progression intracranially. J Pediatr Ophthalmol Strabismus 2006;43:365-366. AUTHORS Drs. Welch, Lessner, and Levine are from the Department of Ophthalmology, Drs. Ignatz and Sullivan are from the Department of Neonatology, and Dr. Peters is from the Department of Radiology, University of Florida, Gainesville, Florida. Originally submitted May 17, 2005. Accepted for publication June 20, 2005. Address reprint requests to Lawrence M. Levine, MD; University of Florida; Department of Ophthalmology; PO Box 100284; Gainesville, FL 32610.

A 34-year-old woman underwent embolization of a left paraorbital arteriovenous malformation guided with a bi-plane x-ray system in two sessions separated by 3 days. Imaging included 110 minutes of fluoroscopy and 46 digital subtraction angiography acquisitions. Entrance skin dose rates were determined with measurements performed on a skull phantom. The maximum possible skin dose was estimated to be 6.6 Gy, which is consistent with the temporary epilation in the right occipital region of the skull reported by the patient approximately 5 weeks later.

We investigated radiation doses to 149 adult patients who underwent interventional neuroradiologic procedures, consisting of 132 patients who had diagnostic imaging examinations and 17 patients who had therapeutic procedures. The interventional procedures were carried out on a biplane system capable of performing fluoroscopy and digital subtraction angiography (DSA). The x-ray imaging system was interfaced to a patient dosimetry system, which computed surface (skin) doses based on the selected radiographic technique factors in each of the radiographic and fluoroscopic imaging modes. For each patient, an assessment was made of the maximum surface dose received during the procedure, which predicts the possibility of inducing deterministic effects. Knowledge of the surface doses, beam quality and x-ray cross sectional area permitted the computation of the total energy imparted to each patient. Energy imparted values were converted to effective dose, which provides an estimate of the stochastic radiation risk to the patient. The median surface dose for the frontal plane during diagnostic imaging examinations was 1.3 Gy, with a maximum surface dose of 5.1 Gy. The median surface dose for the frontal plane during therapeutic procedures was 2.8 Gy with a maximum surface dose of 5.0 Gy. Ratios of the lateral to frontal median surface doses were 0.47 for diagnostic examinations and 0.68 for interventional procedures. The median energy imparted was 1.8 J during fluoroscopy, and 4.3 J during radiography, showing that on average, 66% of the patient exposure comes from radiographic imaging (DSA). For diagnostic examinations, the median patient effective dose was 33 mSv, with a maximum of 152 mSv. For therapeutic procedures, the median patient effective dose was 74 mSv, with a maximum of 156 mSv. In interventional neuroradiology, surface doses could induce deterministic effects, and the corresponding effective doses are noticeably higher than those normally encountered in diagnostic radiology.

Digital subtraction angiography images were obtained of a phantom containing 1 mm diameter vessels. The iodine concentrations ranged from 5 to 50 mg/cc, which permitted the detection threshold iodine concentration to be determined. The source to image receptor distance was 105 cm, and image magnification was varied between 1.15 and 2.0. One experiment was performed at an input exposure of 1 (mu) Gy per frame, and a second experiment was performed at 4 (mu) Gy per frame.

Large and giant paraclinoid aneurysms are challenging to treat by either surgical or endovascular means. Visual dysfunction secondary to optic nerve compression and its relationship with aneurysm size, pulsation and thrombosis is poorly understood. We present a patient with a giant paraclinoid aneurysm resulting in bilateral visual loss that worsened following placement of a Pipeline Embolization Device and adjunctive coiling. Visual worsening occurred in conjunction with aneurysm thrombosis, increase in maximal aneurysm diameter and new adjacent edema. Her visual function spontaneously improved in a delayed fashion to better than pre-procedure, in conjunction with reduced aneurysmal mass effect, size and pulsation artifact on MRI. This report documents detailed ophthalmologic and MRI evidence for the role of thrombosis, aneurysm mass effect and aneurysm pulsation as causative etiologies for both cranial nerve dysfunction and delayed resolution following flow diversion treatment of large cerebral aneurysms.

Objective: MTT map is a sensitive and specific map differentiating ischemic penumbra (IP) from infarct core (IC) in acute stroke. Background We present eight patients with acute ischemic stroke who presented to our emergency department and underwent computed tomography perfusion (CTP) imaging utilizing the Toshiba Aquilion ONE 320-dectector row CT scanner running a Singular Value Decomposition Plus (SVD+) algorithm to generate perfusion maps. Design/Methods: A retrospective analysis of patients who presented with an acute ischemic stroke was performed. Patients receiving a high quality whole-brain CTP scan without evidence of hemorrhage on initial or follow-up CT who additionally underwent follow up MRI with DWI within 48 hours were included. Vitrea FX 3.1 software was utilized by a single, blinded neuroradiologist to process images. At risk territory was defined by the area of delayed perfusion on the time to peak map. The IC volume on the MTT map, as determined by values less than 3 seconds within this at risk territory, was measured on each slice. The total IC volumes were calculated by taking the sum of the IC on individual slices multiplied by the thickness of each slice. Pearson correlation was applied to assess for statistical correlation between IC on CTP and area of restriction on follow up DWI. Results: A comparison was made between the volumes of infarct core utilizing SVD+ MTT maps and DWI MR sequences. There was a significant correlation between infarct core volumes measured on MTT and infarct volumes on follow up DWI (r = 0.79). Conclusions: Although further studies are required to validate this observation, preliminary studies suggest that utilization of the SVD+ MTT map may allow for an accurate assessment of the infarct core and surrounding salvageable tissue. The additional information garnered from accurate interpretation of the SVD+ MTT maps may further guide clinicians in critical decision making during acute ischemic events. Disclosure: Dr. Dababneh has nothing to disclose. Dr. Guerrero has nothing to disclose. Dr. Wilson has nothing to disclose. Dr. Mocco has received personal compensation for activities with Concentric Inc as a consultant. Dr. Bennett has nothing to disclose. Dr. Hoh has received personal compensation for activities with Codman Neurovascular. Dr. Yuzeforich-Khanna has nothing to disclose. Dr. Peters has received personal compensation for activities with Toshiba as a speaker. Dr. Waters has nothing to disclose.

PACS research and development efforts at the University of Florida, Department of Radiology have been directed solely toward solving clinical problems with an objective of incorporating successful products or improving the functionality, performance, and reliability of the system. This paper describes the current network and system, experiences with system upgrades and changed, quality control measures used to verify that the system is operational, and current works in progress.© (1992) COPYRIGHT SPIE--The International Society for Optical Engineering. Downloading of the abstract is permitted for personal use only.

Stereotactic radiosurgery has become a major force in the treatment of arteriovenous malformations (AVMs) of the brain. After treatment, obliteration of flow through the malformation occurs in 75%-85% of cases within 2 years, assuming the entire AVM nidus can be encompassed by the radiation field. Because the follow-up period is relatively long, a noninvasive means to assess residual transnidus blood flow is desirable. The authors report favorable findings after a comparative analysis of 85 posttreatment magnetic resonance images and 27 follow-up cerebral arteriograms in 34 patients treated with stereotactic radiosurgery. The authors found that transnidus flow can be determined from apparent signal intensity differences between tandem two-dimensional gradient-recalled echo images obtained first without and then with gradient moment nulling (flow compensation), with empirically derived pulse parameters. This method provides a means to monitor the reduction in AVM matrix size and to assess the extent of persistent arteriovenous shunting (ie, blood flow) across the nidus.

Background To characterize the patterns of presentation of adults with head injury to the Emergency Department. Methods This is a cohort study that sought to collect injury and outcome variables with the goal of characterizing the very early natural history of traumatic brain injury in adults. This IRB-approved project was conducted in collaboration with our Institution’s Center for Translational Science Institute. Data were entered in REDCap, a secure database. Statistical analyses were performed using JMP 10.0 pro for Windows. Results The cohort consisted of 2,394 adults, with 40% being women and 79% Caucasian. The most common mechanism was fall (47%) followed by motor vehicle collision (MVC) (36%). Patients sustaining an MVC were significantly younger than those whose head injury was secondary to a fall (P < 0.0001). Ninety-one percent had CT imaging; hemorrhage was significantly more likely with worse severity as measured by the Glasgow Coma Score (chi-square, P < 0.0001). Forty-four percent were admitted to the hospital, with half requiring ICU admission. In-hospital death was observed in 5.4%, while neurosurgical intervention was required in 8%. For all outcomes, worse TBI severity per GCS was significantly associated with worse outcomes (logistic regression, P < 0.0001, adjusted for age). Conclusion These cohort data highlight the burden of TBI in the Emergency Department and provide important demographic trends for further research.