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Background Cerebral venous sinus stenting is an established treatment for patients with idiopathic intracranial hypertension (IIH), refractory to medical management and with stenotic venous sinus on conventional cerebral venography. Currently, there are no clear guidelines on optimal noninvasive imaging modality for routine post- stenting follow- up. We investigated diagnostic yield of CT venography (CTV) for evaluation of stent patency. Methods We reviewed our clinical database of patients with a diagnosis of IIH, who underwent stenting of stenotic transverse or transverse/sigmoid sinus junction. Patients who had follow- up CTVs after more than 30 days were included in the final study group. All CTVs were reviewed by two readers for in- stent thrombosis, extrinsic stent compression, juxta- stent stenosis, and new contralateral venous sinus stenosis. Inter- observer agreement and association of stent patency with clinical outcomes (headache and papilledema) were assessed. Results In all 36 included patients with 38 cerebral venograms for stenting, follow- up CTVs demonstrated adequate opacifications of the venous sinuses and stents for confident evaluation for in- stent thrombosis, extrinsic stent compression, juxta- stent stenosis, and new contralateral venous sinus stenosis, with interobserver agreement coefficient of 0.7, 1.0, 0.8, and 1.0 respectively. Association between abnormal CTV and higher rates of persistent headache and lower rates of headache improvement/resolution was statistically significant (P- value of 0.01). Conclusion CTV is a reliable noninvasive imaging modality for evaluation of cerebral venous sinuses and stent patency following treatment of idiopathic intracranial hypertension with venous sinus stenting and could be used as a routine follow- up study. [ABSTRACT FROM AUTHOR]

Aim To describe the impact of steps towards reduction of procedural doses of radiation during neuroendovascular procedures. Methods Phantom exposures under controlled circumstances were performed using a Rando-Alderson adult-sized head phantom. Customized imaging protocols were devised for pediatric and adult imaging and implemented in clinical use. Outcome data for estimated skin doses (ESD) and dose-area product (DAP) following pediatric and adult diagnostic and interventional procedures over 4.5 years were analyzed retrospectively. results Dose estimates were reduced by 50% or more after introduction of customized imaging protocols in association with modification of personnel behavior compared with doses recorded with previously used vendor-recommended protocols. Discussion Substantial reductions in radiation use during neuroendovascular procedures can be achieved through a combination of equipment modification and operator behavior. [ABSTRACT FROM AUTHOR]

Background: Cerebrospinal fluid-venous fistulas (CSFVF) are a common cause of spontaneous intracranial hypotension (SIH). Transvenous embolization has emerged as a reliable treatment option. We review the clinical presentation, imaging, and clinical outcomes of 100 consecutive CSFVF patients who underwent embolization over 2 years., Methods: Baseline clinical characteristics, imaging findings (including Bern SIH score), technical outcomes, and long-term imaging and clinical outcomes were collected. All patients had at least 3 months of clinical follow-up and had baseline MRI. 99/100 patients underwent follow-up imaging at ≥3 months post-treatment., Results: 100 patients were included. Mean imaging and clinical follow-up duration was 8.3±7.7 months and 15.0±6.8 months, respectively. The mean duration of symptoms before embolization was 40.9±52 months. Mean baseline Bern SIH score was 5.9±3.3. The most common baseline symptoms were headache (96 patients), tinnitus (55 patients), and cognitive dysfunction (44 patients). Technical success rate was 100%. Mean post-treatment Bern SIH score was 0.9±1.6 (P<0.0001). Following treatment, 95% of patients reported significant improvement or resolution in symptoms (58 patients reporting resolution and 37 reporting improvement). 5 patients reported no improvement. There were no major procedural or periprocedural complications. 10 patients had minor procedural complications that did not result in any change in management (Onyx emboli, venous perforation). 19 patients had rebound intracranial hypertension requiring acetazolamide therapy. 7 patients had recurrent fistula at the initially treated level., Conclusions: Transvenous embolization of CSFVF in SIH patients is safe and effective with a 95% treatment response, significant improvement in imaging outcomes, and a very low rate of complications., Competing Interests: Competing interests: WB holds equity in Nested Knowledge, Superior Medical Editors, Piraeus Medical, Sonoris Medical, and MIVI Neurovascular. He receives royalties from Medtronic and Balloon Guide Catheter Technology. He receives consulting fees from Medtronic, Stryker, Imperative Care, Microvention, MIVI Neurovascular, Cerenovus, Asahi, and Balt. He serves in a leadership or fiduciary role for MIVI Neurovascular, Marblehead Medical LLC, Interventional Neuroradiology (Editor in Chief), Piraeus Medical, and WFITN. The remaining authors declare no conflicts of interest., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Purpose: CSF-venous fistulas are a common cause of spontaneous intracranial hypotension. The diagnosis and precise localization of these fistulas hinges on specialized myelographic techniques, which mainly include decubitus digital subtraction myelography and decubitus CT myelography (using either energy integrating or photon counting detector CT). A previous case series showed that cone beam CT myelography, performed as an adjunctive tool with digital subtraction myelography, increased the detection of CSF-venous fistulas. Here, we sought to determine the additive yield of cone beam CT myelography for CSF-venous fistula detection in a consecutive series of patients with spontaneous intracranial hypotension who underwent concurrent decubitus digital subtraction myelography and cone beam CT myelography., Materials and Methods: We retrospectively searched our institutional database for all consecutive patients who underwent decubitus digital subtraction myelography with adjunctive cone beam CT myelography between 8/5/2021 and 8/5/2024. We excluded any patients harboring extradural CSF on spine imaging, not meeting International Classification of Headache Disorders (3 rd edition) criteria for spontaneous intracranial hypotension, or not having undergone technically successful cone beam CT myelography in combination with digital subtraction myelography. All myelographic images were independently reviewed by two neuroradiologists. We calculated the diagnostic yield of both myelographic tests for localizing a CSF-venous fistula., Results: We identified 100 patients who underwent decubitus digital subtraction myelography with adjunctive cone beam CT. We excluded 15 patients based on above criteria. 59/85 patients had a single definitive CSF-venous fistula. Among positive cases, the fistula was visible on digital subtraction myelography in 38/59 patients and visible on cone beam CT myelography in 59/59 patients. In 26/85 patients, no definitive fistula was identified on either modality., Conclusions: Cone beam CT myelography increased the diagnostic yield for CSF-venous fistula detection and may be a useful addition to digital subtraction myelography., Abbreviations: CB-CTM = cone beam CT myelography; CVF = CSF-venous fistula; DSM = digital subtraction myelography; EID-CTM = energy integrating detector CT myelography; PCD CTM = photon counting detector CT myelography; SIH = spontaneous intracranial hypotension., Competing Interests: The authors declare no conflicts of interest related to the content of this article., (© 2024 by American Journal of Neuroradiology.)

CSF-venous fistulas (CVFs) are a common cause of spontaneous intracranial hypotension. Despite their relatively frequent occurrence, they can be exceedingly difficult to detect on imaging. Since the initial description of CVFs in 2014, the recognition and diagnosis of this type of CSF leak has continually increased. As a result of multi-institutional efforts, a wide spectrum of imaging modalities and specialized techniques for CVF detection is now available. It is important for radiologists to be familiar with the multitude of available techniques, because each has unique advantages and drawbacks. In this article, we review the spectrum of imaging modalities available for the detection of CVFs, explain the advantages and disadvantages of each, provide typical imaging examples, and discuss provocative maneuvers that may improve the conspicuity of CVFs. Discussed modalities include conventional CT myelography, dynamic myelography, digital subtraction myelography, conebeam CT myelography, decubitus CT myelography by using conventional energy-integrating detector scanners, decubitus photon counting CT myelography, and intrathecal gadolinium MR myelography. Additional topics to be discussed include optimal patient positioning, respiratory techniques, and intrathecal pressure augmentation., (© 2024 by American Journal of Neuroradiology.)

Background and Purpose: CSF-venous fistulas are a common cause of spontaneous intracranial hypotension. Lateral decubitus digital subtraction myelography and CT myelography are the diagnostic imaging standards to identify these fistulas. Photon-counting CT myelography has technological advantages that might improve CSF-venous fistula detection, though no large studies have yet assessed its diagnostic performance. We sought to determine the diagnostic yield of photon-counting detector CT myelography for detection of CSF-venous fistulas in patients with spontaneous intracranial hypotension., Materials and Methods: We retrospectively searched our database for all decubitus photon-counting detector CT myelograms performed at our institution since the introduction of the technique in our practice. Per our institutional workflow, all patients had prior contrast-enhanced brain MR imaging and spine MR imaging showing no extradural CSF. Two neuroradiologists reviewed preprocedural brain MRIs, assessing previously described findings of intracranial hypotension (Bern score). Additionally, 2 different neuroradiologists assessed each myelogram for a definitive or equivocal CSF-venous fistula. The yield of photon-counting detector CT myelography was calculated and stratified by the Bern score using low-, intermediate-, and high-probability tiers., Results: Fifty-seven consecutive photon-counting detector CT myelograms in 57 patients were included. A single CSF-venous fistula was definitively present in 38/57 patients. After we stratified by the Bern score, a definitive fistula was seen in 56.0%, 73.3%, and 76.5% of patients with low-, intermediate-, and high-probability brain MR imaging, respectively., Conclusions: Decubitus photon-counting detector CT myelography has an excellent diagnostic performance for the detection of CSF-venous fistulas. The yield for patients with intermediate- and high-probability Bern scores is at least as high as previously reported yields of decubitus digital subtraction myelography and CT myelography using energy-integrating detector scanners. The yield for patients with low-probability Bern scores appears to be greater compared with other modalities. Due to the retrospective nature of this study, future prospective work will be needed to compare the sensitivity of photon-counting detector CT myelography with other modalities., (© 2023 by American Journal of Neuroradiology.)

Background and Purpose: Several approaches to the treatment of dissecting aneurysms of the vertebrobasilar system have been used. We evaluated our endovascular experience, which includes trapping and proximal occlusion., Methods: Thirty-five patients with intradural vertebrobasilar dissecting aneurysms presented to our institution between 1992 and 2002. Twenty-six were treated by endovascular means and two with surgery. In the endovascular group, 14 were in a supra-posterior inferior cerebellar artery (PICA) location, and three of these extended to the vertebrobasilar junction on the initial angiogram. Ten were located in an infra-PICA location, or no antegrade flow was seen in the PICA or anterior spinal artery. Two were located at the PICA with antegrade flow preserved in the branch. Twelve lesions were treated with trapping; another 14 were initially treated with proximal occlusion techniques, two of which eventually required trapping procedures. Follow-up images were obtained within 1 year of initial treatment in 24 patients. Mean follow-up for these patients was 3.5 years., Results: Initial treatments were technically successful and without complication in all 26 patients. Follow-up examinations showed complete cure in 19 of 24 patients. One patient died of global ischemia after presenting as Hunt and Hess grade 5 with subarachanoid hemorrhage. Two recurrent hemorrhages occurred in patients in the proximal occlusion group; one died, and the other underwent a trapping procedure. One patient developed contralateral vertebral dissection 24 hours after occlusion of a dissecting aneurysm of the dominant vertebral artery and died of a brain stem infarct. Another died of probable vasospasm, and the last died of an unknown cause 1 month after treatment. Two patients had recanalization despite an initial trapping procedure, both underwent further treatment. Mortality rate was 20% in the treated group (including the two patients treated surgically), with four of five deaths occurring during the initial hospital course. Mortality rate was 50% in the six patients in the untreated group who were available for follow-up., Conclusion: Dissecting aneurysms of the vertebrobasilar system remain high-risk lesions because of their natural history. They can be managed by endovascular methods according to aneurysm location, configuration, collateral circulation, and time of presentation. Trapping results in better prevention of rehemorrhage. Proximal occlusion can achieve occlusion without manipulation of the affected segment when more direct endovascular occlusion or stent placement cannot be performed.

Sacral insufficiency fracture is a debilitating injury for which no active treatment is currently available. We present three consecutive cases of elderly patients with sacral insufficiency fractures whose symptoms were relieved immediately by treatment of the fractures by polymethylmethacrylate injections, a so-called sacroplasty.