Value of prominent flow voids without cord edema in the detection of spinal arteriovenous fistulae

Purpose: To determine the prevalence of spinal dural arteriovenous fistulae (SDAVF) in patients presenting with prominent vascular flow voids on imaging without other imaging findings suggestive of SDAVF. Methods: We retrospectively identified patients from January 1, 2005 to March 1, 2012 who underwent spinal angiography for suspected SDAVF with prominent vascular flow voids on prior imaging. We excluded patients with other major spinal pathology or other imaging findings of SDAVF including cord hyperintensity, enhancement, or expansion. We calculated the proportion of patients with positive findings for SDAVF on angiography and evaluated the prevalence of SDAVF for this finding alone and in correlation with clinical findings. Results: 18 patients underwent spinal angiography for prominent flow voids on imaging without other spinal pathology or imaging findings of SDAVF. Three had a SDAVF detected on angiography. The prevalence of SDAVF in this population was low, only 17% (95% CI 6-39%). All of the patients with positive angiography findings had myelopathy, increasing the prevalence to 100% if the additional clinical finding of myelopathy was present. Conclusions: Prominent flow voids without other imaging findings suggestive of SDAVF is poorly predictive of the presence of a SDAVF, unless myelopathy is present clinically. © 2014 Alhilali et al

Imaging of the brachial and sacral plexus

It is widely understood that the brachial and sacral plexuses are networks of peripheral nerves responsible for innervation of the upper and lower limbs. However, knowledge of the anatomic structures and their relationship to adjacent muscles, vessels, and osseous landmarks is less widely appreciated. The authors encourage radiologists to enhance their understanding of these networks, and, in this article, demonstrate how high-resolution magnetic resonance imaging of the brachial and sacral plexus provides important information used to determine the need for biopsy or surgical planning and treatment

Clinical and Neuroimaging Manifestations of Erdheim–Chester Disease: A Review

ABSTRACT Erdheim–Chester disease (ECD) is a rare disorder characterized by accumulation of non‐Langerhans cell histiocytes in multiple organs. The clinical manifestations are protean and vary from asymptomatic focal disease to potentially fatal multisystem disorder. The commonest presentation is symmetric osterosclerotic lesions of lower extremity long bones; other organs, including cardiovascular, nervous, and endocrine system may be affected. Central nervous system involvement can occur in up to 50% cases and is associated with poor prognosis. The disease pathogenesis involves organ involvement secondary to histiocytic infiltration and systemic inflammation driven by Th1 cytokine activation. The recent discovery of activating mutations in proto‐oncogene B‐rapidly accelerated fibrosarcoma (BRAF) V600E and other genes involved in mitogen‐activated protein kinase (MAPK) pathways has led to redefinition of ECD as a myeloid neoplastic disorder. The diagnosis requires histochemical and molecular analysis of histiocytes in tissue biopsies in patients with compatible clinical and imaging features. The treatment options include interferon‐alpha, anakinra, and immunosuppressive therapies. Better understanding of disease pathogenesis has led to development of novel targeted and effective therapies including BRAF and MEK inhibitors. The rarity of the disease and variable clinical features and course often results in diagnostic errors and delays. Rare primary neurological presentation can occur mimicking CNS inflammatory, neoplastic, or demyelinating disorders. We report an unusual case of ECD presenting with progressive encephalopathy and ataxia along with multifocal brainstem and cerebellar lesions. A comprehensive review of clinical and neuroimaging features and immunohistochemical and molecular characteristic of ECD are presented along with review of neuroimaging findings in two previously reported cases

Anomalous Extraocular Muscles: A Case Series of Orbital Bands Connecting the Superior Rectus to Inferior Rectus

Orbital bands are rarely reported abnormal connections of tissue that bridge extraocular muscles and/or the globes. A series of 7 cases of orbital bands that bridged the superior and inferior rectus muscles were reviewed. The bands in this small series were discovered as incidental findings, with no relation to the patients' symptoms and, therefore, may have been of no clinical significance

Sacral morel-lavallée lesion: a not-so-rare diagnosis

Morel-Lavallée lesions are closed soft tissue degloving injuries with a propensity to become infected, arising in the lumbosacral region or even the scalp, common anatomical locations in neuroradiological studies. The radiologist must recognize this entity, its traumatic etiology, and treatment options. Our patient's Morel-Lavallée lesion was evaluated with ultrasound and MRI, demonstrating a predominantly hemorrhagic lesion successfully managed by aspiration

Endovascular Treatment of Isolated Dissecting Aneurysm of the Posterior Inferior Cerebellar Artery

BACKGROUND AND PURPOSE: Isolated dissecting aneurysms of the posterior inferior cerebellar artery (PICA) carry a high risk of rebleeding with an associated increased mortality rate. Although rare, they present a therapeutic challenge. Surgical treatment carries a significant risk of neurologic complications, predominantly lower cranial nerve deficits because of the close relationship of the aneurysm with the brain stem and cranial nerves. The purpose of this article is to show that endovascular treatment of dissecting aneurysms of the PICA can be effective and can allow the patient to avoid the complications associated with surgery. METHODS: Six patients (age range, 28–70 years) with dissecting aneurysms of the PICA were treated at our center by endovascular occlusion with Guglielmi detachable coils or glue and followed for up to 30 months. Inclusion of patients in the study was based on careful angiographic assessment of the vascular anatomy and collateral supply of the posterior fossa. When on the basis of the anatomy, potential lack of sufficient collaterals was suggested, a test occlusion was performed to determine the feasibility of an endovascular approach. Four additional cases, which have been described in the literature, were included in the analysis of results. RESULTS: In all patients, the aneurysm was successfully occluded with no apparent procedure-related complications. Follow-up studies showed stable and complete occlusion of the aneurysm in all patients with no long-term neurologic deficits. CONCLUSIONS: Endovascular treatment by aneurysm and parent artery occlusion is a relatively safe and reliable alternative to surgery for isolated dissecting aneurysms of the PICA

Challenges in Diagnosis and Management of Previously Embolized Spinal Dural Arteriovenous Fistulae

Given the growing prevalence of initial endovascular treatment for type 1 spinal dural arteriovenous fistulae (dAVF), there are an increasing number of patients presenting with progressive symptoms related to recurrent previously embolized spinal dAVF. This study's goal was to identify demographic, clinical, and radiographic variables among patients who have failed embolization of type I spinal dAVF.A retrospective review of 24 consecutive surgeries for type I spinal dAVF performed by the senior author (A.D.L.) identified 5 patients who underwent open surgery for failed embolization. These 5 cases were reviewed for location of fistula, time from embolization to recurrence, preoperative functional status, fistulous point encountered at surgery, and clinical outcome of the patient at 3-month follow-up. A representative example case is reviewed in detail.The median age at time of recurrence was 63 years (range 51–73 years). The median timing of embolization to recurrence of neurologic symptoms was 5 months (range 1–54) and to surgery 7 months (range 2–60 months). The level of the spinal dAVF was most frequently at T12–L1 (n = 3). Spinal magnetic resonance arteriography led to localization of the spinal dAVF in 2 patients and spinal catheter angiogram in 3 cases. All patients had definitive radiographic cure of the dAVF at last clinical follow-up.The increased use of endovascular treatment of spinal dAVF has led to the treatment of refractory cases with a greater degree of surgical complexity. Open surgical ligation continues to provide the most definitive treatment outcomes for this complex spinal vascular entity