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Child's Nervous System : ChNS :... Apr 2024Spontaneous intracranial hypotension may result in debilitating postural headaches and severe neurological symptoms due to secondary cerebellar sagging. The most common... (Review)
Review
Spontaneous intracranial hypotension may result in debilitating postural headaches and severe neurological symptoms due to secondary cerebellar sagging. The most common cause is the cerebrospinal fluid (CSF) leak within the spinal canal. Although previously reported in only a few cases, also paraspinal lymphatic malformations causing vertebral bone destruction may occasionally result in CSF leak to these pathological formations. Here, we present a case of a 9-year-old girl with generalized lymphatic anomaly (GLA) presenting with severe postural headache. Radiological imaging revealed a typical feature of cerebellar sagging. Myelography localized the CSF leakage into vertebral bodies of C7 and Th1, which both were partly involved in pathological paravertebral masses of known lymphatic anomaly, and from there along the right C8 nerve root sleeve into the anomaly. As the C8-nerve root could not be ligated due to the risk of significant neurological injury, we attempted image-guided targeted percutaneous epidural placement of a blood patch directly into the foramen at the affected level. The procedure resulted in obliteration of the fistula and regression of cerebellar sagging, with significant relief of symptoms. Although it is an extremely rare coincidence, patients with paraspinal lymphatic malformations may develop intraspinal CSF leak into these pathological formations. The present case report suggests that besides a direct surgical obliteration of the fistula and sacrificing the nerve root, a targeted percutaneous epidural blood patch may be a possible alternative in the case of a functionally important nerve root.
Topics: Child; Female; Humans; Blood Patch, Epidural; Cerebrospinal Fluid Leak; Fistula; Intracranial Hypotension; Magnetic Resonance Imaging; Myelography
PubMed: 38236406
DOI: 10.1007/s00381-024-06287-x -
International Journal of Surgery Case... Feb 2024Schwannoma, a benign nerve sheath tumor originating from Schwann cells, can migrate within the spine due to various factors, impacting surgical planning. Unforeseen...
INTRODUCTION
Schwannoma, a benign nerve sheath tumor originating from Schwann cells, can migrate within the spine due to various factors, impacting surgical planning. Unforeseen movement complicates treatment, and it is considered a very rare tumor.
CASE PRESENTATION
A 24-year-old woman complained of persistent back pain and was examined at a neurosurgery clinic. Initial MRI found a spinal lesion that later moved, leading to two surgeries. The diagnosis was a Schwannoma, confirmed by examining the tissue under a microscope, showing characteristic features of a Schwannoma, specifically Antoni type A with recent hemorrhage.
DISCUSSION
Schwannoma, a rare nerve cell tumor, often migrates within the spine due to its lack of attachment within the dura. The tumor's movement can be triggered by various factors like nerve root laxity, pressure changes, body positioning, or medical procedures. A case study discussed a woman with back pain; her tumor migrated between two MRI scans, showcasing a common migration pattern. Lower back pain commonly manifests as a primary symptom in most cases. Imaging techniques such as myelography and intraoperative ultrasound assist in locating and managing these mobile tumors, advocating for their utilization to minimize surgical complications.
CONCLUSION
Reported a rare mobile thoracolumbar schwannoma from nerve sheath cells. Its mobility complicates surgery; precise imaging like intraoperative MRI and ultrasound are crucial for localization, preventing complications.
PubMed: 38219519
DOI: 10.1016/j.ijscr.2024.109266 -
Journal of Neurosurgery. Spine Apr 2024Hounsfield unit (HU) measurements of bone density on CT are increasingly used for preoperative planning in spine surgery. Postmyelogram CT is another common preoperative...
OBJECTIVE
Hounsfield unit (HU) measurements of bone density on CT are increasingly used for preoperative planning in spine surgery. Postmyelogram CT is another common preoperative diagnostic study. However, there is no current literature evaluating whether HU measurements on CT are affected by the presence of myelography dye. The purpose of the current study was to determine if the presence of myelography dye affects HU measurements of bone density in CT studies.
METHODS
Twenty-nine preoperative spine surgery patients who underwent both standard and postmyelography CT performed within 6 months of each other were identified. HU measurements were obtained from an elliptical region of interest using the available software on a standard PACS. Measurements were obtained on the axial cut at the midvertebral body on all lumbar vertebrae on three separate occasions and an average value was calculated for comparative analysis. A 6-week gap was used between measurements of the CT scans and the CT myelograms to diminish bias.
RESULTS
The mean age of the cohort was 69 years and the average BMI was 32 kg/m2. Five patients were male and 24 were female. Six of the patients had instrumentation placed prior to the initial CT scan. The average HU measurements for CT levels L1-5 were 165, 171, 145, 154, and 225, respectively, whereas HU measurements for CT myelography of levels L1-5 were 168, 177, 148, 170, and 239, respectively. Strong correlations were noted between the HU measured on CT and CT myelography for L1 (r2 = 0.951), L2 (r2 = 0.966), L4 (r2 = 0.820), and L5 (r2 = 0.900), and moderate for L3 (r2 = 0.668).
CONCLUSIONS
The presence of myelography dye had no clear effect on CT HU measurements of bone density. The results of this study support the use of CT myelograms for bone density assessment in the absence of standard CT images.
Topics: Humans; Male; Female; Aged; Bone Density; Osteoporosis; Absorptiometry, Photon; Tomography, X-Ray Computed; Lumbar Vertebrae; Myelography; Retrospective Studies
PubMed: 38215447
DOI: 10.3171/2023.11.SPINE23890 -
Cureus Dec 2023Degenerative cervical myelopathy (DCM) is a spinal condition of growing importance due to its increasing prevalence within the ageing population. DCM involves the... (Review)
Review
Degenerative cervical myelopathy (DCM) is a spinal condition of growing importance due to its increasing prevalence within the ageing population. DCM involves the degeneration of the cervical spine due to various processes such as disc ageing, osteophyte formation, ligament hypertrophy or ossification, as well as coexisting congenital anomalies. This article provides an overview of the literature on DCM and considers areas of focus for future research. A patient with DCM can present with a variety of symptoms ranging from mild hand paraesthesia and loss of dexterity to a more severe presentation of gait disturbance and loss of bowel/bladder control. Hoffman's sign and the inverted brachioradialis reflex are also important signs of this disease. The gold standard imaging modality is MRI which can identify signs of degeneration of the cervical spine. Other modalities include dynamic MRI, myelography, and diffusion tensor imaging. One important scoring system to aid with the diagnosis and categorisation of the severity of DCM is the modified Japanese Orthopaedic Association score. This considers motor, sensory, and bowel/bladder dysfunction, and categorises patients into mild, moderate, or severe DCM. DCM is primarily treated with surgery as this can halt disease progression and may even allow for neurological recovery. The surgical approach will depend on the location of degeneration, the number of cervical levels involved and the pathophysiological process. Surgical approach options include anterior cervical discectomy and fusion, corpectomy, or posterior approach (laminectomy ± fusion). Conservative management is also considered for some patients with mild or non-progressive DCM or for patients where surgery is not an option. Conservative treatment may include physical therapy, traction, or neck immobilisation. Future recommendations include research into the prevalence rate of DCM and if there is a difference between populations. Further research on the benefit of conservative management for patients with mild or non-progressive DCM would be recommended.
PubMed: 38213348
DOI: 10.7759/cureus.50387 -
Diagnostics (Basel, Switzerland) Dec 2023The accurate preoperative identification of decompression levels is crucial for the success of surgery in patients with multi-level lumbar spinal stenosis (LSS). The...
BACKGROUND
The accurate preoperative identification of decompression levels is crucial for the success of surgery in patients with multi-level lumbar spinal stenosis (LSS). The objective of this study was to develop machine learning (ML) classifiers that can predict decompression levels using computed tomography myelography (CTM) data from LSS patients.
METHODS
A total of 1095 lumbar levels from 219 patients were included in this study. The bony spinal canal in CTM images was manually delineated, and radiomic features were extracted. The extracted data were randomly divided into training and testing datasets (8:2). Six feature selection methods combined with 12 ML algorithms were employed, resulting in a total of 72 ML classifiers. The main evaluation indicator for all classifiers was the area under the curve of the receiver operating characteristic (ROC-AUC), with the precision-recall AUC (PR-AUC) serving as the secondary indicator. The prediction outcome of ML classifiers was decompression level or not.
RESULTS
The embedding linear support vector (embeddingLSVC) was the optimal feature selection method. The feature importance analysis revealed the top 5 important features of the 15 radiomic predictors, which included 2 texture features, 2 first-order intensity features, and 1 shape feature. Except for shape features, these features might be eye-discernible but hardly quantified. The top two ML classifiers were embeddingLSVC combined with support vector machine (EmbeddingLSVC_SVM) and embeddingLSVC combined with gradient boosting (EmbeddingLSVC_GradientBoost). These classifiers achieved ROC-AUCs over 0.90 and PR-AUCs over 0.80 in independent testing among the 72 classifiers. Further comparisons indicated that EmbeddingLSVC_SVM appeared to be the optimal classifier, demonstrating superior discrimination ability, slight advantages in the Brier scores on the calibration curve, and Net benefits on the Decision Curve Analysis.
CONCLUSIONS
ML successfully extracted valuable and interpretable radiomic features from the spinal canal using CTM images, and accurately predicted decompression levels for LSS patients. The EmbeddingLSVC_SVM classifier has the potential to assist surgical decision making in clinical practice, as it showed high discrimination, advantageous calibration, and competitive utility in selecting decompression levels in LSS patients using canal radiomic features from CTM.
PubMed: 38201362
DOI: 10.3390/diagnostics14010053 -
AJNR. American Journal of Neuroradiology Dec 2023Photon-counting detector CT myelography is a recently described technique that has several advantages for the detection of CSF-venous fistulas, one of which is improved...
Photon-counting detector CT myelography is a recently described technique that has several advantages for the detection of CSF-venous fistulas, one of which is improved spatial resolution. To maximally leverage the high spatial resolution of photon-counting detector CT, a sharp kernel and a thin section reconstruction are needed. Sharp kernels and thin slices often result in increased noise, degrading image quality. Here, we describe a novel deep-learning-based algorithm used to denoise photon-counting detector CT myelographic images, allowing the sharpest and thinnest quantitative reconstruction available on the scanner to be used to enhance diagnostic image quality. Currently, the algorithm requires 4-6 hours to create diagnostic, denoised images. This algorithm has the potential to increase the sensitivity of photon-counting detector CT myelography for detecting CSF-venous fistulas, and the technique may be valuable for institutions attempting to optimize photon-counting detector CT myelography imaging protocols.
Topics: Humans; Phantoms, Imaging; Photons; Tomography, X-Ray Computed; Neural Networks, Computer; Fistula
PubMed: 38164538
DOI: 10.3174/ajnr.A8097 -
AJNR. American Journal of Neuroradiology Dec 2023CSF-venous fistulas (CVFs) associated with spontaneous intracranial hypotension (SIH) may have a transient appearance, relative to contrast arrival, which may influence...
Lateral Decubitus Dynamic CT Myelography with Real-Time Bolus Tracking (dCTM-BT) for Evaluation of CSF-Venous Fistulas: Diagnostic Yield Stratified by Brain Imaging Findings.
BACKGROUND AND PURPOSE
CSF-venous fistulas (CVFs) associated with spontaneous intracranial hypotension (SIH) may have a transient appearance, relative to contrast arrival, which may influence the diagnostic performance of lateral decubitus CT myelography (CTM). We developed a dynamic CTM protocol using real-time bolus-tracking (dCTM-BT) to improve the temporal resolution and standardize the timing of CTM acquisitions post-intrathecal contrast administration. The purpose of our study was to evaluate the feasibility of the dCTM-BT technique and evaluate its diagnostic yield for CVF detection, stratified by brain MRI SIH findings.
MATERIALS AND METHODS
Patients with suspected SIH without extradural fluid collection on spine MRI who underwent dCTM-BT were retrospectively reviewed. CT bolus monitoring was performed at the upper thoracic level. Following the visualization of dense intrathecal contrast, at least 3 CTM acquisitions of the spine were obtained and reviewed by 2 neuroradiologists. The Bern SIH score was calculated on the brain MRI. The diagnostic yield for CVF detection was evaluated, stratified by Bern score categories and a receiver operating characteristic (ROC) analysis.
RESULTS
Out of 48 patients, 23 (48%) had a CVF on dCTM-BT, located at T1-5 ( = 4), T6-12 ( = 18), L1 ( = 1), with 70% on the right. CVF was identified in 22/22 (100%) of patients who had a high Bern score, 1/7 (14%) of those who had an intermediate score, and 0/19 (0%) of those who had a low score. The area under the ROC curve was 0.99 (95% CI, 0.98-1.00). The optimal cutoff was a Bern score of ≥5 (96% sensitivity, 100% specificity).
CONCLUSIONS
dCTM-BT is feasible and has excellent diagnostic performance for CVF identification/localization. The Bern score is strongly associated with CVF detection and may help inform who will benefit from dCTM-BT.
Topics: Humans; Cerebrospinal Fluid Leak; Retrospective Studies; Myelography; Intracranial Hypotension; Tomography, X-Ray Computed; Magnetic Resonance Imaging; Neuroimaging; Fistula
PubMed: 38164531
DOI: 10.3174/ajnr.A8082 -
Interventional Neuroradiology : Journal... Dec 2023Precise localization and understanding of the origin of cerebrospinal fluid (CSF) leak is crucial to allow targeted treatment. We report the technical feasibility and...
BACKGROUND
Precise localization and understanding of the origin of cerebrospinal fluid (CSF) leak is crucial to allow targeted treatment. We report the technical feasibility and utility of dorsal-decubitus dynamic computed tomography (DDDCT) myelography to localize posteriorly located dural defects in patients with suspicion of posterolateral dural tears.
METHODS
This study reports a series of four consecutive patients with posteriorly located SLEC and suspicion of posterolateral CSF leak who received DDDCT to localize the site of the leak. Patients were collected between October 2022 and October 2023. The technique of DDDCT and its efficacy to detect the site of CSF leak are reported.
RESULTS
In all four patients (three females, one male, mean age 39 years), DDDCT myelography was technically successful and precisely demonstrated the site of the CSF leak. In one patient with both anterior and posterior SLEC, DDDCT allowed to exclude the presence of a posteriorly located leak, while a subsequent ventral decubitus dynamic CT myelography localized the leak. Leak sites were all thoracic, except for one that was cervical. Information obtained from the DDDCT myelography was considered useful to target the treatment of the leak.
CONCLUSIONS
Based on our experience, DDDCT provided sufficient spatial and temporal resolution to pinpoint fast CSF leaks and it may be considered to localize posterolateral dural defects.
PubMed: 38151024
DOI: 10.1177/15910199231222672 -
The Neuroradiology Journal Dec 2023CT myelography has been traditionally used to evaluate post-operative paraspinal fluid collections to discern CSF leaking into a pseudomeningocele versus a contained...
CT myelography has been traditionally used to evaluate post-operative paraspinal fluid collections to discern CSF leaking into a pseudomeningocele versus a contained seroma. Rather than performing a lumbar puncture and injecting intrathecal contrast for myelography, we present the first report of direct contrast injection into a post-operative paraspinal pseudomeningocele for CSF leak confirmation and localization. This is a simple procedure that has several advantages over a conventional CT myelogram for the evaluation of post-operative paraspinal fluid collections.
PubMed: 38146822
DOI: 10.1177/19714009231224413 -
AJNR. American Journal of Neuroradiology Dec 2023CSF-venous fistula can be diagnosed with dynamic decubitus CT myelography. This study aimed to analyze the temporal characteristics of CSF-venous fistula visualization...
BACKGROUND AND PURPOSE
CSF-venous fistula can be diagnosed with dynamic decubitus CT myelography. This study aimed to analyze the temporal characteristics of CSF-venous fistula visualization on multiphase decubitus CT myelography.
MATERIALS AND METHODS
A retrospective, multisite study was conducted on patients diagnosed with CSF-venous fistula at 2 institutions between June 2017 and February 2023. Both institutions perform decubitus CT myelography with imaging immediately following injection and usually with at least 1 delayed scan. The conspicuity of CSF-venous fistula was assessed on each phase of imaging.
RESULTS
Forty-eight patients with CSF-venous fistula were analyzed. CSF-venous fistulas were better visualized on the early pass in 25/48 cases (52.1%), the delayed pass in 6/48 cases (12.5%) and were seen equally on both passes in 15/48 cases (31.3%). Of 25 cases in which the CSF-venous fistula was better visualized on the early pass, 21/25 (84%) fistulas were still at least partially visible on a delayed pass. Of 6 cases in which the CSF-venous fistula was better visualized on a delayed pass, 4/6 (67%) were partially visible on the earlier pass. Six of 48 (12.5%) CSF-venous fistulas were visible only on a single pass. Of these, 4/6 (66.7%) were seen only on the first pass, and 2/6 (33.3%) were seen only on a delayed pass. One fistula was found with one pass only, and one fistula was discovered upon contralateral decubitus imaging without a dedicated second injection.
CONCLUSIONS
A dynamic decubitus CT myelography imaging protocol that includes an early and delayed phase, likely increases the sensitivity for CSF-venous fistula detection. Further studies are needed to ascertain the optimal timing and technique for CSF-venous fistula visualization on dynamic decubitus CT myelography and its impact on patient outcomes.
Topics: Humans; Cerebrospinal Fluid Leak; Intracranial Hypotension; Retrospective Studies; Cohort Studies; Myelography; Tomography, X-Ray Computed; Fistula
PubMed: 38123910
DOI: 10.3174/ajnr.A8078