American Society of Neuroradiology

A 42-year-old woman presented to the emergency department with sudden-onset uncontrollable laughter, 'fou rire prodromique' (prodrome of crazy laughter), and left leg weakness. Imaging revealed a right cerebral haemorrhage of the premotor cortex corresponding to the leg cortical representation. A history of excess phenylephrine use for sinusitis and migraine was subsequently obtained. The patient's neurological recovery was good, enabling a return to her pre-stroke employment. The neurological causes of pathological laughter and the brain networks involved are discussed in this report. The role of sympathomimetics in the causation of cerebral haemorrhage potentially via the initiation of a reversible cerebral vasoconstriction syndrome is highlighted. The use of over-the-counter substances should be part of medication history in such cases.

IntroductionDiscriminating between bipolar disorder (BD) and behavioral variant Frontotemporal Dementia (bvFTD) is a clinical challenge as it is still based on clinical judgement, which often leads to misdiagnosis. This challenge is particularly pronounced in cases involving the C9orf72 hexanucleotide expansion, a genetic factor responsible for a substantial portion of familial FTD cases, as in these patients the development of late psychoses is particularly frequent. Moreover, individuals with C9orf72 bvFTD are also characterized by behavioral changes that resemble those seen in late-life BD, especially during the early stages of the disease. This raises questions about whether the clinical similarities between BD and bvFTD are rooted in specific alterations within the brain networks involved in cognitive processing or in selective genetic and epigenetic mutations. In light of this, our recently published neuroimaging study has shed light on the presence of distinctive structural and metabolic characteristics in elderly individuals with BD and bvFTD. These findings offer valuable neurobiological insights that may lead to differentiate between bvFTD and elderly BD patients.ObjectivesBuilding on our previous research, this study further explores the existence of similar epigenetic expression patterns in plasma neural derived extra cellular vesicles (NDEs), such as miRNA and lncRNA, and seeks to correlate these epigenetic data with shared or distinct biological markers obtained through structural Magnetic Resonance Imaging and [18F]-fluorodeoxyglucose (FDG)-Positron Emission Tomography (PET).MethodsWe will plan to conduct statistical analyses on epigenetic and neuroimaging data on C9orf72 and sporadic bvFTD as well as on late-and early-onset BD patients and on healthy controls. Additionally, A PET study will be also performed on a subpopulation of these patients.ResultsOur hypothesis posits that selective epigenetic modifications may impact the brain’s structure and function, in a way that can change the glutamatergic neurotransmission in prefrontal regions, with subsequent indirect effects on subcortical areas.ConclusionsOur findings will not only help identifying the specific biological signatures of BD and bvFTD, which might have important implications not only in prevention but also in differential diagnosis and treatment, but also offer insights into potential targets for slowing the onset and progression of the structural alterations characterizing these disorders.Disclosure of InterestNone Declared

In a setting of acute spinal trauma, imaging delineates all osseous and soft-tissue injuries and helps to guide potential surgical intervention. CT is the technique of choice in the setting of acute trauma. However, MR imaging is integral in the assessment of traumatic spinal injury, specifically assessing discoligamentous structures otherwise not seen on CT. We describe the critical imaging parameters of cervical spine injuries in accordance with the Arbeitsgemeinschaft für Osteosynthesefragen (AO) Spine classification system and its impact on neurosurgical management. T2 fat-saturation sagittal and coronal images are valuable in assessing cervical spine ligaments. MR imaging at 3T offers superior resolution than 1.5T. The AO Spine classification for cervical spine injuries is now widely used and is more robust and correlates well with MR imaging. Type A injuries can be managed conservatively. Type B injuries are potentially unstable. B1 osseous injuries alone can be managed conservatively. Anterior or posterior tension band injuries (B2/B3 type) are unstable and are considered for surgical intervention or halo immobilization. Type C injuries have marked ligamentous injury and often require surgery. Identifying key MR imaging findings and using the AO Spine classification system and a reporting template helps bridging the knowledge gap between neuroradiologists and neurosurgeons, in turn influencing patient management.Learning Objectives: To understand the nuances of critical imaging findings of cervical spine injuries in accordance with the AO classification: how to minimize errors in reports using a simple MR imaging reporting template or a checklist; incorporating a universally accepted nomenclature and terminologies to remove bias and ensure consistency in communication with neurosurgical teams; and bridging the knowledge gap between neuroradiologists and neurosurgeons in the management of blunt cervical spinal trauma

ObjectivePlacement of an active transcutaneous bone-conduction implant (BCI) requires drilling of a precise bone bed to accommodate the device and allow for fixation points to make appropriate contact with bone, which can be difficult even when lifts are used. We describe a subtemporalis muscle middle cranial fossa bone-island craniotomy technique that simplifies the procedure and obviates the need for lifts in securing the device.Study DesignProspective case series.SettingTertiary academic medical center.PatientsSeventeen patients underwent surgery for placement of 18 transcutaneous BCIs, 14 for conductive or mixed hearing loss, and 4 for single-sided deafness.InterventionsSurgical placement of a transcutaneous BCI with a bone-island craniotomy technique.Main Outcome MeasuresFunctional gain in air-conduction thresholds, aided air-bone gap, frequency of need for lifts, and minor and major complications.ResultsFor the conductive or mixed hearing loss cohort, with the transcutaneous BCI in place, there was a highly statistically significant mean functional gain of 35.4 dB hearing level (HL) (range, 16.7–50.25 dB HL; standard deviation, 12.4 dB HL) compared with the unaided condition (p < 0.0001; 95% confidence interval, 36.6–51.6 dB HL). Lifts were not needed in any case. There was one minor complication requiring a second procedure in a patient who had previously received radiation and no major complications. There was no device loss or failure.ConclusionsA subtemporalis muscle middle cranial fossa bone-island craniotomy technique eliminates the need for lifts and is a safe and effective method for placement of a transcutaneous BCI.

Background and Purpose- Prehospital stroke code activations help reducing workflow times during in-hospital triage. We aim to identify predictors of endovascular treatment (EVT) among stroke codes (SC) activated within 6 hours from symptom onset. Methods- CICAT (Codi Ictus Catalunya) is a prospective official mandatory registry of all SC in Catalunya. We studied all CICAT entries from 6 comprehensive stroke centers for 18 months. We recorded demographic, clinical, and imaging variables on admission. We explored the relationship between these variables and EVT Results- From 3944 SC, 2778 (70.4%) were admitted within 6 hours from symptom onset. Mean age was 72±15.3 years, median Rapid Arterial Occlusion Evaluation scale score 4 (interquartile range [IQR], 2-6), median onset-to-door time 89 minutes (IQR, 54-158), median National Institutes of Health Stroke Scale score 9 (IQR, 4-18), median Alberta Stroke Program Early CT Score 10 (IQR, 8-10). Final diagnosis was ischemic stroke in 1762 patients (63.4%), hemorrhagic stroke in 359 (13.0%), transient ischemic attack in 164 (5.9%), and stroke-mimic in 493 (17.7%). A large vessel occlusion was confirmed in 720 (25.6%) patients. Of all SC, 16% (n=444) received EVT, with a median door-to-groin time of 77 minutes (IQR, 55-102). Baseline variables associated with EVT were premorbid modified Rankin Scale score <2 ( P<0.001), prehospital Rapid Arterial Occlusion Evaluation scale score >4 ( P=0.003), and National Institutes of Health Stroke Scale on admission >8 ( P<0.001). National Institutes of Health Stroke Scale on admission was the only independent predictor of EVT. Although the rate of Alberta Stroke Program Early CT Score 10 progressively decreased over time (0-3 hours, 73.2% versus 3-6 hours, 57.1%; P<0.01), the rate of Alberta Stroke Program Early CT Score 6 remained >90% along time (0-3 hours, 95.1% versus 3-6 hours, 94.0%; P=0.25) and did not decrease over time. The chances to receive EVT and the presence of large vessel occlusion decreased over time. However, the rate of EVT was not different between patients admitted 0 to 3 hours (26.1%) and those admitted 3 to 6 hours (22.9%; P=0.2). Conclusions- Among SC within 6 hours from symptom onset, National Institutes of Health Stroke Scale on admission was the only factor independently associated with EVT. Only 5% of these patients show an Alberta Stroke Program Early CT Score <6 and this rate does not significantly increase over time. These data may be useful to generate direct transfer to angio-suite protocols based mainly on clinical severity.

Neuroradiology is in the fifth year of subspecialty recertification. New requirements for the MOC process include a PQI initiative. The purpose of this report was to survey compliance of ASNR members with the MOC process. A 12-question Internet-based survey was sent to the 2864 members of the ASNR through e-mail addresses. The survey asked questions regarding compliance with cognitive testing, SAMs, CME credits, and PQI. Multiple reminders were sent and open comments graded for attitudes toward the MOC process. While most respondents were engaged in the MOC process (878/1074 [81.8%]) and were aware of CME and SAMs, (736/1067 [69%]) and cognitive testing requirements of the recertification, the PQI initiative had limited participation and many questions about the component. Of the 1057 respondents, 687 (490 not started, 87 registered but not started, 110 unaware of PQI) or 65% had not started a PQI project at the time of the survey. The ASNR was asked to help with the cognitive examination by 25 (4.4%), CME offerings by 53 (9.4%), SAM modules by 88 (14.0%), and PQI projects by 205 (36.2%) respondents. Open comments were generally unfavorable toward the MOC-PQI process by a 3:1 ratio. Compliance with the MOC process has improved since a prior survey 3 years ago; however, confusion over the PQI process remains the primary concern of ASNR members.

Background and PurposePosterior fossa syndrome (PFS) occurs in approximately 25% of pediatric patients receiving surgery for midline posterior fossa tumors. Increasing evidence suggests that PFS represents a complex supratentorial cortical dysfunction related to surgery-induced disruption of critical cerebello-cerebral connections. The purpose of this study was to determine whether or not a consistent surgical damage pattern may be identified in PFS patients by early post-operative anatomical imaging analysis of the proximal efferent cerebellar pathway (pECP) and to test whether or not dynamic susceptibility-weighted contrast-enhanced perfusion MRI (DSC) can detect corresponding changes in cerebral cortical perfusion to indicate a secondary, remote functional disturbance which could suggest a diaschisis-like pathomechanism.Materials and MethodsEleven patients with post-operative PFS were evaluated retrospectively and paired with age-gender matched controls that did not develop PFS. MRI work-up included DSC within 3-4 weeks post surgery as well as early post-operative anatomical imaging to evaluate components of the pECP.ResultsDSC showed significant decreases in cerebral blood flow (CBF) within frontal regions (p<0.05) and a trend to global cerebral cortical hypoperfusion in patients with PFS. Logistic regression analysis suggested a strong (potentially predictive) relationship between bilateral damage to pECP and the development of PFS (p=0.04).ConclusionOur data suggest that the primary cause of PFS is the bilateral surgical damage to the pECP. This leads to a trans-synaptic cerebral cortical dysfunction (a form of bilateral crossed cerebello-cerebral diaschisis), which manifests with DSC-detectable global, but dominantly frontal, cortical hypoperfusion in PFS patients when compared with age-sex matched controls.

3D-constructive interference in steady state (3D-CISS) sequence has been used to assess the CSF pathways. The aim of this study was to investigate the additive value of 3D-CISS compared with conventional sequences in the diagnosis of obstructive membranes in hydrocephalus. A total of 134 patients with hydrocephalus underwent MR imaging examination with a 3T unit consisting of turbo spin-echo, 3D-CISS, and cine phase-contrast (cine PC) sequences. 3D-CISS was used to assess obstructive membranes in CSF pathways compared with other sequences. Cine PC, follow-up imaging, and surgical findings were used to confirm obstructive membranes. Comparing the number of noncommunicating cases by using the conventional and 3D-CISS images, we found 26 new cases (19.4%) of 134 cases that were previously misdiagnosed as communicating hydrocephalus by conventional images. 3D-CISS sequence identified obstructive membranes invisible in other sequences, which facilitated selection of neuroendoscopy in the treatment of 31 patients (23.1%) in total who would have been otherwise treated with shunt insertion. These patients included 26 newly diagnosed noncommunicating cases after demonstration of intraventricular and/or fourth ventricular outlet membranes and 5 cases of communicating hydrocephalus with obstructing cisternal membranes. There were obstructions of the foramina of Luschka in 22 of 26 newly found noncommunicating cases. Conventional sequences are insensitive to obstructive membranes in CSF pathways, especially in the fourth ventricular exit foramina and the basal cisterns. 3D-CISS sequence, revealing these obstructive membranes, can alter patient treatment and prognosis.

The hand motor cortex (HMC) has been classically described as having an omega or epsilon shape in axial-plane images obtained with CT and MR imaging. The aim of this study was to use MR imaging and Talairach normalization in a large sample population that was homogeneous for age and handedness to evaluate in a sex model a new classification with 5 morphologic variants of the HMC in the axial plane (omega, medially asymmetric epsilon, epsilon, laterally asymmetric epsilon, and null). Structural brain MR images were obtained from 257 right-handed healthy subjects (143 men and 114 women; mean age, 23.1 +/- 1.1 years) via a Talairach space transformed 3D magnetization-prepared rapid acquisition of gradient echo sequence. The frequencies of the different HMC variants were reported for hemisphere and sex. The new variants of the HMC (medially asymmetric epsilon, laterally asymmetric epsilon, and null) were observed in 2.9%, 7.0%, and 1.8% of the hemispheres, respectively. Statistically significant sex differences were observed: The epsilon variant was twice as frequent in men, and an interhemispheric concordance for morphologic variants was observed only for women. The large study population permitted the description of a new morphologic classification that included 3 new variants of the HMC. This new morphologic classification should facilitate the identification of the precentral gyrus in subsequent studies and in everyday practice.