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To assess the frequency of silent brain infarcts (SBIs) and white matter disease (WMD) and associations with stroke risk factors (RFs) in a real-world population.

Introduction There is increased interest in the use of artificial intelligence-based (AI) software packages in the evaluation of neuroimaging studies for acute ischemic stroke. We studied whether, compared to standard image interpretation without AI, Brainomix e-ASPECTS software improved interobserver agreement and accuracy in detecting ASPECTS regions affected in anterior circulation LVO.Methods We included 60 consecutive patients with anterior circulation LVO who had TICI 3 revascularization within 60 minutes of their baseline CT. A total of 16 readers, including senior neuroradiologists, junior neuroradiologists and vascular neurologists participated. Readers interpreted CT scans on independent workstations and assessed final ASPECTS and evaluated whether each individual ASPECTS region was affected. Two months later, readers again evaluated the CT scans, but with assistance of e-ASPECTS software. We assessed interclass correlation coefficient for total ASPECTS and interobserver agreement with Fleiss’ Kappa for each ASPECTS region with and without assistance of the e-ASPECTS. We also assessed accuracy for the readers with and without e-ASPECTS assistance. In our assessment of accuracy, ground truth was the 24 hour CT in this cohort of patients who had prompt and complete revascularization.Results Interclass correlation coefficient for total ASPECTS without e-ASPECTS assistance was 0.395, indicating fair agreement compared, to 0.574 with e-ASPECTS assistance, indicating good agreement (P < 0.01). There was significant improvement in inter-rater agreement with e-ASPECTS assistance for each individual region with the exception of M6 and caudate. The e-ASPECTS software had higher accuracy than the overall cohort of readers (with and without e-ASPECTS assistance) for every region except the caudate.Conclusions Use of Brainomix e-ASPECTS software resulted in significant improvements in inter-rater agreement and accuracy of ASPECTS score evaluation in a large group of neuroradiologists and neurologists. e-ASPECTS software was more predictive of final infarct/ASPECTS than the overall group interpreting the CT scans with and without e-ASPECTS assistance.

Dilated perivascular spaces (PVSs) are common and easily recognized on imaging. However, rarer giant tumefactive PVSs (GTPVSs) can have unusual multilocular cystic configurations, and are often confused for other pathologic entities, including neoplasms, cystic infarctions, and neuroepithelial cysts. Because GTPVSs are scarcely encountered and even more infrequently operated upon, many radiologists are unaware of the imaging and pathologic features of these lesions. Here, a case of a resected GTPVS is presented, highlighting both its radiologic and histologic characteristics, and discussing how such lesions can be differentiated from their closest mimickers on imaging.

Retrospective cohort study. To describe the demographics, clinical presentation, and functional outcomes of fibrocartilaginous embolic myelopathy (FCEM). Academic inpatient rehabilitation unit in the midwestern United States. We retrospectively searched our database to identify patients admitted between January 1, 1995 and March 31, 2016, with a high probability of FCEM. Demographic, clinical, and functional outcome measures, including Functional Independence Measure (FIM) information was obtained by chart review. We identified 31 patients with findings suggestive of FCEM (52% male), which was 2% of the nontraumatic spinal cord injury population admitted to inpatient rehabilitation. The age distribution was bimodal, with peaks in the second and sixth-to-seventh decades. The most common clinical presentation was acute pain and rapid progression of neurologic deficits consistent with a vascular myelopathy. Only three patients (10%) had FCEM documented as a diagnostic possibility. Most patients had paraplegia and neurologically incomplete injuries and were discharged to home. Nearly half of the patients required no assistive device for bladder management at discharge, but most were discharged with medications for bowel management. Median FIM walking locomotion score for all patients was 5, but most patients were discharged using a wheelchair for primary mobility. Median motor FIM subscale score was 36 at admission and 69 at discharge, with a median motor efficiency of 1.41. FCEM may be underdiagnosed and should be considered in those with the appropriate clinical presentation, because their functional outcomes may be more favorable than those with other causes of spinal cord infarction.

Study design:This was a retrospective cohort study.Objectives:The objectives of this study were to determine clinical features of infection-related myelopathy (IRM) and functional outcomes compared with other nontraumatic and traumatic myelopathies.Setting:US academic inpatient rehabilitation unit.Methods:This was a 16-year retrospective review of patients with myelopathy discharged from inpatient rehabilitation between 1 January 1995 and 31 December 2010. Patients comprised three injury groups: IRM, nontraumatic myelopathy (NTM) and traumatic spinal cord injury (TSCI). Information collected includes demographic characteristics, functional data, length of stay, injury completeness and discharge destination. Primary outcome measures were change in Functional Independence Measure (FIM) and daily FIM change. For IRM, data were collected regarding injury characteristics, risk factors, presenting symptoms, neurologic impairment level and treatment.Results:Of the 1601 patients, 40 (2.5%) had IRM, 1105 (69.0%) had NTM and 456 (28.5%) had TSCI. IRM mean (s.d.) age was 58.6 (15.7) years (male gender, 72.5%). The majority in each group had incomplete injuries. IRM had longer lengths of stay (P<0.001), lower admission (P=0.001) and discharge (P=0.005) FIM scores and lower FIM daily change (P=0.002) than NTM. Degree of functional improvement was similar in all groups, and most patients in each group were discharged home. Infectious pathogens were bacterial (80.0%, n=32), viral (7.5%, n=3), tuberculous (7.5%, n=3), parasitic (2.5%, n=1) and multiple types (2.5%, n=1). The most common bacterial cause (65.6%) was Staphylococcus aureus.Conclusions:Infectious etiologies comprise a small proportion of NTM but represent a unique entity with distinct recovery patterns and outcomes. These patients can achieve similar functional improvements as other NTM patients during inpatient rehabilitation, although over a longer period of time.

The article discusses the issues surrounding the ambitious pipeline project of the Canadian corporate giant Enbridge Inc. in the Midwest and North Dakota. It refers to the expansion of the Sandpiper Pipeline Project which hit a wall and public outcry in Minnesota from citizens and tribal groups. The company relied on the approval of regulatory agencies that forgot their responsibility to the public.

The imaging and clinical spectrum of unusual intervertebral disk disease is presented, including disk herniations in unusual locations, those with uncommon imaging features, and those with unusual pathophysiologic findings.

Pachymeningeal enhancement and brain sagging are recognized neuroimaging manifestations of craniospinal hypovolemia (CSH).1Typically, CSF leaks from a dural defect, pools in the epidural space, and is absorbed into epidural veins. It is subsequently seen as early radiotracer activity on cisternography or as contrast in the renal pelvis on CT myelography. Not infrequently, despite extensive investigations, a dural defect is not identified in patients with CSH.2Many of these patients undergo repeated single or multilevel blood patches with limited benefit.

To determine whether favorable clinical response and magnitude of improvement are associated with increased aqueductal cerebrospinal fluid (CSF) flow rates in patients who undergo ventriculoperitoneal shunting (VPS) for idiopathic normal-pressure hydrocephalus (NPH).

Article abstract –We performed a retrospective study of 53 consecutive “nonlesional” temporal lobectomy patients to assess the relative utility of MRI versus interictal single-photon emission computed tomography (SPECT) in this patient population. We compared the seizure lateralizing properties of MRI and SPECT using multiple blinded expert reviewers for both SPECT and MRI with a test-retest reviewer paradigm and measurements of hippocampal volume from MRI. The criterion standard for seizure lateralization was satisfactory postoperative seizure control (n 43). The rate of correct seizure lateralization was significantly greater for MRI than for SPECT (p≤ 0.01), and the rate of incorrect lateralization was significantly less for MRI than for SPECT. The most accurate MRI measure was hippocampal volume measurements, which correctly lateralized the seizures in 86.0 of cases. The correct lateralization rate for SPECT was 45.4. The MRI and SPECT studies tended to be noncomplementary with respect to seizure lateralization, and SPECT was likely to give an incorrect or indeterminate result in patients who were not lateralized by MRI. Concordant MRI-EEG lateralization was a strong predictor of satisfactory postoperative seizure control, while no relationship between postoperative seizure control and SPECT findings was present.

The incidence and distribution of left ventricular false tendons were studied in a series of 483 autopsy specimens of human hearts from subjects evenly distributed by sex and age. False tendons were observed in 265 specimens (55%), and their incidence was greater in hearts from male than from female subjects (61 versus 49%; p < 0.01). Neither the incidence nor the location of false tendons varied appreciably with age. Of the 265 specimens containing false tendons, 100 (38%) exhibited 2 or more, such that the total number of false tendons identified was 414. Of these 414, 272 (66%) were located between the posteromedial papillary muscle and the ventricular septum, 49 (12%) between the two papillary muscles, 47 (11%) between the anterolateral papillary muscle and the ventricular septum, 38 (9%) between the free wall and the septum and 3 (< 1%) between two aspects of the free wall; 5(1%) had three or more points of insertion and formed weblike structures.

Background:White matter disease (WMD) and silent brain infarction (SBI) are known to be risk markers for dementia. Nevertheless, the effects of incidentally-discovered WMD and SBI on routinely-obtained neuroimages is unknown.Methods:In the retrospective cohort study, Kaiser Permanente-Southern California (KPSC) health plan enrollees aged ≥ 50 years old with a brain cross-sectional image (CT or MRI) between 2009-2019 and without a prior history of ischemic stroke, transient ischemic attack, or dementia were identified. Natural language processing (NLP) was used to identify patients with SBI and WMD on the first qualifying neuroimaging report. Cox proportional hazards regression model was applied to estimate the effects of WMD and SBI on dementia, controlling for major cardiovascular risk factors.Results:Among 262,875 individuals receiving brain neuroimaging, 13,154 (5.0%) and 78,330 (29.8%) had SBI and WMD, respectively. The table below summarizes the crude dementia incidence rates. The crude hazard ratio (HR) was 3.69 (95% CI 3.58-3.80) for WMD and 2.80 (95% CI 2.68-2.93) for SBI. In the multivariable model controlling for all major cardiovascular risk factors, the effect of WMD on dementia risk was found to be stronger in younger compared to older patients and for CT- compared to MRI-discovered lesions. With CT, the adjusted HR was 3.08 (95% CI 2.84-3.34) for those < age 70 and 1.90 (95% CI 1.83-1.97) for those ≥ age 70. With MRI, the adjusted HR was 2.58 (95% CI 2.31-2.87) for those < age 70 and 1.59 (95% CI 1.45-1.75) for those ≥ age 70. The adjusted HR associated with a finding of SBI was 2.01 (95% CI 1.78-2.32) for patients age <70 and 1.26 (95% CI 1.20-1.32) for patients age ≥70, and was not modified by imaging modality.Conclusion:Incidentally-discovered WMD and SBI are common in patients ≥ age 50 and are associated with substantial increase in the risk of subsequent dementia. The findings may represent an opportunity for dementia prevention.

Background:White matter disease (WMD) and silent brain infarction (SBI) are known to be risk markers for stroke. Nevertheless, the predictive value of these changes when seen incidentally on routinely-obtained neuroimages is unknown.Methods:In this retrospective cohort study, Kaiser Permanente-Southern California health plan enrollees aged ≥ 50 years old with a brain CT or MRI scan between 2009-2019 and without a prior history of ischemic stroke, transient ischemic attack, or dementia were identified. Natural language processing (NLP) was used to identify patients with SBI and WMD on the index neuroimaging report. We used Cox proportional hazards to estimate the risk of future ischemic stroke associated with the presence of SBI and of WMD, controlling for major stroke risk factors.Results:Among 262,875 individuals receiving brain neuroimaging, 13,154 (5.0%) and 78,330 (29.8%) had SBI and WMD, respectively. The Table below summarizes the crude stroke incidence rates. The crude hazard ratio (HR) was 3.40 (95% CI 3.25-3.56) for SBI and 2.63 (95% CI 2.54-2.71) for WMD. In the multivariable model controlling for all major stroke risk factors, the effect of SBI was found to be stronger in younger versus older patients and for MRI- versus CT-discovered lesions. With MRI, the average adjusted HR over time was 2.95 (95% CI 2.53-3.44) for those < age 65 and 2.15 (95% CI 1.91-2.41) for those ≥ age 65. With CT scan, the average adjusted HR over time was 2.48 (95%CI 2.19-2.81) for those < age 65 and 1.81 (95% CI 1.71-1.91) for those ≥ age 65. The adjusted HR associated with a finding of WMD was 1.76 (95% CI 1.69-1.82) and was not modified by age or imaging modality. The effect of SBI decreased gradually over time, while the effect of WMD remained constant.Conclusion:Incidentally-discovered SBI and WMD are common in patients ≥ age 50 and are associated with substantial increases in the risk of subsequent symptomatic stroke. The findings may represent an opportunity for stroke prevention.

A 59-year-old man presented with orthostatic headaches, memory complaints, pronounced choreiform movements, and related hyperkinetic dysarthria and titubations. Head MRI findings were suggestive of CSF leak. CSF pressure was low. CT myelography documented CSF leak at the cervicothoracic junction. Targeted epidural blood patch led to resolution of symptoms, including complete disappearance of choreiform movements.