Efrat Saraf-Lavi

MR angiography of the spine and spinal cord.

Objectives This review has three objectives: 1) to describe spinal vascular anatomy, focusing on thoracolumbar intradural vessels detectable by both magnetic resonance angiography (MRA) and digital subtraction x-ray angiography (DSA), 2) to compare the MRA techniques that have been used to detect the major intradural vessels, and 3) to illustrate the clinical application of these MRA techniques, especially their efficacy in characterizing spinal dural arteriovenous fistulae (AVF). Methods MRA is an adjunct to conventional magnetic resonance imaging. MRA is usually implemented as a three-dimensional (3D) contrast-enhanced (CE) gradient-echo technique, with two approaches to data acquisition: 1) “standard” 3D CE MRA, requiring ∼10 minutes per 3D volume, and 2) “fast” (bolus/dynamic) 3D CE MRA, requiring ∼0.5 to 2 minutes per 3D volume depending on k-space sampling schemes. Vessels are displayed on targeted maximum intensity projection images. Results Normal intradural vessels detected on standard CE MRA are primarily veins (medullary and median), whereas both arteries and veins are detected on fast CE MRA. Identification of arteries (artery of Adamkiewicz, anterior spinal artery) is limited, and their differentiation from veins can be incomplete. Intradural vessels in patients with dural fistulae have abnormal features on MRI (length of flow voids and postcontrast serpentine enhancement) and standard 3D CE MRA (length, tortuosity, and qualitative size of dominant perimedullary vessel), which differ significantly from those of normal vessels. Standard MRA added to a conventional MRI study significantly (P = 0.016) increased the rate of detection of the spinal level of a dural fistula. The correct level ± one vertebral segment was identified in 73% of true-positive patients. Conclusions Application of spinal MRA requires knowledge of vascular anatomy, specifically the major intradural vessels, and careful implementation of 3D CE MRA techniques. The standard technique allows for more effective noninvasive screening for vascular lesions, particularly dural AVF, than magnetic resonance imaging alone. Preliminary results indicate that the fast technique may further improve characterization of normal and abnormal intradural vessels, especially if continued technical advances yield greater temporal resolution while maintaining adequate spatial resolution.

FLAIR Distal Hyperintense Vessels as a Marker of Perfusion‐Diffusion Mismatch in Acute Stroke

Distal hyperintense vessels (DHV) on MRI FLAIR sequences in acute brain ischemia are thought to represent leptomeningeal collateral flow. We hypothesized that DHV are more common in acute stroke patients with perfusion‐diffusion weighted mismatch (PDM) than in those without.

Posterior spinal artery aneurysm rupture after ‘Ecstasy’ abuse

Posterior spinal artery (PSA) aneurysms are a rare cause of subarachnoid hemorrhage (SAH). The commonly abused street drug 3,4-methylenedioxymethamphetamine (MDMA) or ‘Ecstasy’ has been linked to both systemic and neurological complications. A teenager presented with neck stiffness, headaches and nausea after ingesting ‘Ecstasy’. A brain CT was negative for SAH but a CT angiogram suggested cerebral vasculitis. A lumbar puncture showed SAH but a cerebral angiogram was negative. After a spinal MR angiogram identified abnormalities on the dorsal surface of the cervical spinal cord, a spinal angiogram demonstrated a left PSA 2 mm fusiform aneurysm. The patient underwent surgery and the aneurysmal portion of the PSA was excised without postoperative neurological sequelae. ‘Ecstasy’ can lead to neurovascular inflammation, intracranial hemorrhage, SAH and potentially even de novo aneurysm formation and subsequent rupture. PSA aneurysms may be treated by endovascular proximal vessel occlusion or open surgical excision.

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 patients Morel-Lavallée lesion was evaluated with ultrasound and MRI, demonstrating a predominantly hemorrhagic lesion successfully managed by aspiration.

Value of diffusion kurtosis imaging in assessing low-grade gliomas: Diffusion Kurtosis Imaging in Gliomas

Diffusion kurtosis imaging (DKI) measures have been shown to provide increased sensitivity relative to diffusion tensor imaging (DTI) in detecting pathologies.

Case Report: Posterior spinal artery aneurysm rupture after ‘Ecstasy’ abuse

Posterior spinal artery (PSA) aneurysms are a rare cause of subarachnoid hemorrhage (SAH). The commonly abused street drug 3,4-methylenedioxymethamphetamine (MDMA) or ‘Ecstasy’ has been linked to both systemic and neurological complications. A teenager presented with neck stiffness, headaches and nausea after ingesting ‘Ecstasy’. A brain CT was negative for SAH but a CT angiogram suggested cerebral vasculitis. A lumbar puncture showed SAH but a cerebral angiogram was negative. After a spinal MR angiogram identified abnormalities on the dorsal surface of the cervical spinal cord, a spinal angiogram demonstrated a left PSA 2 mm fusiform aneurysm. The patient underwent surgery and the aneurysmal portion of the PSA was excised without postoperative neurological sequelae. ‘Ecstasy’ can lead to neurovascular inflammation, intracranial hemorrhage, SAH and potentially even de novo aneurysm formation and subsequent rupture. PSA aneurysms may be treated by endovascular proximal vessel occlusion or open surgical excision.

Acute presentation of brachial plexus schwannoma secondary to infarction

Schwannomas of the brachial plexus are rare and typically present as slowly growing masses. We describe a case of a 37-year-old female who presented with acute onset of severe left upper extremity pain. Magnetic resonance imaging (MRI) showed a 2.3 × 2.1 cm peripherally enhancing centrally cystic lesion in the left axilla, along the cords of the left brachial plexus, with significant surrounding edema and enhancement. The mass was surgically removed. Pathology was consistent with a schwannoma with infarction. The pain completely resolved immediately after surgery.