Editor’s Choices

Spinal Dural Fistulas without Swelling and Edema of the Cord as Incidental Findings • W.J. van Rooij, R.J. Nijenhuis, J.P. Peluso, M. Sluzewski, G.N. Beute, and B. van der Pol
This short report describes 5 patients with incidentally found spinal dural AVFs without cord edema. All patients were adults and were being imaged for nonspecific back pain. Four AVFs were conal and one was cervical. Generally, at the time of diagnosis, patients with spinal AVFs have long-standing symptoms and cord edema and the classic imaging triad of cord edema, dilated perimedullary veins, and, at times, contrast cord enhancement makes the diagnosis easy. This nicely illustrated report seems to indicate that symptoms in spinal AVFs correlate with the presence of edema, a finding not present when these are incidentally found.

Clinical Stroke Penumbra: Use of National Institutes of Health Stroke Scale as a Surrogate for CT Perfusion in Patient Triage for Intra-Arterial Middle Cerebral Artery Stroke Therapy • J.L. Boxerman, M.V. Jayaraman, W.A. Mehan, J.M. Rogg, and R.A. Haas
Because CTA and CTP generally need repeat contrast material injections, these authors sought to determine if just CTA, noncontrast head CT, and clinical examination could substitute for perfusion studies that are used to determine the presence and size of penumbra. NCCT, CTA, CTP, and NIHSS score were studied in 36 patients at 8 hours after MCA infarctions. They found that knowing the NIHSS score and interpreting it with the head NCCT and CTA was an acceptable substitute for knowledge obtained from CTP and adequately triaged the patient for treatment. Thus, replacing CTP with NIHSS score may reduce radiation and contrast exposure.

Differentiation between Brain Glioblastoma Multiforme and Solitary Metastasis: Qualitative and Quantitative Analysis Based on Routine MR Imaging • X.Z. Chen, X.M. Yin, L. Ai, Q. Chen, S.W. Li, and J.P. Dai
This article addresses a common clinical dilemma: is a solitary lesion a GBM or a metastasis? The authors here studied, qualitatively and quantitatively, findings on routine MR brain imaging. They simply measured the T2 signal intensity of the peritumoral edema in both lesions and normalized it to the contralateral corresponding area. GBMs had a higher normalized edema signal intensity when compared with metastases. Thus, this simple method may aid in distinguishing between these 2 lesions.

Fellows’ Journal Club

Incidence of Cerebellar Tonsillar Ectopia in Idiopathic Intracranial Hypertension: A Mimic of the Chiari I Malformation • A.H. Aiken, J.A. Hoots, A.M. Saindane, and P.A. Hudgins
Some patients with intracranial hypertension may have nonrelated Chiari I malformations that are not responsive to surgical decompression. These authors set out to identify a subset of patients with IH who had tonsillar ectopia. They found that 21% of their patients with IH had cerebellar tonsillar ectopia that was often peglike and simulated true Chiari I malformations. An ancillary helpful finding was that in patients with IH and tonsillar ectopia the fourth ventricular obex was lower than in controls, implying that all posterior fossa structures are inferiorly displaced in this group of patients.

Severe Traumatic Head Injury: Prognostic Value of Brain Stem Injuries Detected at MRI • A. Hilario, A. Ramos, J.M. Millan, E. Salvador, P.A. Gomez, M. Cicuendez, R. Diez-Lobato, and A. Lagares
Because traumatic brain stem injuries are thought to imply a poor prognosis, these authors studied 188 patients with TBI and correlated their imaging findings with outcomes at 6 months. Brain stem lesions were found in 51 instances and 66% of these patients had a poor outcome, with those who had bilateral, posteriorly located, and hemorrhagic lesions having the worst outcome. Nonhemorrhagic brain stem lesions had the best outcome in this group of patients.

Incidental Head and Neck Findings on MRI in Young Healthy Volunteers: Prevalence and Clinical Implications • L. Reneman, M.M.L. de Win, J. Booij, W. van den Brink, G.J. den Heeten, N. Freling, and C.B.L.M. Majoie
This short article reports the prevalence and significance of incidental findings on head and neck studies done in young (18-35 years; mean: 21 years) healthy volunteers. Nearly 10% of brain studies and 37% of neck studies showed incidental findings. Of these, 4.4% in the brain and 5.5% in the neck were classified as needing referral, but there was only 1 skull lesion (fibrous dysplasia) that was actually referred. Although the prevalence of incidental findings was high, their clinical implications were negligible.