Background: Severe traumatic brain injuries (TBI), commonly due to motor vehicle accidents may cause death and long-term disability especially when the acceleration-deceleration force on the brain is massive. This may cause shearing of the axonal connections within the cerebral cortex and brainstem in a process referred to as diffuse axonal injury (DAI). Extensive DAI has been postulated to be a poor prognostic indicator for neurological recovery. In our institution, several patients with Grade 3 DAI were observed to recover and achieve neurological outcomes greater than expected given the presence of brainstem injury. Methods: MRI studies from 100 patients admitted to a large tertiary trauma center for TBI were retrospectively analyzed by two fellowship-trained neuroradiologists. The size of DAI lesions, location of injury within the brainstem, and the number of discrete DAI lesions were measured and recorded. Glasgow Coma Scale (GCS) on arrival and at discharge was noted, as well as the presence of other neurological injuries. Results: Of 20 patients initially noted to have DAI with lesions of the brainstem, eight of them were discharged with Glasgow Coma Scale (GCS) of 14–15. The 12 patients discharged with reduced consciousness (average GC 7.1) demonstrated a greater number of larger lesions, with a predilection for the dorsal pons. Conclusion: These results suggest that large, numerous pontine lesions may indicate worse neurological outcomes in patients with these findings.

Background In the absence of frank craniocervical dissociation, there is a lack of consensus regarding what patterns of craniocervical junction ligamentous injuries require occipital-cervical fusion. This study was undertaken to examine the integrity of the craniocervical junction ligaments and analyze clinical outcomes in patients who underwent occipital-cervical fusion for craniocervical junction injury. Methods Adult patients requiring occipital-cervical fusion were identified retrospectively utilizing keyword searches in cervical computed tomography and magnetic resonance imaging reports between 2012 and 2020 using Nuance mPower software (Nuance, Burlington, MA). The cervical magnetic resonance imaging examinations for these patients were reviewed for craniocervical ligamentous injury by two neuroradiologists. Descriptions of craniocervical junction injuries, demographic information, clinical history, surgical management, and global outcomes were recorded. Results Nine adult patients were identified with an acute, post-traumatic craniocervical junction injury requiring occipital-cervical fusion. All nine patients demonstrated a ligamentous tear in at least one of the four major craniocervical junction ligaments - the occipital condylar-C1 capsular ligaments, alar ligaments, tectorial membrane, and posterior atlantooccipital membrane. The tectorial membrane was the most commonly torn ligament followed by the alar ligament(s), posterior atlantooccipital membrane, and capsular ligament(s). There was wide variability in the number of major craniocervical junction ligaments torn, ranging from one ligament to all four ligaments. Four patients suffered persistent neurologic deficits following surgery. Conclusion Craniocervical injury is best evaluated by cervical magnetic resonance imaging. In the absence of overt craniocervical dissociation, we propose that an injury of the tectorial membrane in the adult population may indicate patients with significant craniocervical instability, possibly necessitating occipital-cervical fusion.

The medial longitudinal fasciculus (MLF) is a paired, highly specialized, and heavily myelinated nerve bundle responsible for extraocular muscle movements, including the oculomotor reflex, saccadic eye movements an smooth pursuit, and the vestibular ocular reflex. Clinically, lesions of the MLF are classically associated with internuclear ophthalmoplegia. However, clinical manifestations of a lesion in the MLF may be more complex and variable. We provide an overview of the neuroanatomy, neurologic manifestations, and correlative examples of the imaging findings on brain MRI of MLF lesions to provide the clinician and radiologist with a more comprehensive understanding of the MLF and potential clinical manifestations for an MLF lesion.

Craniopharyngiomas (CPs) are slow growing, histologically benign intracranial tumors located in the sellar–suprasellar region. Although known to have low mortality, their location and relationship to the adjacent neural structures results in patients having significant neurologic, endocrine, and visual comorbidities. The invasive nature of this tumor makes complete resection a challenge and contributes to its recurrence. Additionally, these tumors are bimodally distributed, being treated with surgery, and are followed by other adjuncts, such as focused radiation therapy, e.g., Gamma knife. Advances in surgical techniques, imaging tools, and instrumentations have resulted in the evolution of surgery using endoscopic techniques, with residual components being treated by radiotherapy to target the residual tumor. Advances in molecular biology have elucidated the main pathways involved in tumor development and recurrence, but presently, no other treatments are offered to patients, besides surgery, radiation, and endocrine management, as the disease and tumor evolve. We review the contemporary management of these tumors, from the evolution of surgical treatments, utilizing standard open microscopic approaches to the more recent endoscopic surgery, and discuss the current recommendations for care of these patients. We discuss the developments in radiation therapy, such as radiosurgery, being used as treatment strategies for craniopharyngioma, highlighting their beneficial effects on tumor resections while decreasing the rates of adverse outcomes. We also outline the recent chemotherapy modalities, which help control tumor growth, and the immune landscape on craniopharyngiomas that allow the development of novel immunotherapies.

Hypertrophic olivary degeneration is a rare condition caused by a lesion in the Guillain-Mollaret triangle which leads to trans-synaptic degeneration resulting in the degenerative hypertrophy of the inferior olivary nucleus. This condition presents clinically with palatal tremor but can also produce ocular myoclonus or cerebellar signs. While any lesion that occurs within the Guillian-Mollaret triangle and results in the deafferentation of the inferior olive can lead to hypertrophic olivary degeneration, the most common etiologies include ischemic and hemorrhagic stroke, vascular malformation, neoplasm, and iatrogenic injury related to surgery. We report a series of 7 patients who presented with this condition bilaterally on MRI imaging, including 1 case which represents the first report of toxoplasmosis leading to the development of bilateral hypertrophic olivary degeneration and only the third reported case, unilateral or bilateral, related to an infectious etiology.

Craniotomy, or a surgical opening into the skull, has been observed as early as Paleolithic and Neolithic periods. Early craniotomies carried great morbidity and mortality and standardized during the 20th century, improving surgical outcomes. The simultaneous evolution of medical imaging and stereotactic navigation systems has allowed imaging to correlate findings with surgical approaches, further optimizing patient safety. We review the history of craniotomy and provide an imaging review of the most common craniotomy approaches.

Purpose: To review the impact of a weekly multidisciplinary neuroradiology imaging review on the management of patients undergoing radiotherapy.Methods: A prospective study of the management of 118 patients (30=head and neck, 40=skull base, central nervous system=48) was conducted over a 12-month period from January 2018 through January 2019. After review of each patient’s history and relevant imaging, a radiation oncologist completed a form detailing the changes that were made in diagnosis and management. Imaging source (external and internal examinations), availability of outside reports, report timeliness, the value of reports, changes in interpretation, changes in clinical management, and changes in prognosis were documented. Changes in interpretation and management were designated as major or minor depending on the significance of the change. The managing radiation oncologist indicated whether the imaging review conference substituted for a peer-to-peer consultation with a neuroradiologist.Results: Nearly half (47%) of all patients had a change in interpretation. Of those, 32% of patients had a major change in interpretation, while 14% had a minor change in interpretation. The existence of the multidisciplinary imaging review conference prevented a peer-to-peer consultation (interruption) by the radiation oncologists to the neuroradiologists in 90% of the cases presented. Further analysis was performed.Conclusion: The involvement of neuroradiologists in a joint radiation oncology imaging review conference resulted in changes in diagnostic imaging interpretation that led to significant changes in management, expected prognosis, and workflow.

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