We present five cases of axillary lymphadenopathy which occurred after COVID-19 vaccination and that mimicked metastasis in oncologic patients. Initial radiologic diagnosis raised concerns...

BACKGROUND AND PURPOSE: Prior studies regarding acute toxic leukoencephalopathy (ATL) are either small, or preliminary. Our aim was to evaluate etiologies of and differences in imaging severity and outcomes among various etiologies of ATL. MATERIALS AND METHODS: MRIs of patients with suspected ATL over 15 years were retrospectively reviewed; inclusion criteria were: MRI 6 patients were statistically compared. RESULTS: Of 101 included patients, the 4 subgroups of n > 6 were the following: chemotherapy (n = 35), opiates (n = 19), acute hepatic encephalopathy (n = 14), and immunosuppressants (n = 11). Other causes (n = 22 total) notably included carbon monoxide (n = 3) metronidazole (n = 2), and uremia (n = 1). The mean DWI/FLAIR severity scores were 2.6/2.3, 3.3/3.3, 2.1/2.1 and 2.0/2.5 for chemotherapeutics, opiates, AHE and immunosuppressants, respectively, with significant differences in both imaging severity and outcome (P = .003–.032) among subgroups, particularly immunosuppressant versus chemotherapy-related ATL and immunosuppressants versus opiates (P = .004–.032) related ATL. DWI and FLAIR severity weakly correlated with outcome (ρ = 0.289–.349, P < .005) but correlated stronger in the chemotherapy (ρ = 0.460–.586, P < .010) and opiate (ρ =.472–.608, P < .05) subgroups, which had the worst outcomes. ATL clinically resolved in 36%, with severe outcomes in 23% (coma or death, 9/16 deaths from fludarabine). Notable laboratory results were elevated CSF myelin basic protein levels in 8/9 patients and serum blood urea nitrogen levels in 24/91. CONCLUSIONS: Clinical outcomes of ATL vary on the basis of etiology, being worse in chemotherapeutic- and opiate-related ATL. Uremia may be a predisposing or exacerbating factor.

SUMMARY: Interlaminar lumbar puncture and cervical puncture may not be ideal in all circumstances. Recently, we have used a transforaminal approach in selected situations. Between May 2016 and December 2017, twenty-six transforaminal lumbar punctures were performed in 9 patients (25 CT-guided, 1 fluoroscopy-guided). Seven had spinal muscular atrophy and were referred for intrathecal nusinersen administration. In 2, CT myelography was performed via transforaminal lumbar puncture. The lumbar posterior elements were completely fused in 8, and there was an overlying abscess in 1. The L1–2 level was used in 2; the L2–3 level, in 10; the L3–4 level, in 12; and the L4–5 level, in 2 procedures. Post-lumbar puncture headache was observed on 4 occasions, which resolved without blood patching. One patient felt heat and pain at the injection site that resolved spontaneously within hours. One patient had radicular pain that resolved with conservative treatment. Transforaminal lumbar puncture may become an effective alternative to classic interlaminar lumbar puncture or cervical puncture.

Rationale: A definitive dietary preparation recommendation is not possible based on literature in achievement of myocardial suppression for diagnosis of cardiac sarcoidosis (CS) with ¹⁸F-FDG PET/CT. Our goal is to compare three different dietary preparations in achievement of the best myocardial suppression and CS diagnosis. Methods: We retrospectively reviewed and compared three dietary preparations used at our institution. Three different diets were applied from 03/2014 to 12/2019. 24-h ketogenic diet with overnight fasting (n = 94); 18h-fasting (n = 44); 72-h daytime ketogenic diet with 3-day overnight fasting (n = 98). The interpretation of initial reports was recorded, and an independent radiologist (observer) retrospectively re-evaluated each case regarding CS diagnosis (Negative, Positive, Indeterminant) and myocardial suppression (Complete, Failed, Partial). Interobserver agreement was analyzed. We measured MaxSUV from bloodpool, liver, and the most suppressed normal myocardium. Results: We identified superior myocardial suppression with the 72-h preparation indicated by a higher bloodpool/myocardium and liver/myocardium ratios (P<0.001). Myocardial suppression rates for 72-h ketogenic diet, 24-h ketogenic diet and 18-h fasting preparations are as follows; Complete myocardial suppression: 96.9%/68.1%/52.3%, Failed myocardial suppression: 0%/23.4%/25%, Partial myocardial suppression: 3.1%/8.5%/22.7%) (P<0.001). The 72-hour preparation had significantly fewer “indeterminant” and “positive” exams. CS diagnosis rates for 72-h ketogenic diet, 24-h ketogenic diet and 18-h fasting preparations are as follows; Negative: 82.7%/52.1%/27.3%, Indeterminant: 2.0%/24.5%/40.9%, Positive: 15.3%/23.4%/31.8% (P<0.001). High agreement was present with the observer and the report (κ=0.88) Conclusion: A 72-h daytime ketogenic diet with 3-day overnight fasting, achieved substantially superior myocardial suppression versus 24-h ketogenic diet with overnight fasting and 18h-fasting using ¹⁸F-FDG PET/CT. This 72-h preparation results in significantly fewer “indeterminant” and potentially “false positive” CS results.

The first commercially available 7-T MRI scanner (Magnetom Terra) was approved by the FDA in 2017 for clinical imaging of the brain and knee. After initial protocol development and sequence optimization efforts in volunteers, the 7-T system, in combination with an FDA-approved 1-channel transmit/32-channel receive array head coil, can now be routinely used for clinical brain MRI examinations. The ultrahigh field strength of 7-T MRI has the advantages of improved spatial resolution, increased SNR, and increased CNR but also introduces an array of new technical challenges. The purpose of this article is to describe an institutional experience with the use of the commercially available 7-T MRI scanner for routine clinical brain imaging. Specific clinical indications for which 7-T MRI may be useful for brain imaging include brain tumor evaluation with possible perfusion imaging and/or spectroscopy, radiotherapy planning; evaluation of multiple sclerosis and other demyelinating diseases, evaluation of Parkinson disease and guidance of deep brain stimulator placement, high-detail intracranial MRA and vessel wall imaging, evaluation of pituitary pathology, and evaluation of epilepsy. Detailed protocols, including sequence parameters, for these various indications are presented, and implementation challenges (including artifacts, safety, and side effects) and potential solutions are explored.

Nusinersen is a drug approved in December 2016 for treatment of spinal muscular atrophy (SMA). We want to share our initial experience with image-guided, non-image-guided, and port-delivered nusinersen injections in a large single-center SMA patient cohort, treating both pediatric and adult patients with focus on technical considerations and other patient concerns from a combined perspective of patient, neurologist, and radiologist. All nusinersen injections between February 2017 and September 2018 were retrospectively reviewed. We obtained age, sex, SMA type and technical details of the injections and postprocedure complications for each procedure. A total of 52 patients (24 women [46%]; 4 patients with SMA-1 [7.6%]; 30 patients with SMA-2 [57.8%]; 18 patients with SMA-3 [34.6%]; mean age, 25.5 years [7 months to 62 years]) with a total of 265 injections were included. Of the 265 injections, 206 (77.9%) were performed with local anesthetic, 25 (9.4%) with moderate sedation, and 23 (8.6%) under general anesthesia. We performed 65 CT-guided transforaminal injections in 13 patients, 106 fluoroscopy-guided lumbar punctures in 24 patients and 83 lumbar punctures in 16 patients using conventional technique. Only 6 of 265 injections (2.2%) ended up with a post-lumbar puncture headache (PLPH) requiring medical treatment. None required an epidural blood patch. Fourteen PLPH (5.2%) occurred and resolved at the same day without any treatment. After 6 of 265 injections (2.2%), patients reported soreness at the injection site which resolved spontaneously. Three elected to have an intrathecal reservoir placement (2 lumbar, 1 intraventricular) with a total of 11 injections. One patient with lumbar catheter developed infection after surgery with subsequent meningitis and treatment delay. After the resolution of meningitis, a new intraventricular reservoir was placed without any complication in the following injections. With the introduction of nusinersen treatment, neurologists and radiologists play an important role in treatment of SMA patients and therefore should be familiar with different techniques and complications of drug administration. Using good technique, it is possible to have very low complication rates even in this complex patient population, and various image-guided procedures can be a safe alternative to surgical approach, even in the most difficult cases.