All Publications

  • Feasibility of Intrathecal Therapeutic Injections in Spinal Muscular Atrophy Patients via a Percutaneous Trans-Sacral Hiatus Route: An Initial Neuroimaging Morphometric Study. Muscle & nerve Dhawan, S. S., Trinh, A., Massoud, T. F. 2022


    INTRODUCTION/AIMS: Standard fluoroscopic lumbar puncture (LP) can be impossible in patients with severe spinal deformities from spinal muscular atrophy (SMA) who require intrathecal nusinersen therapy. There usually exists a straight trajectory in the lower sacral canal (SC) that could allow image-guided percutaneous trans-sacral hiatus puncture of the lumbosacral dural sac. Here, we determine if sacra are comparatively straighter in SMA patients (SMAps) versus healthy controls (HCs), which may facilitate unhindered trans-sacral hiatus spinal needle insertion for intrathecal nusinersen therapy.METHODS: We retrospectively analyzed lumbosacral spine computed tomograms (CTs) or CT-myelogram images of 38 SMAps and age- and sex-matched HCs. We digitally measured ventrodorsal sacral curvatures, SC surface areas, dural sac termination levels, and distances from sacral hiatus to the most caudad aspects of dural sacs ('needle distance').RESULTS: Mean ages of HCs and SMAps were 32.7 and 31.7years, respectively, with dural sacs terminating at similar levels. Mean values for morphometrics were: (a) Midsagittal SC surface area for HCs=701.2mm2 , and for SMAps=601.5mm2 (ns). (b) Using a 'line method', sacral curvature for HCs=61.9°, and SMAp=35.7° (p =0.0009), and was similar when using an 'angle summation method'. (c) Width of sacral hiatus for HCs=14.9mm, and SMAps=15.0mm (ns). (d) 'Needle distance' for HCs=54.7mm, and SMAps=49.9mm (ns).DISCUSSION: SMAps have significantly straighter sacra compared to HCs, which theoretically renders them more amenable to percutaneous trans-sacral hiatus puncture of the dural sac. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1002/mus.27782

    View details for PubMedID 36576208

  • Clinical Review of Computed Tomography and MR Perfusion Imaging in Neuro-Oncology. Radiologic clinics of North America Trinh, A., Wintermark, M., Iv, M. 2021; 59 (3): 323–34


    Neuroimaging plays an essential role in the initial diagnosis and continued surveillance of intracranial neoplasms. The advent of perfusion techniques with computed tomography and MR imaging have proven useful in neuro-oncology, offering enhanced approaches for tumor grading, guiding stereotactic biopsies, and monitoring treatment efficacy. Perfusion imaging can help to identify treatment-related processes, such as radiation necrosis, pseudoprogression, and pseudoregression, and can help to inform treatment-related decision making. Perfusion imaging is useful to differentiate between tumor types and between tumor and nonneoplastic conditions. This article reviews the clinical relevance and implications of perfusion imaging in neuro-oncology and highlights promising perfusion biomarkers.

    View details for DOI 10.1016/j.rcl.2021.01.002

    View details for PubMedID 33926680

  • Imaging Anatomy of the Vertebral Canal for Trans-Sacral Hiatus Puncture of the Lumbar Cistern. Clinical anatomy (New York, N.Y.) Trinh, A., Hashmi, S. S., Massoud, T. F. 2020


    A standard lumbar puncture may be impossible for many anatomic or technical reasons. Previous accounts of caudal epidural anesthesia and other procedures via the sacral hiatus prompted us to test if image-guided percutaneous trans-sacral hiatus access to the lumbosacral subarachnoid cistern would be anatomically feasible. To study vertebral canal morphometry and curvature, we analyzed midsagittal CT-myelogram images of 40 normal subjects and digitally measured sacral curvatures between S1 to S5 and S2 to S4 using two methods whereby a lower angle signifies a straighter sacrum. We measured midsagittal vertebral canal area, hiatus width, dural sac termination levels, and distance from sacral hiatus to the dural sac tip (needle distance). Subjects were F:M=25:15, with a mean age of 44.9years. The two S1-S5 full sacral curvature mean angles were 57.3° and 60.4°. Almost all sacral hiatuses were at S4, and dural sac terminations were at S1-S2. The mean S2-S4 sacral curvature was 25.1°, and the mean needle distance was 57.7mm. Using two-way ANOVA, there were significant sex differences for needle distances (p=.001), and full and limited sacral curvatures (p=.02, and p=.046, respectively). There were no significant linear regression correlations between age and sacral curvature, needle distance, canal area, or hiatus width. Therefore, despite a frequently prominent full sacral curvature, the combination of S1-S2 dural sac termination plus a relatively straight trajectory of the lower vertebral canal between S2 and S4 support the theoretical feasibility of percutaneous trans-sacral hiatus and vertebral canal access to the lumbosacral cistern using a standard spinal needle. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1002/ca.23612

    View details for PubMedID 32323367

  • Interobserver Agreement for the CT Severity Grading Scales for Acute Traumatic Brain Injury (TBI). Journal of neurotrauma Creeden, S., Ding, V., Parker, J. J., Jiang, B., Li, Y., Lanzman, B., Trinh, A., Khalaf, A., Wolman, D., Halpern, C., Boothroyd, D., Wintermark, M. 2020


    PURPOSE: To determine the interobserver variability among providers of different specialties and levels of experience across five established computed tomography (CT) scoring systems for acute traumatic brain injury (TBI).MATERIALS & METHODS: One hundred cases were selected at random from a retrospective population of adult patients transported to our emergency department and subjected to a non-contrast head CT due to suspicion for TBI. Eight neuroradiologists and neurosurgeons in trainee (residents and fellows) and attending roles independently scored each non-contrast head CT scan on the Marshall, Rotterdam, Helsinki, Stockholm and NeuroImaging Radiological Interpretation System (NIRIS) head CT scales. Interobserver variability of scale scores - overall and by specialty and level of training - was quantified using the intraclass correlation coefficient (ICC), and agreement with respect to National Institutes of Health Common Data Elements (NIH CDEs) was assessed using Cohen's kappa.RESULTS: All CT severity scoring systems showed high interobserver agreement as evidenced by high ICCs, ranging from 0.75 - 0.89. For all scoring systems, neuroradiologists (ICC range from 0.81 - 0.94) tended to have higher interobserver agreement than neurosurgeons (ICC range from 0.63 - 0.76). For all scoring systems, attendings (ICC range from 0.76 - 0.89) had similar interobserver agreement to trainees (ICC range from 0.73 - 0.89). Agreement with respect to NIH CDEs was high for ascertaining presence/absence of hemorrhage, skull fracture, and mass effect, with estimated kappa statistics of least 0.89.CONCLUSION: Acute TBI CT scoring systems demonstrate high interobserver agreement. These results provide scientific rigor for future use of these systems for the classification of acute TBI.

    View details for DOI 10.1089/neu.2019.6871

    View details for PubMedID 31996087