Diagnostic neuroradiology:Ready for the neurointerventional age?

Acute cerebral ischemia or stroke is currently considered an emergency for which therapeutic options are available if the therapeutic window of 4.5 h is respected.Imaging modalities have progressed greatly over the last few decades,rendering ischemia detectable in the first hours after the event.However,in order for treatment to be efficacious it is necessary to speed up all the processes before the start of therapy.Thus,one must decrease the time to arrival at the hospital and to the radiological method that is to be employed(be it computed tomography or magnetic resonance imaging);only then will the medical or interventional techniques available fulfill their potential.

Interventional neuroradiology of stroke, still not dead

Since the National Institute of Neurological Disorders and Stroke trial,intravenous thrombolysis has been gaining wide acceptance as the modality of treatment for acute embolic stroke,with a current therapeutic window of up to 4.5 h.Both imaging[with either magnetic resonance imaging(MRI)or computed tomography(CT)]and interventional techniques(thrombolysis and/or thrombectomy)have since improved and provided us with additional imaging of the penumbra using CT or MRI and more advanced thrombolysis or thrombectomy strategies that have been embraced in many centers dealing with patients with acute cerebral ischemia.These techniques,however,have come under scrutiny due to their accrued healthcare costs and have been questioned following major recent studies.These studies basically showed that interventional techniques were not superior to the traditional intravenous thrombolysis techniques and that penumbra imaging could not determine what patients would benefit from more aggressive(i.e.,interventional)treatment.We discuss this in the light of the latest developments in both diagnostic and interventional neuroradiology and point out why further studies are needed in order to define the right choices for patients with acute stroke.Indeed,these studies were in part conducted with suboptimal patient recruitment strategies and did not always use the latest interventional techniques available today.So,while these studies may have raised some relevant questions,at the same time,definitive answers have not been given,in our opinion.

为 interventional neuroradiologist 的诊断 neuroradiology

In order to further improve the impact of the continuously evolving neurointerventional techniques, the interventional neuroradiologist needs to have at his disposal more powerful techniques to image the central nervous system. With the recent development of diagnostics techniques that are computed tomography and magnetic resonance based we are now able to assess not just morphology, but also physiology, physiopathology and function. This review discusses the place of diagnostic techniques in the evaluation that the interventional neuroradiologist hast to make when confronted with patients. We provide an overview of current techniques for the brain and spine.

Use of Interventional Neuroradiology Devices (Solitaire AB and Cascade Net) in the Treatment of Complex Renal Aneurysms through Stent-Assisted Coil Embolisation

Introduction: The risk of rupture of true renal artery aneurysms is low but when they are bigger than 2 - 2.5 cm it increases significantly, making treatment essential. The need to use alternatives to conventional techniques in order to avoid predictable complications as coil migration is mandatory. Discussion: Routinely-used techniques in interventional neuroradiology such as flow diverters or those assisted with an occlusion balloon or stent have are suitable alternatives for complex aneurysms. Conclusion: Interventional neuroradiology devices such as the Cascade Net stent (Perflow Medical and Grupo Logsa) and Solitaire AB stent retriever (Medtronic) are valid and safe options. We describe the technique of such devices.

对由磁性的回声成像的灰色的事 heterotopia 的评价

AIM:To evaluate magnetic resonance imaging(MRI) features of different types of gray matter heterotopia.METHODS:Between June 2005 and December 2009,the medical records and MRI studies of patients with gray matter heterotopia were reviewed.The MRI morphologic findings of heterotopia were recorded along with the presence and type of associated cranial malformations.Available clinical and electrophysiological data were also recorded.RESULTS:20 patients were included in the study.Their ages ranged from 9 mo to 39 years with a mean age of 15 years.All patients suffered from epileptic seizures.According to the location of heterotopia,patients were classified into three groups:subependymal(12),subcortical(5) and band(3) heterotopia.CONCLUSION:MRI was useful in diagnosing and differentiating between various types of gray matter heterotopia.The severity of clinical manifestations of heterotopia was related to the location and pattern of heterotopia.Determination of heterotopia type and its extent is useful for management planning and predicting prognosis.

Vascular depression for radiology: A review of the construct,methodology,and diagnosis

Vascular depression(VD)as defined by magnetic resonance imaging(MRI)has been proposed as a unique subtype of late-life depression.The VD hypothesis posits that cerebrovascular disease,as characterized by the presence of MRIdefined white matter hyperintensities,contributes to and increases the risk for depression in older adults.VD is also accompanied by cognitive impairment and poor antidepressant treatment response.The VD diagnosis relies on MRI findings and yet this clinical entity is largely unfamiliar to neuroradiologists and is rarely,if ever,discussed in radiology journals.The primary purpose of this review is to introduce the MRI-defined VD construct to the neuroradiology community.Case reports are highlighted in order to illustrate the profile of VD in terms of radiological,clinical,and neuropsychological findings.A secondary purpose is to elucidate and elaborate on the measurement of cerebrovascular disease through visual rating scales and semi-and fully-automated volumetric methods.These methods are crucial for determining whether lesion burden or lesion severity is the dominant pathological contributor to VD.Additionally,these rating methods have implications for the growing field of computer assisted diagnosis.Since VD has been found to have a profile that is distinct from other types of late-life depression,neuroradiologists,in conjunction with psychiatrists and psychologists,should consider VD in diagnosis and treatment planning.

Differentiation of true anophthalmia from clinical anophthalmia using neuroradiological imaging

Anophthalmia is a condition of the absence of an eye and the presence of a small eye within the orbit.It is associated with many known syndromes.Clinical findings,as well as imaging modalities and genetic analysis,are important in making the diagnosis.Imaging modalities are crucial scanning methods.Cryptophthalmos,cyclopia,synophthalmia and congenital cystic eye should be considered in differential diagnoses.We report two clinical anophthalmic siblings,emphasizing the importance of neuroradiological and orbital imaging findings in distinguishing true congenital anophthalmia from clinical anophthalmia.

Magnetic resonance imaging differential diagnosis of brainstem lesions in children

Differential diagnosis of brainstem lesions,either isolated or in association with cerebellar and supra-tentorial lesions,can be challenging. Knowledge of the structural organization is crucial for the differential diagnosis and establishment of prognosis of pathologies with involvement of the brainstem. Familiarity with the location of the lesions in the brainstem is essential,especially in the pediatric population. Magnetic resonance imaging(MRI) is the most sensitive and specific imaging technique for diagnosing disorders of the posterior fossa and,particularly,the brainstem. High magnetic static field MRI allows detailed visualization of the morphology,signal intensity and metabolic content of the brainstem nuclei,together with visualization of the normal development and myelination. In this pictorial essay we review the brainstem pathology in pediatric patients and consider the MR imaging patterns that may help the radiologist to differentiate among vascular,toxico-metabolic,infectiveinflammatory,degenerative and neoplastic processes. Helpful MR tips can guide the differential diagnosis: These include the location and morphology of lesions,the brainstem vascularization territories,gray and white matter distribution and tissue selective vulnerability.

在盖伦的静脉以后的认知、功能的地位动脉瘤的畸形性 endovascular 吸藏

AIM:To study the clinical outcomes of treating vein of Galen aneurysmal malformations(VGAM),we assessed our patient cohort using standardized cognitive and functional measures.METHODS:A retrospective review of patients with VGAM treated by a single practitioner between 2003 and 2009 was performed for this study.In addition to routine clinical assessment,all patients were evaluated for cognitive and functional impairment using validated measures including the Neurobehavioral Rating ScaleRevised,the Bicêtre outcome score,and the Barthel index.RESULTS:Five patients underwent combined transarterial and transvenous embolization of their VGAM during the study period.VGAMs were classified based on angioarchitecture as either choroidal(1/5) or mural(4/5) according to the classification scheme of Lasjaunias.In total,13 embolization procedures were performed consisting of 1 to 3 treatment stages per patient.Complete or near complete occlusion was achieved in 4 patients,while subtotal occlusion was achieved in 1 patient.During follow-up(median 62.6 mo),all patients were either unchanged or cognitively and neurologically intact.CONCLUSION:VGAM can be safely and effectively treated by staged transarterial and transvenous embolization.Using this strategy,excellent long-term cognitive and functional outcomes can be achieved.

Correlation Between Activated Clotting Time and Activated Partial Thromboplastin Time During Endovascular Treatment of Cerebral Aneurysms

Purpose: Endovascular treatment (EVT) of intracranial aneurysms (IA) requires a continuous anticoagulation to avoid thromboembolic complications. In order to monitor the anticoagulation, different tests may be used including the activated clotting time (ACT) and the activated partial thromboplastin time (APTT). The aim of this study was to compare ACT and APTT for the monitoring of the anticoagulation during EVT of IA. Methods: Patients referred for EVT of an IA were included. After induction, baseline ACT and APTT were recorded, followed by a bolus infusion of unfractionated heparin (50 UI.kg–1). The same tests were controlled five minutes later with the purpose of doubling the baseline ACT value. Correlation and agreement between both tests were evaluated for the percentage of change after the bolus. Multiple linear regressions were also calculated in order to show confounding factors. Complications and outcomes were also recorded. Results: 45 patients were checked for enrolment and 24 were included for analysis. Mean (SD) % variation for APTT was 432.1 (75.7) and 60.6 (23.0) for ACT with p < 0.0001. With the Bland-Altman method, value of Bias (SD) is 372 (86) with 95% limits of agreement range from 203 to 540. Pearson correlation for % variation shows r (95% CI) = –0.23 (–0.58 to 0.19) with p = 0.29 and R square = 0.05. 100% of the APTT values could be defined as excessive anticoagulation by opposition of the 8% obtained with ACT. Conclusions: This prospective observational study shows that ACT test is not well correlated with APTT and leads to a systematic excessive coagulation during EVT of IA.

Giant Serpentine Cerebral Aneurysm of the Middle Cerebral Artery: Case Report

A 43-year-old male presented with severe intermittent headaches since two years accompanied by multiple episodes of generalized seizures and left hand weakness. MRI scan and cerebral angiography confirmed the diagnosis of a giant serpentine cerebral aneurysm arising from the middle cerebral artery. The patient was admitted for a possible cerebral embolization after undergoing a Balloon Occlusion Test (BOT). Since he tolerated the occlusion test, he underwent coil embolization afterwards with successful occlusion followed by an uneventful recovery and no complications. Later on, the patient was discharged home in a stable and good general condition without any neurological deficits. A six-month angiography follow-up revealed a complete occlusion with no re-canalization of the coiled giant serpentine aneurysm. Therefore, we concluded that parent artery occlusion is a good and safe procedure providing that the patient tolerated both the occlusion and the hemodynamic stress tests.

Heroin-Induced Toxic Leukoencephalopathy

Toxic leukoencephalopathy is an important complication of heroin abuse and has mostly been described after inhaling heroin vapor, known as “chasing the dragon syndrome” or heroin inhalation leukoencephalopathy (HIL). We present a 51 year-old male patient with toxic leukoencephalopathy following intranasal administration of heroin.

Nitinol Stenting in Post-Traumatic Pseudo-Aneurysm of Internal Carotid Artery

Background: A pseudoaneurysm of the internal carotid artery (ICA) at its cervicl part, is a rare and often lethal com-plication after cervical trauma. The treatment of choice is anticoagulation. Patients with a contraindication for anticoagulation or those who do not improve with standard treatment, warrant either a surgical repair or stent placement.Stent placement posses both short and long term risks such as immediate ischemic events, in-stent stenosis and stent breakage, thus the choice of stent type is critical. Advances in stent technology have made cervical stent placement a viable option. We report our experience with the LEO + (Balt Extrusion, Montmorency, France) nitinol flexible self expanding stent for post-traumatic ICA aneurysms. Methods: 5 patients suffering a post-traumatic cervical ICA pseudo-aneurysms refractory to standard treatment were treated with nitinol braided flexible self expanding stent. This stent has a shape memory and superelasticity virtues making it suitable. Diagnosis was made with CT angiography and confirmed by catheter angiography. All procedures were preformed under local anesthesia. Time between trauma and treatment ranged six days to over five years. Follow-up was performed by CT angiography or conventional angiography. Results: Five patients, having eight aneurysms were treated using 12 stents. In all cases, appropriate stent placement was achieved. No immediate or late complications, as well as no neurological sequele reported at 6 months. Radiological follow-up exams demonstrated complete pseudoaneurysm closure. Conclusion: Stent placement can be a safe and definitive treatment option for patients to conventional medical treatment.

Swine model of arterial bifurcation aneurysm

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Clinical and neuroradiological features of 15 patients diagnosed with Marchiafava-Bignami disease

We retrospectively reviewed the clinical data of 15 patients with MBD who visited at The Affiliated Hospital of Jiujiang University and The Third Affiliated Hospital of Nanchang University between January 2014 and December 2018.The diagnosis of MBD was made based on the following criteria:(1) a history of chronic alcoholism or malnutrition;(2) acute or sub-acute onset of neuropsychiatric symptoms;(3) symmetrical hyperintensity of the CC on T2-weighted and FLAIR images;(4) exclusion of other diseases including Wernicke encephalopathy (WE),reversible splenial lesion syndrome,intra-cranial infections,cerebrovascular diseases,and demyelinating diseases of the central nervous system.Clinical data,including demographics (gender and onset age),risk factors,types of onset,clinical presentations,MRI findings,treatment and outcome,were collected.At the time of follow-up (time range:1-2 months),the treatment outcomes were classified as complete,partial,and bad according to the objective improvement in neurological findings during drug therapy (death,apathetic state,or vegetative state was considered as a bad outcome).