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.

Recurrent Transient Ischemic Attacks Revealing Cerebral Amyloid Angiopathy: A Comprehensive Case

This case report investigates the manifestation of cerebral amyloid angiopathy (CAA) through recurrent Transient Ischemic Attacks (TIAs) in an 82-year-old patient. Despite initial diagnostic complexities, cerebral angiography-MRI revealed features indicative of CAA. Symptomatic treatment resulted in improvement, but the patient later developed a fatal hematoma. The discussion navigates the intricate therapeutic landscape of repetitive TIAs in the elderly with cardiovascular risk factors, emphasizing the pivotal role of cerebral MRI and meticulous bleeding risk management. The conclusion stresses the importance of incorporating SWI sequences, specifically when suspecting a cardioembolic TIA, as a diagnostic measure to explore and exclude CAA in the differential diagnosis. This case report provides valuable insights into these challenges, highlighting the need to consider CAA in relevant cases.

Stent-assisted coiling of intracranial carotid ophthalmic segment aneurysm segment aneurysms:Long-term follow-up from a single center

Background:To evaluate the efficacy of stent-assisted coiling(SAC)for the treatment of carotid ophthalmic segment aneurysm segment aneurysms(OSAs)of the internal carotid artery(ICA)through detailed long-term follow-up of a large patient cohort.Methods:We retrospectively analyzed 88 consecutive patients with OSAs between January 2009 and January 2020 at our center.Angiographic results were evaluated using the modified Raymond grading system and clinical outcomes were evaluated using the mRS scale.The primary endpoints were major aneurysm recurrence and poor clinical outcomes for at least 18 months of follow-up.The patients were asked to attend clinical follow-up assessments and possibly undergo DSA or MR via telephone.Results:We enrolled 88 patients with 99 OSAs treated with coiling,of whom 76 were treated with SAC.The coiling procedures were successful in all 88 patients.Overall,complications occurred in 8 patients(9.1%).No procedure-related mortality was observed.67(76.1%)experienced immediate aneurysm occlusion at the end of the procedure.Long-term angiographic follow-up(18 months)was available in 45/88 aneurysms(51%)(average 18.7±5.2 months).Four patients continued their follow-up for 5 years after initial aneurysm treatment.After a clinical follow-up time of 28.7 months(range,12-51 months),85 patients(95.5%)achieved favorable clinical outcomes(mRS scores of 0-2).Conclusions:This study indicates that SAC treatment is a safe and effective therapeutic alternative for ruptured and unruptured OSAs.The procedural risks are low with relatively long-term effectiveness.

Treatment of the acute thromboembolic event during endovascular embolization of intracranial aneurysm

Objective:The study aimed to discuss the treatment of acute thromboembolic event(TE)during endovascular embolization of intracranial aneurysms.Methods:Between April 2013 and April 2019,158 patients with 167 intracranial aneurysms were treated with endovascular embolization in our hospital,in which 9 cases of acute TEs occurred during the embolization procedures.The clinical data,radiological findings and treatments of the 9 patients were reviewed and analyzed.Results:The TEs occurred at the aneurysmal neck in 3 patients,at distal part of the parent artery in 3,in the stent in 2,and at the proximal part of the parent artery in 1.Intra-arterial(IA)infusion of tirofiban were performed in 6 patients,mechanical thromboectomy(MT)with a stent in 2 patients,and combined use of the two methods in 1 patients.According to the modified Thrombolysis In Cerebral Infarction(mTICI)score,7 patients had recanalization of 2b/3a,1 patients had recanalization of 1,and 1 patients had recanalization of 0.At discharge,the mRS score was 0 in 3 patients,1 in 3 patients,and 2,3,4 in 1 patient each.6 months after the endovascular treatment,the mRS score was 0 in 5 patients,1 in 2 patients,and 3 in 1 patient.Conclusions:IA tirofiban and MT are effective remedies for the acute TE during endovascular embolization of intracranial aneurysm,reasonable selection of which may improve the prognosis of patients.

脊柱旁肌水-脂肪MRI测量与等长肌力测量的关系

目的基于化学位移编码的水-脂肪MRI衍生的脊髓旁肌肉质子密度脂肪分数(PDFF)已成为肌肉减少、腰痛、损伤和神经肌肉疾病病人的替代标志物。本研究旨在探讨椎旁肌PDFF及横断面面积(CSA)对等长肌力的预测能力。

Microglia activation,classification and microglia-mediated neuroinflammatory modulators in subarachnoid hemorrhage

Subarachnoid hemorrhage is a devastating disease with significant mortality and morbidity,despite advances in treating cerebral aneurysms.There has been recent progress in the intensive care management and monitoring of patients with subarachnoid hemorrhage,but the results remain unsatisfactory.Microglia,the resident immune cells of the brain,are increasingly recognized as playing a significant role in neurological diseases,including subarachnoid hemorrhage.In early brain injury following subarachnoid hemorrhage,microglial activation and neuroinflammation have been implicated in the development of disease complications and recovery.To understand the disease processes following subarachnoid hemorrhage,it is important to focus on the modulators of microglial activation and the pro-inflammatory/anti-inflammatory cytokines and chemokines.In this review,we summarize research on the modulators of microglia-mediated inflammation in subarachnoid hemorrhage,including transcriptome changes and the neuroinflammatory signaling pathways.We also describe the latest developments in single-cell transcriptomics for microglia and summarize advances that have been made in the transcriptome-based classification of microglia and the implications for microglial activation and neuroinflammation.

Effectiveness of MRA on embolized intracranial aneurysms: a comparison of DSA, CE-MRA, and TOF-MRA

Purpose: The endovascular treatment of intracranial aneurysms was proven safe and effective compared to the alternative method of surgical clipping, despite the high recurrence rate. Follow-up of embolized intracranial aneurysms is mandatory for the early detection of recurrence and improved outcomes. DSA is used as the reference standard for this assessment. To determine the effectiveness of MRA in follow-up evaluations of intracranial aneurysms after embolization by comparing DSA, CE-MRA, and TOF-MRA. Materials and Methods: Sixty-eight consecutive patients undergoing DSA, TOF-MRA, and CE-MRA during an interval of <1 week were enrolled in this 6-month study. Images were evaluated for occlusion status, patency of the parent vessels, and artifacts. The modified Raymond-Roy occlusion classification and Aneurysm Embolization Grades were used to assess the occlusion status and initial DSA images for detection of recurrence in two filtered study phases with optimized selection criteria. Seventeen observers(phase I: 9, phase II: 8) independently interpreted the double-blinded images. Agreement was expressed with a Fleiss kappa value; p < 0.05 was considered significant. Results: This study included 68 patients with 77 aneurysms; 38(49.35%) were treated with coil alone and 39(50.65%) with stent-assisted coiling. In both phases, DSA was superior to TOF-MRA and CE-MRA using MRRC(Phase I: k = 0.567, p ≤ 0.001; k = 0.287, p ≤ 0.001; k = 0.117, p ≤ 0.001, respectively; Phase II: k = 0.503, p ≤ 0.001; k = 0.303, p ≤ 0.001; k = 0.115, p = 0.038, respectively). TOF-MRA was as effective as DSA(TOF: k = 0.335, p ≤ 0.001; DSA: k = 0.323, p ≤ 0.001) for recurrence detection. Conclusion: We suggest TOF-MRA as a first-line follow-up tool to detect aneurysm recurrence, and DSA to quantify the filling space to make a definite decision on re-embolization.

Microstructural analysis of pineal volume using trueFISP imaging

AIM:To determine the spectrum of pineal microstructures (solid/cystic parts) in a large clinical population using a high-resolution 3D-T2-weighted sequence. METHODS:A total of 347 patients enrolled for cranial magnetic resonance imaging were randomly included in this study. Written informed consent was obtained from all patients. The exclusion criteria were artifacts or mass lesions prohibiting evaluation of the pineal gland in any of the sequences. True-FISP-3D-imaging (1.5-T, isotropic voxel 0.9 mm) was performed in 347 adults (55.4 ± 18.1 years). Pineal gland volume (PGV), cystic volume, and parenchyma volume (cysts exclud- ed) were measured manually. RESULTS:Overall, 40.3% of pineal glands were cystic. The median PGV was 54.6 mm 3 (78.33 ± 89.0 mm 3 ), the median cystic volume was 5.4 mm 3 (15.8 ± 37.2mm 3 ), and the median parenchyma volume was 53.6 mm 3 (71.9 ± 66.7 mm 3 ). In cystic glands, the standard deviation of the PGV was substantially higher than in solid glands (98% vs 58% of the mean). PGV declined with age (r = -0.130, P = 0.016). CONCLUSION:The high interindividual volume variation is mainly related to cysts. Pineal parenchyma volume decreased slightly with age, whereas genderrelated effects appear to be negligible.

肝硬化中肝细胞癌的动态对比增强CT成像:根据示踪动力学模型行延迟双期检查方案的可行性

应用双期动态对比增强成像对4例肝细胞癌行CT检查．首先应用初始快速动态成像观察早期强化用以评估灌注情况,其后应用逐渐增加时间间隔的延迟成像来监测随后的组织增强表现以评估组织通透性。利用双人路双室分布参数模型来分析动态对比增强CT影像．分别评估血流量和通透性及血管内外容积分数。结果表明,半透膜分隔的双室模型能恰当地显示肝细胞癌和周围肝硬化组织的增强曲线。与背景肝组织相比,肝细胞癌的强化更早。

脑MRI影像组学在预测转移瘤类型中的应用

目的探讨在未知原发病灶的病人中,运用多分类机器学习方法中不同脑转移瘤的MRI影像组学特征预测肿瘤类型的可行性。材料与方法这项单中心回顾性分析纳入189例病人(女101例,男88例;年龄32~85岁,平均61岁)共658幅脑转移瘤的MR影像,包括T1平扫、T1增强与液体衰减反转恢复(FLAIR)序列影像。

Bumetanide promotes neural precursor cell regeneration and dendritic development in the hippocampal dentate gyrus in the chronic stage of cerebral ischemia

Bumetanide has been shown to lessen cerebral edema and reduce the infarct area in the acute stage of cerebral ischemia. Few studies focus on the effects of bumetanide on neuroprotection and neurogenesis in the chronic stage of cerebral ischemia. We established a rat model of cerebral ischemia by injecting endothelin-1 in the left cortical motor area and left corpus striatum. Seven days later, bumetanide 200 μg/kg/day was injected into the lateral ventricle for 21 consecutive days with a mini-osmotic pump. Results demonstrated that the number of neuroblasts cells and the total length of dendrites increased, escape latency reduced, and the number of platform crossings increased in the rat hippocampal dentate gyrus in the chronic stage of cerebral ischemia. These findings suggest that bumetanide promoted neural precursor cell regeneration, dendritic development and the recovery of cognitive function, and protected brain tissue in the chronic stage of ischemia.

扩散张量成像对于正常脑表现的发育迟缓儿童胼胝体微观结构异常的显示

胼胝体纤维在精神运动和认知功能等方面具有重要作用。本研究的目的是对常规MRI脑表现正常的发育迟缓的儿童进行研究,探讨其胼胝体存在微观结构异常的可能性。本组研究对象为17例发育迟缓的患儿（年龄1-9岁）。分别在胼胝体膝部和压部测量T2值和部分各向异性（FA）值。除了对胼胝体行纤维示踪、容积测定外,还计算纤维密度。测量结果同年龄相匹配的健康受试者比较。疾病组胼胝体膝部的T2值普遍升高（疾病组105ms／正常组95ms）,

Qualitative and Quantitative Perfusion Parameters Determined by 3D Single-Shot GRASE ASL MR Imaging

Rationale and Objectives: A particular arterial spin (ASL) labeling technique, called 3D-single-shot GRASE ASL is discussed with respect to the ability and limits of quantifying perfusion parameters. Materials and Methods: The technique enables the acquisition of perfusion weighted signal at multiple delay times (TI) in one scan. The readout part is a gradient and spin-echo combination (GRASE) that uses switched gradient rephrasing of signals to produce several times as many signals as turbo-spin-echo, which translates into faster imaging time and higher signal-to-noise ratio (SNR) per imaging time. The technique provides the possibility for model based quantification of cerebral blood flow and the determination of the bolus arrival information without use of contrast agent and thus the characterization and determina-tion of regions that are supported by collaterals. Results: Whereas for a quantification of the permeability using ASL the SNR is not high enough, at least qualitative permeability maps can be determined, if an optimal homogenous SNR was guaranteed. This was accomplished in brain regions with a high blood supply, typically given in tumors, and by using a correction for coil sensitivity at the highest possible additional scaling. Conclusion: The single-shot 3D GRASE ASL can provide information about the principal blood supply, the transit delay of the blood flow due to a stenosis or collaterals and a qualitative measure of the permeability.

<i>De novo</i>cavernous aneurysms development after contralateral parent artery occlusion—Two cases report

A 53-year-old woman developed a de novo aneurysm after contralateral internal carotid artery occlusion, and another 42-year-old woman developed a de novo aneurysm after contralateral vertebral artery occlusion. Both patients experienced a rapid development of de novo aneurysm formation, 6 and 9 months, respectively. The development of de novo aneurysm on the contralateral artery after parent artery occlusion showed that female and medium age may be contributory factors. In addition, the hemodynamic changes may be associated with the development of de novo aneurysm after contralateral parent artery occlusion.

CO_(2)BOLD assessment of moyamoya syndrome:Validation with single photon emission computed tomography and positron emission tomography imaging

AIM To compare the assessment of cerebrovascular reserve(CVR) using CO_2 BOLD magnetic resonance imaging(MRI) vs positron emission tomography(PET) and single photon emission computed tomography(SPECT) as reference standard.METHODS Ten consecutive patients(8 women, mean age of 41 ± 26 years) with moyamoya syndrome underwent 14 presurgical evaluations for external-internal carotid artery bypass surgery. CVR was assessed using CO_2 BOLD and PET(4)/SPECT(11) with a maximum interval of 36 d, andevaluated by two experienced neuroradiologists.RESULTS The inter-rater agreement was 0.81 for SPECT(excellent), 0.43 for PET(fair) and 0.7 for CO_2 BOLD(good). In 9/14 cases, there was a correspondence between CO_2 BOLD and PET/SPECT. In 4/14 cases, CVR was over-estimated in CO_2 BOLD, while in 1/14 case, CVR was underestimated in CO_2 BOLD. The sensitivity of CO_2 BOLD was 86% and a specificity of 43%. CONCLUSION CO_2 BOLD can be used for pre-surgical assessment of CVR in patients with moyamoya syndrome and combines the advantages of absent irradiation, high availability of MRI and assessment of brain parenchyma, cerebral vessels and surrogate CVR in one stop.

Subcostal artery bleeding after endoscopic combined intrarenal surgery: Signs and treatment

Percutaneous nephrolithotomy is the first option in renal stones>2 cm.One of the most serious complications of this procedure is postoperative bleeding[1].Various risk factors(multiple punctures,position,access size,stone volume,operative time,and non-papillary puncture)were considered in the literature with no clear conclusions[[1],[2]].

Resolution of Symptoms after Parent Artery Occlusion Treatment for Giant Cavernous Carotid Artery Aneurysms

Background and Objective: Giant cavernous carotid artery aneurysms (CCAAs) often produce a variety of neurological deficits, primarily those related to ophthalmoplegia/paresis and headache. This study was designed to evaluate the resolution of symptoms after parent artery occlusion (PAO) treatment for giant CCAAs. Methods: We retrospectively reviewed a series of 17 consecutive giant CCAAs treated with PAO treatment. All patients were evaluated by balloon occlusion test (BOT) before treatment. Patients who could tolerate BOT were treated by PAO. The following outcomes were analyzed: angiographic assessment, evolution of symptoms and outcome at clinical follow-up using modified Rankin Scale (mRS). Results: A total number of 17 giant CCAAs were treated by PAO. The initial post-procedure and follow-up angiogram revealed complete occlusion in all patients, no new lesion was detected. Periprocedural infarcts occurred in 1 patient (5.9%). Procedure-related mortality and morbidity were 0% and 5.9%, respectively. At mean 31.8 months clinical follow-up, symptoms had disappeared in 7 (41.2%) of the patients, partially improved in 5 (29.4%), remained unchanged in 4 (23.5%) and worsened in 1 (5.9%) of cases. Sixteen (94.1%) patients presented a good clinical outcome (mRS 0 - 1). Conclusion: Most patients in our series improved or remained stable after PAO. The results of this study indicate that PAO can improve the outcome of those symptomatic giant CCAAs if BOT can be tolerated.

Complete Remission and Long Term Survival in Recurrent Malignant Glioblastoma Treated with Fotemustine Monotherapy: A Case Report

Glioblastoma multiforme (GBM) is the most malignant primary brain tumor. Conventional therapies are considered palliative and long-term progression-free survival remains low for most GBM patients even after surgical excision, concomitant radiotherapy and/or chemotherapy with nitrosoureas or Temozolomide. We report the case of a 47-year-old man who presented worsening headache over a month, accompanied by episodes of morning vomiting and hyposthenia of the left hemisoma. Cerebral tomographic scan revealed an expansive process on the right frontal site. Following surgical resection, the patient was diagnosed with diffusely infiltrating GBM. After surgery, the patient underwent radiotherapy and chemotherapy with Temozolomide for 6 months. Eleven months later, the patient underwent a second-look surgery with excision of a new right superior frontal nodule. This time the patient refused both radio and chemotherapy and underwent follow-up only. After 12 months he underwent a new craniotomy for the excision of a third GBM relapse. Following resection, the patient agreed to be treated for 6 months with fotemustine (FTM) 100 mg/m2 intravenously every 4 weeks as chemotherapy. After 3 months of treatment the patient underwent a full physical examination and diagnostic monitoring of the tumor using Magnetic Resonance Imaging (MRI) of the brain and whole body Computerised Tomography (CT). During FTM treatment, the most frequent, but reversible toxic effect was hematological grade 2 anemia and thrombocytopenia but no other grade >2 toxicity was recorded, so there was no reduction or delay in treatment. Presently, after 8 years of follow-up, the patient is in excellent health and has no evidence of intracranial disease recurrence. In light of this case, post-surgical FTM treatment seems to represent an interesting well-tolerated treatment possibility in patients with recurrent malignant GBM of the brain, given that there are very few reports of such a remission in the literature.

A cardioembolic stroke

A 76-year-old woman with unspecified congenital heart disease was admitted on April 25th for TIA. She had a possible history of atrial fibrillation. A slight fever was noted on admission. Her ECG was abnormal, as well as her transthoracic echocardiography (TTE). Troponin I was slightly increased. On May 11th, a stroke occurred, in relation with an occlusion of the basilar artery. The patient was transferred to our institution for an emergency desobstruction. A dramatic improvement allowed her to be discharged to a rehabilitation center on May 18th. However, she was re-hospitalized on June 5th, due to sepsis and neurological worsening. MRI showed new ischemic brain lesions. Several episodes of paroxysmal atrial fibrillation were documented, as well as pulmonary hypertension. Effective heparin therapy was initiated and transesophageal echocardiography (TEE) was requested this time. It revealed a congenital valvular heart disease (a subaortic membrane), complicated by infective endocarditis. Despite a monitoring of aPTT, a fatal hemorrhagic shock occurred. We report this unfortunately remarkable case to address the following important points: 1) In the setting of a neurological event, abnormal ECG and/or abnormal TTE and/or Troponin I elevation may indicate a cardioembolic mechanism and therefore seek a cardiac source of embolism. 2) When TTE fails to identify a cardiac source of embolism, TEE should be performed, especially when a preexisting heart disease is suspected or known. 3) The multiplicity in space (infarcts in both the anterior and posterior circulation, or bilateral) and/or the multiplicity in time (infarcts of different age) may indicate a cardioembolic stroke. 4) Congenital subaortic membrane predisposes to infective endocarditis. 5) When anticoagulant therapy is initiated on strong arguments in a septic patient (much discussed in infective endocarditis), aPTT monitoring alone may not be enough. An anti-Xa monitoring may be more appropriate.