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Wintermark, M.;Coombs, L.;Druzgal, T.J.;Field, A.S.;Filippi, C.G.;Hicks, R.;Horton, R.;Lui, Y.W.;Law, M.;Mukherjee, P.;Norbash, A.;Riedy, G.;Sanelli, P.C.;Stone, J.R.;Sze, G.;Tilkin, M.;Whitlow, C.T.;Wilde, E.A.;York, G.;Provenzale, J.M.;
2015 American Journal of Neuroradiology
doi: 10.3174/ajnr.A4254pmid: 25655872
SUMMARY: The past decade has seen impressive advances in the types of neuroimaging information that can be acquired in patients with traumatic brain injury. However, despite this increase in information, understanding of the contribution of this information to prognostic accuracy and treatment pathways for patients is limited. Available techniques often allow us to infer the presence of microscopic changes indicative of alterations in physiology and function in brain tissue. However, because histologic confirmation is typically lacking, conclusions reached by using these techniques remain solely inferential in almost all cases. Hence, a need exists for validation of these techniques by using data from large population samples that are obtained in a uniform manner, analyzed according to well-accepted procedures, and correlated with closely monitored clinical outcomes. At present, many of these approaches remain confined to population-based research rather than diagnosis at an individual level, particularly with regard to traumatic brain injury that is mild or moderate in degree. A need and a priority exist for patient-centered tools that will allow advanced neuroimaging tools to be brought into clinical settings. One barrier to developing these tools is a lack of an age-, sex-, and comorbidities-stratified, sequence-specific, reference imaging data base that could provide a clear understanding of normal variations across populations. Such a data base would provide researchers and clinicians with the information necessary to develop computational tools for the patient-based interpretation of advanced neuroimaging studies in the clinical setting. The recent “Joint ASNR-ACR HII-ASFNR TBI Workshop: Bringing Advanced Neuroimaging for Traumatic Brain Injury into the Clinic” on May 23, 2014, in Montreal, Quebec, Canada, brought together neuroradiologists, neurologists, psychiatrists, neuropsychologists, neuroimaging scientists, members of the National Institute of Neurologic Disorders and Stroke, industry representatives, and other traumatic brain injury stakeholders to attempt to reach consensus on issues related to and develop consensus recommendations in terms of creating both a well-characterized normative data base of comprehensive imaging and ancillary data to serve as a reference for tools that will allow interpretation of advanced neuroimaging tests at an individual level of a patient with traumatic brain injury. The workshop involved discussions concerning the following: 1) designation of the policies and infrastructure needed for a normative data base, 2) principles for characterizing normal control subjects, and 3) standardizing research neuroimaging protocols for traumatic brain injury. The present article summarizes these recommendations and examines practical steps to achieve them. ABBREVIATIONS: ABIDE Autism Brain Imaging Data Exchange ACR American College of Radiology ADNI Alzheimer Disease Neuroimaging Initiative AFSNR American Society of Functional Neuroradiology ASNR American Society of Neuroradiology CDE Common Data Element DART Data Archive and Research Toolkit DKI diffusional kurtosis imaging FITBIR Federal Interagency TBI Research LONI Laboratory of Neuroimaging LORIS Longitudinal On-line Research and Imaging System NIH National Institutes of Health NITRC Neuroinformatics Tools and Resources TBI traumatic brain injury TRIAD Translational Research Informatics and Data Management Grid
2015 American Journal of Neuroradiology
doi: 10.3174/ajnr.A3954pmid: 24831592
SUMMARY: For patients presenting with clinically isolated syndrome, the treating clinician needs to advise the patient on the probability of conversion to clinically definite multiple sclerosis. MR imaging may give useful prognostic information, and there is large body of literature pertaining to the use of MR imaging in assessing patients presenting with clinically isolated syndrome. This literature review evaluates the accuracy of MR imaging in predicting which patients with clinically isolated syndrome will go on to develop long-term disease and/or disability. New and emerging MR imaging technologies and their applicability to patients with clinically isolated syndrome are also considered. ABBREVIATIONS: CDMS clinically definite multiple sclerosis CIS clinically isolated syndrome EDSS Expanded Disability Status Scale T2LV T2 lesion volume
Wittschieber, D.;Karger, B.;Niederstadt, T.;Pfeiffer, H.;Hahnemann, M.L.;
2015 American Journal of Neuroradiology
doi: 10.3174/ajnr.A3989pmid: 24948499
SUMMARY: Are subdural hygromas the result of abusive head trauma? CT and MR imaging represent important tools for the diagnosis of abusive head trauma in living infants. In addition, in-depth understanding of the pathogenesis of subdural hygromas is increasingly required by neuroradiologists, pediatricians, and forensic physicians. Therefore, the current knowledge on subdural hygromas is summarized and forensic conclusions are drawn. The most important diagnostic pitfalls, benign enlargement of the subarachnoid space, and chronic subdural hematoma, are discussed in detail. Illustrative cases from forensic practice are presented. Literature analysis indicates that subdural hygromas can occur immediately or be delayed. If other infrequent reasons can be excluded, the presence of subdural hygromas strongly suggests a posttraumatic state and should prompt the physician to search for other signs of abuse. To differentiate subdural hygromas from other pathologies, additional MR imaging of the infant's head is indispensable after initial CT scan. ABBREVIATIONS: AHT abusive head trauma BESS benign enlargement of subarachnoid space BV bridging vein cSDH chronic subdural hematoma SDH subdural hematoma SDHy subdural hygroma
Schneider, T.;Huisman, T.A.G.M.;Fiehler, J.;Savic, L.J.;Yousem, D.M.;
2015 American Journal of Neuroradiology
doi: 10.3174/ajnr.A4132pmid: 25273537
BACKGROUND AND PURPOSE: No previous study compares neuroradiology training programs and teaching schedules across the globe, to our knowledge. This study was conducted to better understand international program requisites. MATERIALS AND METHODS: Data from 43 countries were collected by an e-mail-based questionnaire (response rate, 84.0%). Radiologists across the world were surveyed regarding the neuroradiology training schemes in their institutions. Answers were verified by officers of the national neuroradiology societies. RESULTS: While many countries do not provide fellowship training in neuroradiology ( n = 16), others have formal postresidency curricula ( n = 27). Many programs have few fellows and didactic sessions, but the 1- or 2-year duration of fellowship training is relatively consistent ( n = 23/27, 85%). CONCLUSIONS: There is a wide variety of fellowship offerings, lessons provided, and ratios of teachers to learners in neuroradiology training programs globally. ABBREVIATIONS: ACGME Accreditation Council for Graduate Medical Education DNR diagnostic neuroradiology ESNR European Society of Neuroradiology INR interventional neuroradiology NR neuroradiology
Bhalsing, K.S.;Kumar, K.J.;Saini, J.;Yadav, R.;Gupta, A.K.;Pal, P.K.;
2015 American Journal of Neuroradiology
doi: 10.3174/ajnr.A4138pmid: 25339653
BACKGROUND AND PURPOSE: Impairment of cognitive functions occurs in essential tremor, though the mechanism is largely unknown. The aim of this study was to find microstructural correlates of cognitive dysfunction seen in essential tremor by using DTI and neuropsychological assessment. MATERIALS AND METHODS: Fifty-five patients with essential tremor and 55 matched healthy controls were evaluated. Essential tremor was diagnosed by using the National Institutes of Health criteria. Subjects were assessed by using a structured neuropsychological battery. DTI data were acquired by using 3T MR imaging and were analyzed by using tract-based spatial statistics. Fractional anisotropy, mean diffusivity, radial diffusivity, and axial diffusivity were analyzed. RESULTS: Patients were considered cognitively impaired when the test score was 1.5 SDs below or above the mean of healthy controls (depending on the type of test) in ≥3 neuropsychological tests. Patients with cognitive impairment had significantly higher mean diffusivity, radial diffusivity, and axial diffusivity values in the bilateral frontoparietal regions. In patients with cognitive impairment, mean diffusivity, radial diffusivity, and axial diffusivity showed correlations with various neuropsychological test scores. Executive function correlated with DTI measures of the frontal white matter, cingulum, inferior superior longitudinal and uncinate fasciculi, anterior thalamic radiations, and posterior lobe of the cerebellum. Visuospatial function correlated with the right parieto-occipital lobe, whereas visual-verbal memories correlated with the anterior thalamic radiations, inferior longitudinal and uncinate fasciculi, and the posterior lobe of the cerebellum. No significant correlations were found between fractional anisotropy and any of the neuropsychological test scores. CONCLUSIONS: The present study demonstrates a correlation between neuropsychological test scores and DTI measures, suggesting a neuroanatomic basis for cognitive impairment seen in patients with essential tremor. ABBREVIATIONS: ET essential tremor ETCI ET with cognitive impairment ETNCI ET without cognitive impairment HC healthy controls TBSS tract-based spatial statistics
Meijer, F.J.A.;van Rumund, A.;Fasen, B.A.C.M.;Titulaer, I.;Aerts, M.;Esselink, R.;Bloem, B.R.;Verbeek, M.M.;Goraj, B.;
2015 American Journal of Neuroradiology
doi: 10.3174/ajnr.A4140pmid: 25339647
BACKGROUND AND PURPOSE: The differentiation between Parkinson disease and atypical parkinsonian syndromes can be challenging in clinical practice, especially in early disease stages. Brain MR imaging can help to increase certainty about the diagnosis. Our goal was to evaluate the added value of SWI in relation to conventional 3T brain MR imaging for the diagnostic work-up of early-stage parkinsonism. MATERIALS AND METHODS: This was a prospective observational cohort study of 65 patients presenting with parkinsonism but with an uncertain initial clinical diagnosis. At baseline, 3T brain MR imaging with conventional and SWI sequences was performed. After clinical follow-up, probable diagnoses could be made in 56 patients, 38 patients diagnosed with Parkinson disease and 18 patients diagnosed with atypical parkinsonian syndromes, including 12 patients diagnosed with multiple system atrophy–parkinsonian form. In addition, 13 healthy controls were evaluated with SWI. Abnormal findings on conventional brain MR imaging were grouped into disease-specific scores. SWI was analyzed by a region-of-interest method of different brain structures. One-way ANOVA was performed to analyze group differences. Receiver operating characteristic analyses were performed to evaluate the diagnostic accuracy of conventional brain MR imaging separately and combined with SWI. RESULTS: Disease-specific scores of conventional brain MR imaging had a high specificity for atypical parkinsonian syndromes (80%–90%), but sensitivity was limited (50%–80%). The mean SWI signal intensity of the putamen was significantly lower for multiple system atrophy–parkinsonian form than for Parkinson disease and controls ( P < .001). The presence of severe dorsal putaminal hypointensity improved the accuracy of brain MR imaging: The area under the curve was increased from 0.75 to 0.83 for identifying multiple system atrophy–parkinsonian form, and it was increased from 0.76 to 0.82 for identifying atypical parkinsonian syndromes as a group. CONCLUSIONS: SWI improves the diagnostic accuracy of 3T brain MR imaging in the work-up of parkinsonism by identifying severe putaminal hypointensity as a sign indicative of multiple system atrophy–parkinsonian form. ABBREVIATIONS: AP atypical parkinsonian syndromes AUC area under the curve CBS corticobasal syndrome DLB dementia with Lewy bodies HC healthy controls MSA multiple system atrophy MSA-P multiple system atrophy–parkinsonian form PD Parkinson disease PSP progressive supranuclear palsy ROC receiver operating characteristic SI signal intensity
Cosottini, M.;Frosini, D.;Pesaresi, I.;Donatelli, G.;Cecchi, P.;Costagli, M.;Biagi, L.;Ceravolo, R.;Bonuccelli, U.;Tosetti, M.;
2015 American Journal of Neuroradiology
doi: 10.3174/ajnr.A4158pmid: 25376811
BACKGROUND AND PURPOSE: Standard neuroimaging fails in defining the anatomy of the substantia nigra and has a marginal role in the diagnosis of Parkinson disease. Recently 7T MR target imaging of the substantia nigra has been useful in diagnosing Parkinson disease. We performed a comparative study to evaluate whether susceptibility-weighted angiography can diagnose Parkinson disease with a 3T scanner. MATERIALS AND METHODS: Fourteen patients with Parkinson disease and 13 healthy subjects underwent MR imaging examination at 3T and 7T by using susceptibility-weighted angiography. Two expert blinded observers and 1 neuroradiology fellow evaluated the 3T and 7T images of the sample to identify substantia nigra abnormalities indicative of Parkinson disease. Diagnostic accuracy and intra- and interobserver agreement were calculated separately for 3T and 7T acquisitions. RESULTS: Susceptibility-weighted angiography 7T MR imaging can diagnose Parkinson disease with a mean sensitivity of 93%, specificity of 100%, and diagnostic accuracy of 96%. 3T MR imaging diagnosed Parkinson disease with a mean sensitivity of 79%, specificity of 94%, and diagnostic accuracy of 86%. Intraobserver and interobserver agreement was excellent at 7T. At 3T, intraobserver agreement was excellent for experts, and interobserver agreement ranged between good and excellent. The less expert reader obtained a diagnostic accuracy of 89% at 3T. CONCLUSIONS: Susceptibility-weighted angiography images obtained at 3T and 7T differentiate controls from patients with Parkinson disease with a higher diagnostic accuracy at 7T. The capability of 3T in diagnosing Parkinson disease might encourage its use in clinical practice. The use of the more accurate 7T should be supported by a dedicated cost-effectiveness study. ABBREVIATIONS: HS healthy subjects PD Parkinson disease SN substantia nigra SWAN susceptibility-weighted angiography UHF ultra-high-field
Lin, P.-Y.;Chao, T.-C.;Wu, M.-L.;
2015 American Journal of Neuroradiology
doi: 10.3174/ajnr.A4137pmid: 25339652
BACKGROUND AND PURPOSE: Quantitative susceptibility mapping of the human brain has demonstrated strong potential in examining iron deposition, which may help in investigating possible brain pathology. This study assesses the reproducibility of quantitative susceptibility mapping across different imaging sites. MATERIALS AND METHODS: In this study, the susceptibility values of 5 regions of interest in the human brain were measured on 9 healthy subjects following calibration by using phantom experiments. Each of the subjects was imaged 5 times on 1 scanner with the same procedure repeated on 3 different 3T systems so that both within-site and cross-site quantitative susceptibility mapping precision levels could be assessed. Two quantitative susceptibility mapping algorithms, similar in principle, one by using iterative regularization (iterative quantitative susceptibility mapping) and the other with analytic optimal solutions (deterministic quantitative susceptibility mapping), were implemented, and their performances were compared. RESULTS: Results show that while deterministic quantitative susceptibility mapping had nearly 700 times faster computation speed, residual streaking artifacts seem to be more prominent compared with iterative quantitative susceptibility mapping. With quantitative susceptibility mapping, the putamen, globus pallidus, and caudate nucleus showed smaller imprecision on the order of 0.005 ppm, whereas the red nucleus and substantia nigra, closer to the skull base, had a somewhat larger imprecision of approximately 0.01 ppm. Cross-site errors were not significantly larger than within-site errors. Possible sources of estimation errors are discussed. CONCLUSIONS: The reproducibility of quantitative susceptibility mapping in the human brain in vivo is regionally dependent, and the precision levels achieved with quantitative susceptibility mapping should allow longitudinal and multisite studies such as aging-related changes in brain tissue magnetic susceptibility. ABBREVIATIONS: PDF projection onto dipole fields QSM quantitative susceptibility mapping SHARP sophisticated harmonic artifact reduction for phase data
Larvie, M.;Timerman, D.;Thum, J.A.;
2015 American Journal of Neuroradiology
doi: 10.3174/ajnr.A4172pmid: 25477358
BACKGROUND AND PURPOSE: Developmental venous anomalies are the most common intracranial vascular malformation and are typically regarded as inconsequential, especially when small. While there are data regarding the prevalence of MR imaging findings associated with developmental venous anomalies, FDG-PET findings have not been well-characterized. MATERIALS AND METHODS: Clinical information systems were used to retrospectively identify patients with developmental venous anomalies depicted on MR imaging examinations who had also undergone FDG-PET. Both the MR imaging and FDG-PET scans were analyzed to characterize the developmental venous anomalies and associated findings on the structural and functional scans. Qualitative and quantitative assessments were performed, including evaluation of the size of the developmental venous anomaly, associated MR imaging findings, and characterization of the FDG uptake in the region of the developmental venous anomaly. RESULTS: Twenty-five developmental venous anomalies in 22 patients were identified that had been characterized with both MR imaging and FDG-PET, of which 76% (19/25) were associated with significant metabolic abnormality in the adjacent brain parenchyma, most commonly hypometabolism. Patients with moderate and severe hypometabolism were significantly older (moderate: mean age, 65 ± 7.4 years, P = .001; severe: mean age, 61 ± 8.9 years, P = .008) than patients with developmental venous aberrancies that did not have abnormal metabolic activity (none: mean age, 29 ± 14 years). CONCLUSIONS: Most (more than three-quarters) developmental venous anomalies in our series of 25 cases were associated with metabolic abnormality in the adjacent brain parenchyma, often in the absence of any other structural abnormality. Consequently, we suggest that developmental venous anomalies may be better regarded as developmental venous aberrancies. ABBREVIATION: DVA developmental venous anomaly
Chen, H.-J.;Chen, R.;Yang, M.;Teng, G.-J.;Herskovits, E.H.;
2015 American Journal of Neuroradiology
doi: 10.3174/ajnr.A4146pmid: 25500314
BACKGROUND AND PURPOSE: White matter abnormalities have been demonstrated to play an important role in minimal hepatic encephalopathy. In this study, we aimed to evaluate whether WM diffusion tensor imaging can be used to identify minimal hepatic encephalopathy among patients with cirrhosis. MATERIALS AND METHODS: Our study included 65 patients with cirrhosis with covert hepatic encephalopathy (29 with minimal hepatic encephalopathy and 36 without hepatic encephalopathy). Participants underwent DTI, from which we generated mean diffusivity and fractional anisotropy maps. We used a Bayesian machine-learning technique, called Graphical-Model-based Multivariate Analysis, to determine WM regions that characterize group differences. To further test the clinical significance of these potential biomarkers, we performed Cox regression analysis to assess the potential of these WM regions in predicting survival. RESULTS: In mean diffusivity or fractional anisotropy maps, 2 spatially distributed WM regions (predominantly located in the bilateral frontal lobes, corpus callosum, and parietal lobes) were consistently identified as differentiating minimal hepatic encephalopathy from no hepatic encephalopathy and yielded 75.4%–81.5% and 83.1%–92.3% classification accuracy, respectively. We were able to follow 55 of 65 patients (median = 18 months), and 15 of these patients eventually died of liver-related causes. Survival analysis indicated that mean diffusivity and fractional anisotropy values in WM regions were predictive of survival, in addition to the Child-Pugh score. CONCLUSIONS: Our findings indicate that WM DTI can provide useful biomarkers differentiating minimal hepatic encephalopathy from no hepatic encephalopathy, which would be helpful for minimal hepatic encephalopathy detection and subsequent treatment. ABBREVIATIONS: FA fractional anisotropy GAMMA Graphical-Model-based Multivariate Analysis HE hepatic encephalopathy HR hazard ratio MD mean diffusivity MHE minimal hepatic encephalopathy NHE no hepatic encephalopathy
Beyer, S.E.;Thierfelder, K.M.;von Baumgarten, L.;Rottenkolber, M.;Meinel, F.G.;Janssen, H.;Ertl-Wagner, B.;Reiser, M.F.;Sommer, W.H.;
2015 American Journal of Neuroradiology
doi: 10.3174/ajnr.A4131pmid: 25523589
BACKGROUND AND PURPOSE: Collateral blood flow is an important prognostic marker in the acute stroke situation but approaches for assessment vary widely. Our aim was to compare strategies of collateral blood flow assessment in dynamic and conventional CTA in their ability to predict the follow-up infarction volume. MATERIALS AND METHODS: We retrospectively included all patients with an M1 occlusion from an existing cohort of 1912 consecutive patients who underwent initial multimodal stroke CT and follow-up MR imaging or nonenhanced CT. Collateralization was assessed in both conventional CT angiography and dynamic CT angiography by using 3 different collateral grading scores and segmentation of the volume of hypoattenuation. Arterial, arteriovenous, and venous phases were reconstructed for dynamic CT angiography, and all collateral scores and the volume of hypoattenuation were individually assessed for all phases. Different grading systems were compared by using the Bayesian information criterion calculated for multivariate regression analyses (Bayesian information criterion difference = 2–6, “positive”; Bayesian information criterion difference = 6–10, “strong”; Bayesian information criterion difference = >10, “very strong”). RESULTS: One hundred thirty-six patients (mean age, 70.4 years; male sex, 41.2%) were included. In the multivariate analysis, models containing the volume of hypoattenuation showed a significantly better model fit than models containing any of the 3 collateral grading scores in conventional CT angiography (Bayesian information criterion difference = >10) and dynamic CT angiography (Bayesian information criterion difference = >10). All grading systems showed the best model fit in the arteriovenous phase. For the volume of hypoattenuation, model fit was significantly higher for models containing the volume of hypoattenuation as assessed in the arteriovenous phase of dynamic CT angiography compared with the venous phase (Bayesian information criterion difference = 6.2) and the arterial phase of dynamic CT angiography (Bayesian information criterion difference = >10) and in comparison with conventional CT angiography (Bayesian information criterion difference = >10). CONCLUSIONS: The use of dynamic CT angiography within the arteriovenous phase by using quantification of the volume of hypoattenuation is the superior technique for assessment of collateralization among the tested approaches. ABBREVIATIONS: BIC Bayesian information criterion NECT nonenhanced CT VH volume of hypoattenuation
Hwang, Y.-H.;Kang, D.-H.;Kim, Y.-W.;Kim, Y.-S.;Park, S.-P.;Liebeskind, D.S.;
2015 American Journal of Neuroradiology
doi: 10.3174/ajnr.A4151pmid: 25376808
BACKGROUND AND PURPOSE: The relationship between reperfusion and clinical outcome is time-dependent, and the effect of reperfusion on outcome can vary on the basis of the extent of collateral flow. We aimed to identify the impact of time-to-reperfusion on outcome relative to baseline angiographic collateral grade in patients successfully treated with endovascular revascularization for acute large-vessel anterior circulation stroke. MATERIALS AND METHODS: Two hundred seven patients were selected for analysis from our prospectively maintained registry. Inclusion criteria were M1 MCA ± ICA occlusions, onset-to-puncture time within 8 hours, and successful endovascular reperfusion. Baseline angiographic collateral grades were independently evaluated and dichotomized into poor (0–1) versus good (2–4). Multivariable analyses were performed to identify the effect of collateral-flow adequacy on favorable outcome on the basis of onset-to-reperfusion time and puncture-to-reperfusion time. RESULTS: In the poor collateral group, the odds of favorable outcome significantly dropped for patients with onset-to-reperfusion time of >300 minutes or puncture-to-reperfusion time of >60 minutes (onset-to-puncture time: ≤300, 59% versus >300, 32%; OR, 0.24; P = .011; puncture-to-reperfusion time: ≤60, 73% versus >60, 32%; OR, 0.21, P = .011), whereas the probability of favorable outcome in the good collateral group was not significantly influenced by onset-to-reperfusion time or puncture-to-reperfusion time. In the subgroup lesion-volume growth analysis by using DWI, the effect of puncture-to-reperfusion time of >60 minutes was significantly greater compared with the effect of puncture-to-reperfusion time of <60 minutes in the poor collateral group (β = 41.6 cm 3 , P = .001). CONCLUSIONS: Time-to-reperfusion including onset-to-reperfusion time and puncture-to-reperfusion time in patients with poor collaterals is an important limiting factor for favorable outcome in a time-dependent fashion. Future trials may benefit from a noninvasive imaging technique to detect poor collaterals along with a strategy for rapid reperfusion. ABBREVIATIONS: HI hemorrhagic infarction OPT onset-to-puncture time ORT onset-to-reperfusion time PH parenchymal hematoma PRT puncture-to-reperfusion time
Crombé, A.;Saranathan, M.;Ruet, A.;Durieux, M.;de Roquefeuil, E.;Ouallet, J.C.;Brochet, B.;Dousset, V.;Tourdias, T.;
2015 American Journal of Neuroradiology
doi: 10.3174/ajnr.A4152pmid: 25376810
BACKGROUND AND PURPOSE: In multiple sclerosis, gadolinium enhancement is used to classify lesions as active. Regarding the need for a standardized and accurate method for detection of multiple sclerosis activity, we compared 2D-spin-echo with 3D-gradient-echo T1WI for the detection of gadolinium-enhancing MS lesions. MATERIALS AND METHODS: Fifty-eight patients with MS were prospectively imaged at 3T by using both 2D-spin-echo and 3D-gradient recalled-echo T1WI in random order after the injection of gadolinium. Blinded and independent evaluation was performed by a junior and a senior reader to count gadolinium-enhancing lesions and to characterize their location, size, pattern of enhancement, and the relative contrast between enhancing lesions and the adjacent white matter. Finally, the SNR and relative contrast of gadolinium-enhancing lesions were computed for both sequences by using simulations. RESULTS: Significantly more gadolinium-enhancing lesions were reported on 3D-gradient recalled-echo than on 2D-spin-echo ( n = 59 versus n = 30 for the junior reader, P = .021; n = 77 versus n = 61 for the senior reader, P = .017). The difference between the 2 readers was significant on 2D-spin-echo ( P = .044), for which images were less reproducible (κ = 0.51) than for 3D-gradient recalled-echo (κ = 0.65). Further comparisons showed that there were statistically more small lesions (<5 mm) on 3D-gradient recalled-echo than on 2D-spin-echo ( P = .04), while other features were similar. Theoretic results from simulations predicted SNR and lesion contrast for 3D-gradient recalled-echo to be better than for 2D-spin-echo for visualization of small enhancing lesions and were, therefore, consistent with clinical observations. CONCLUSIONS: At 3T, 3D-gradient recalled-echo provides a higher detection rate of gadolinium-enhancing lesions, especially those with smaller size, with a better reproducibility; this finding suggests using 3D-gradient recalled-echo to detect MS activity, with potential impact in initiation, monitoring, and optimization of therapy. ABBREVIATIONS: FSPGR fast-spoiled gradient recalled GRE gradient recalled-echo SE spin-echo
Lee, H.-J.;Wu, C.-C.;Wu, H.-M.;Hung, S.-C.;Lirng, J.-F.;Luo, C.-B.;Chang, F.-C.;Guo, W.-Y.;
2015 American Journal of Neuroradiology
doi: 10.3174/ajnr.A4142pmid: 25339645
BACKGROUND AND PURPOSE: Suprasellar papillary craniopharyngiomas and germ cell tumors in adults share some clinical and imaging similarities but have different therapeutic strategies and outcomes. This study aimed to evaluate the pretreatment diagnosis of these 2 tumors to improve the therapeutic outcome. MATERIALS AND METHODS: We retrospectively enrolled 18 adults with papillary craniopharyngiomas and 17 with germ cell tumors. The MR imaging findings were evaluated, including signal change and anatomic extension. The medical records were reviewed to collect clinical findings, management, and outcomes. RESULTS: The clinical findings of papillary craniopharyngiomas versus germ cell tumors were as follows: age: 46 ± 13.9 years versus 23 ± 7.1 years ( P < .0001); diabetes insipidus: 2/18 (11%) versus 11/17 (65%) ( P = .001); recurrence 13/16 (81%) versus 4/17 (24%) ( P = .0031). The MR imaging findings of papillary craniopharyngiomas versus germ cell tumors were as follows—pituitary stalk thickening: 1.6 ± 0.4 mm versus 5.4 ± 4.2 mm ( P < .0001); vertical infundibular extension: 1/18 (6%) versus 16/17 (94%) ( P < .0001); sagittal spheric shape: 17/18 (94%) versus 1/17 (6%) ( P < .0001); diffusion restriction: 1/17 (6%) versus 8/12 (67%) ( P = .0009). CONCLUSIONS: Younger age, diabetes insipidus, MR imaging characteristics of restricted diffusion, and vertical infundibular extension favor the diagnosis of germ cell tumors. Spheric shape without infundibular infiltration provides clues to papillary craniopharyngiomas, which originate from the pars tuberalis and are located outside the third ventricle. We suggest that suprasellar germ cell tumor is possibly an intraventricular lesion. Appropriate treatment planning can be initiated according to the diagnosis and anatomic location. ABBREVIATIONS: GCT germ cell tumor PCP papillary craniopharyngioma
Méndez Orellana, C.;Visch-Brink, E.;Vernooij, M.;Kalloe, S.;Satoer, D.;Vincent, A.;van der Lugt, A.;Smits, M.;
2015 American Journal of Neuroradiology
doi: 10.3174/ajnr.A4147pmid: 25355817
BACKGROUND AND PURPOSE: Determining language dominance with fMRI is challenging in patients with brain tumor, particularly in cases of suspected atypical language representation. Supratentorial activation patterns must be interpreted with great care when the tumor is in or near the presumed language areas, where tumor tissue or mass effect can lead to false-negative fMRI results. In this study, we assessed cerebrocerebellar language fMRI lateralization in healthy participants and in patients with brain tumors with a focus on atypical language representation. MATERIALS AND METHODS: Twenty healthy participants and 38 patients with a brain tumor underwent fMRI with a verb-generation task. Cerebral and cerebellar language lateralizations were separately classified as left-sided, right-sided, or symmetric. Electrocortical stimulation was performed in 19 patients. With the McNemar test, we evaluated the dependency between language lateralization in the cerebrum and cerebellum, and with Pearson correlation analysis, the relationship between the cerebral and cerebellar lateralization indices. RESULTS: There was a significant dependency between cerebral and cerebellar language activation, with moderate negative correlation (Pearson r = −0.69). Crossed cerebrocerebellar language activation was present in both healthy participants and patients, irrespective of handedness or typical or atypical language representation. There were no discordant findings between fMRI and electrocortical stimulation. CONCLUSIONS: Language lateralization in the cerebellum can be considered an additional diagnostic feature to determine language dominance in patients with brain tumor. This is particularly useful in cases of uncertainty, such as the interference of a brain tumor with cerebral language activation on fMRI and atypical language representation. ABBREVIATIONS: ECS electrocortical stimulation HP healthy participant LI lateralization index
Brinjikji, W.;Murad, M.H.;Rabinstein, A.A.;Cloft, H.J.;Lanzino, G.;Kallmes, D.F.;
2015 American Journal of Neuroradiology
doi: 10.3174/ajnr.A4159pmid: 25395655
BACKGROUND AND PURPOSE: A number of studies have suggested that anesthesia type (conscious sedation versus general anesthesia) during intra-arterial treatment for acute ischemic stroke has implications for patient outcomes. We performed a systematic review and meta-analysis of studies comparing the clinical and angiographic outcomes of the 2 anesthesia types. MATERIALS AND METHODS: In March 2014, we conducted a computerized search of MEDLINE and EMBASE for reports on anesthesia and endovascular treatment of acute ischemic stroke. Using random-effects meta-analysis, we evaluated the following outcomes: recanalization rate, good functional outcome (mRS ≤ 2), asymptomatic and symptomatic intracranial hemorrhage, death, vascular complications, respiratory complications, procedure time, time to groin, and time from symptom onset to recanalization. RESULTS: Nine studies enrolling 1956 patients (814 with general anesthesia and 1142 with conscious sedation) were included. Compared with patients treated by using conscious sedation during stroke intervention, patients undergoing general anesthesia had higher odds of death (OR = 2.59; 95% CI, 1.87–3.58) and respiratory complications (OR = 2.09; 95% CI, 1.36–3.23) and lower odds of good functional outcome (OR = 0.43; 95% CI, 0.35–0.53) and successful angiographic outcome (OR = 0.54; 95% CI, 0.37–0.80). No difference in procedure time ( P = .28) was seen between the groups. Preintervention NIHSS scores were available from 6 studies; in those, patients receiving general anesthesia had a higher average NIHSS score. CONCLUSIONS: Patients with acute ischemic stroke undergoing intra-arterial therapy may have worse outcomes with general anesthesia compared with conscious sedation. However, the difference in stroke severity at the onset may confound the comparison in the available studies; thus, a randomized trial is necessary to confirm this association. ABBREVIATION: ICH intracranial hemorrhage
Janiga, G.;Berg, P.;Sugiyama, S.;Kono, K.;Steinman, D.A.;
2015 American Journal of Neuroradiology
doi: 10.3174/ajnr.A4157pmid: 25500315
BACKGROUND AND PURPOSE: Rupture risk assessment for intracranial aneurysms remains challenging, and risk factors, including wall shear stress, are discussed controversially. The primary purpose of the presented challenge was to determine how consistently aneurysm rupture status and rupture site could be identified on the basis of computational fluid dynamics. MATERIALS AND METHODS: Two geometrically similar MCA aneurysms were selected, 1 ruptured, 1 unruptured. Participating computational fluid dynamics groups were blinded as to which case was ruptured. Participants were provided with digitally segmented lumen geometries and, for this phase of the challenge, were free to choose their own flow rates, blood rheologies, and so forth. Participants were asked to report which case had ruptured and the likely site of rupture. In parallel, lumen geometries were provided to a group of neurosurgeons for their predictions of rupture status and site. RESULTS: Of 26 participating computational fluid dynamics groups, 21 (81%) correctly identified the ruptured case. Although the known rupture site was associated with low and oscillatory wall shear stress, most groups identified other sites, some of which also experienced low and oscillatory shear. Of the 43 participating neurosurgeons, 39 (91%) identified the ruptured case. None correctly identified the rupture site. CONCLUSIONS: Geometric or hemodynamic considerations favor identification of rupture status; however, retrospective identification of the rupture site remains a challenge for both engineers and clinicians. A more precise understanding of the hemodynamic factors involved in aneurysm wall pathology is likely required for computational fluid dynamics to add value to current clinical decision-making regarding rupture risk. ABBREVIATIONS: CFD computational fluid dynamics OSI oscillatory shear index Re Reynolds RRT relative residence time TAWSS temporal-averaged wall shear stress WSS wall shear stress
Brinjikji, W.;Kallmes, D.F.;Cloft, H.J.;Lanzino, G.;
2015 American Journal of Neuroradiology
doi: 10.3174/ajnr.A4139pmid: 25339646
BACKGROUND AND PURPOSE: Treatment of cerebral aneurysms with flow diverters often mandates placement of the device across the ostia of major branches of the internal carotid artery. We determined the patency rates of the anterior choroidal artery after placement of flow-diversion devices across its ostium. MATERIALS AND METHODS: We analyzed a consecutive series of patients in whom a Pipeline Embolization Device was placed across the ostium of an angiographically visible anterior choroidal artery while treating the target aneurysm. Patency of the anterior choroidal artery after Pipeline Embolization Device placement was determined at immediate postoperative and follow-up angiography. Data on pretreatment aneurysm rupture status, concomitant coiling, number of Pipeline Embolization Devices used, neurologic status at follow-up, and follow-up MR imaging/CT findings were collected. RESULTS: Fifteen patients with 15 treated aneurysms were included in this study. In the immediate postprocedural setting, the anterior choroidal artery was patent on posttreatment angiography for all 15 patients. Of the 14 patients with follow-up angiography at least 6 months after Pipeline Embolization Device placement, 1 (7%) had occlusion of the anterior choroidal artery and 14 had a patent anterior choroidal artery (93%). No patients had new neurologic symptoms or stroke related to anterior choroidal artery occlusion at follow-up. Of the 9 patients with follow-up CT or MR imaging, none had infarction in the vascular territory of the anterior choroidal artery. CONCLUSIONS: In this small study, placement of a Pipeline Embolization Device across the anterior choroidal artery ostium resulted in occlusion of the artery in only 1 patient. It was not associated with ischemic changes in the distribution of the anterior choroidal artery in any patient. ABBREVIATIONS: AchoA anterior choroidal artery PED Pipeline Embolization Device
Lubicz, B.;Van der Elst, O.;Collignon, L.;Mine, B.;Alghamdi, F.;
2015 American Journal of Neuroradiology
doi: 10.3174/ajnr.A4143pmid: 25376806
BACKGROUND AND PURPOSE: The Silk flow-diverter stent is increasingly used to treat complex intracranial aneurysms including wide-neck, fusiform aneurysms. Sparse data are available concerning long-term results of this technique. We report our 5-year experience with Silk stent treatment of intracranial aneurysms. MATERIALS AND METHODS: A retrospective review of our prospectively maintained database identified all patients treated by the Silk stent in 2 institutions. Clinical charts, procedural data, and angiographic results were reviewed. RESULTS: Between July 2009 and May 2014, we identified 58 patients with 70 intracranial aneurysms. Endovascular treatment was successful in 93% of patients with 32 treated with the first-generation Silk stent and 26 with the new Silk+ stent. Mean follow-up in 47 patients was 22 months. Despite an 11% delayed complication rate, overall permanent neurologic morbidity was 5.5%. All complications were seen with the first-generation Silk stent. There was no procedure-related mortality. Long-term anatomic results showed 73% with complete occlusion, 16% with neck remnants, and 11% with incomplete occlusion. No recanalization or retreatment was performed. The midterm intrastent stenosis rate was 57%, of which 60% improved or disappeared, 28% were stable, and 12% led to vessel occlusion. Seventy-four percent of stenosis and all vessel occlusions occurred with the first-generation Silk stent. CONCLUSIONS: Endovascular treatment of complex intracranial aneurysms with the Silk stent is an effective therapeutic option. Despite a high rate of delayed complications with the first-generation stents, the current Silk+ stent appears safer. This treatment achieves a high rate of adequate and stable occlusion at long-term follow-up. ABBREVIATIONS: CLARITY Clinical and Anatomical Results in the Treatment of Ruptured Intracranial Aneurysms PAO parent artery occlusion
Mokin, M.;Setlur Nagesh, S.V.;Ionita, C.N.;Levy, E.I.;Siddiqui, A.H.;
2015 American Journal of Neuroradiology
doi: 10.3174/ajnr.A4149pmid: 25376809
BACKGROUND AND PURPOSE: A new in vitro cerebrovascular occlusion model of the intracranial circulation was developed recently for testing thrombectomy devices. Using this model, we compared recanalization success associated with different modern endovascular thrombectomy approaches. MATERIALS AND METHODS: Model experiments were performed in 4 thrombectomy test groups: 1) primary or direct Stentriever thrombectomy with a conventional guide catheter (control group), 2) primary Stentriever thrombectomy with a balloon-guide catheter, 3) combined Stentriever–continuous aspiration approach, and 4) direct aspiration alone. Successful recanalization was defined as a TICI score of 2b or 3. RESULTS: Seventy-one thrombectomy experiments were conducted. Similar rates of TICI 2b–3 scores were achieved with balloon-guide and conventional guide catheters ( P = .34). The combined Stentriever plus aspiration approach and the primary aspiration thrombectomy resulted in significantly higher rates of TICI 2b or 3 than the conventional guide-catheter approach in the control group ( P = .008 and P = .0001, respectively). The primary Stentriever thrombectomy with the conventional guide catheter showed the highest rate of embolization to new territories (53%). CONCLUSIONS: Data from our in vitro model experiments show that the Stentriever thrombectomy under continuous aspiration and primary aspiration thrombectomy approaches led to the highest degree of recanalization. ABBREVIATIONS: ADAPT direct aspiration first pass technique EDT embolization in distal territory ENT embolization in new territory SWIFT Solitaire FR With the Intention for Thrombectomy TREVO 2 Thrombectomy REvascularization of large Vessel Occlusions in acute ischemic stroke
Klisch, J.;Sychra, V.;Strasilla, C.;Taschner, C.A.;Reinhard, M.;Urbach, H.;Meckel, S.;
2015 American Journal of Neuroradiology
doi: 10.3174/ajnr.A4133pmid: 25324495
BACKGROUND AND PURPOSE: Mechanical thrombectomy by using a single stent retriever system has demonstrated high efficacy for recanalization of large-artery occlusions in acute stroke. We aimed to evaluate the feasibility, safety, and efficacy of a novel double Solitaire stent retriever technique as an escalating treatment for occlusions that are refractory to first-line single stent retriever mechanical thrombectomy. MATERIALS AND METHODS: All patients treated with the double stent retriever technique by using the Solitaire system were retrospectively selected from 2 large neurointerventional centers. Time to recanalization, angiographic (TICI) and clinical outcomes (mRS), and complications were assessed. RESULTS: Ten patients (median NIHSS score, 16; mean age, 70 years) with MCA M1 segment ( n = 5) and terminal ICA ( n = 5 including 2 ICA tandem) occlusions were included. Prior single stent retriever mechanical thrombectomy had been performed in 9 patients (median number of passes, 3). Median time to recanalization was 60 minutes (interquartile range, 45–87 minutes). Procedure-related complications occurred in 1 patient; overall mortality was 20%. Recanalization of the target vessel (TICI 2b/3) was achieved in 80%. Good clinical outcome (mRS 0–2) was 50%. CONCLUSIONS: In this preliminary feasibility study, the double Solitaire stent retriever technique proved to be an effective method for recanalization of anterior circulation large-artery occlusions refractory to standard stent retriever mechanical thrombectomy. ABBREVIATIONS: DAC distal-access catheter ICAT internal carotid artery terminus MT mechanical thrombectomy SR stent retriever
Martin, A.R.;Cruz, J.P.;O'Kelly, C.;Kelly, M.;Spears, J.;Marotta, T.R.;
2015 American Journal of Neuroradiology
doi: 10.3174/ajnr.A4170pmid: 25395659
SUMMARY: Flow diversion has become an established treatment option for challenging intracranial aneurysms. The use of small devices of ≤3-mm diameter remains unapproved by major regulatory bodies. A retrospective review of patients treated with Pipeline Embolization Devices of ≤3-mm diameter at 3 Canadian institutions was conducted. Clinical and radiologic follow-up data were collected and reported. Twelve cases were treated with ≥1 Pipeline Embolization Device of ≤3-mm diameter, including 2 with adjunctive coiling, with a median follow-up of 18 months (range, 4–42 months). One patient experienced a posttreatment minor complication (8%) due to an embolic infarct. No posttreatment hemorrhage or delayed complications such as in-stent stenosis/thrombosis were observed. Radiologic occlusion was seen in 9/12 cases (75%) and near-occlusion in 2/12 cases (17%). Intracranial aneurysm treatment with small-diameter flow-diverting stents provided safe and effective aneurysm closure in this small selected sample. These devices should be further studied and considered for regulatory approval. ABBREVIATIONS: PED Pipeline Embolization Device PICA posterior inferior cerebellar artery
Schubert, T.;Pansini, M.;Bieri, O.;Stippich, C.;Wetzel, S.;Schaedelin, S.;von Hessling, A.;Santini, F.;
2015 American Journal of Neuroradiology
doi: 10.3174/ajnr.A4148pmid: 25395658
BACKGROUND AND PURPOSE: Physiologic and pathologic arterial tortuosity may attenuate blood flow pulsatility. The aim of this prospective study was to assess a potential effect of the curved V3 segment (Atlas slope) of the vertebral artery on arterial flow pulsatility. The pulsatility index and resistance index were used to assess blood flow pulsatility. MATERIALS AND METHODS: Twenty-one healthy volunteers (17 men, 4 women; mean age, 32 years) were examined with a 3T MR imaging system. Blood velocities were measured at 2 locations below (I and II) and at 1 location above the V3 segment (III) of the vertebral artery by using a high-resolution 2D-phase-contrast sequence with multidirectional velocity-encoding. RESULTS: Pulsatility and resistance indices decreased along all measurement locations from proximal to distal. The pulsatility index decreased significantly from location II to III and from I to II. However, the decrease was more pronounced along the Atlas slope than in the straight-vessel section below. The decrease of the resistance index was highly significant along the Atlas slope (location II to III). The decrease from location I to II was small and not significant. CONCLUSIONS: The pronounced decrease in pulsatility and resistance indices along the interindividually uniformly bent V3 segment compared with a straight segment of the vertebral artery indicates a physiologic attenuating effect of the Atlas slope on arterial flow pulsatility. A similar effect has been described for the carotid siphon. A physiologic reduction of pulsatility in brain-supplying arteries would be in accordance with several recent publications reporting a correlation of increased arterial flow pulsatility with leukoencephalopathy and lacunar stroke. ABBREVIATIONS: PC phase-contrast PI pulsatility index RI resistance index Vmax maximum blood velocity Vmean mean blood velocity Vmin minimum blood velocity
Lee, T.C.;Chansakul, T.;Huang, R.Y.;Wrubel, G.L.;Mukundan, S.;Annino, D.J.;Pribaz, J.J.;Pomahac, B.;
2015 American Journal of Neuroradiology
doi: 10.3174/ajnr.A4141pmid: 25339651
SUMMARY: Face transplantation is being performed with increasing frequency. Facial edema, fluid collections, and lymphadenopathy are common postoperative findings and may be due to various etiologies, some of which are particular to face transplantation. The purpose of this study was to demonstrate how postoperative imaging and image-guided minimally invasive procedures can assist in diagnosing and treating complications arising from face transplantation. Retrospective evaluation of 6 consecutive cases of face transplantation performed at Brigham and Women's Hospital between April 2009 and March 2014 was performed with assessment of postoperative imaging and image-guided procedures, including aspiration of postoperative fluid collection, lymph node biopsy, and treatment of salivary gland leak. Through these cases, we demonstrate that early postoperative imaging and image-guided procedures are key components for the management of complications following face transplantation.
Whitehead, M.T.;Oh, C.;Raju, A.;Choudhri, A.F.;
2015 American Journal of Neuroradiology
doi: 10.3174/ajnr.A4153pmid: 25355815
BACKGROUND AND PURPOSE: Calcifications of the pineal, habenula, choroid plexus, and dura are often physiologic. In the modern CT era with thin-section images and multiplanar reformats, intracranial calcifications have become more conspicuous. We aimed to discover the CT prevalence of pineal region, choroid plexus, and dural calcifications in the first decade of life. MATERIALS AND METHODS: Five hundred head CTs from different patients (age range, 0–9 years) encountered during a consecutive 6-month period at a single academic children's hospital were reviewed retrospectively after excluding examinations with artifacts and pineal region masses/hemorrhage. All studies were performed on a 320-detector CT, with 0.5-mm collimation and a 512 × 512 matrix. Five-millimeter reformatted axial, sagittal, and coronal images were analyzed for location and extent of intracranial calcifications. RESULTS: The mean age was 3.5 ± 5.7 years (range, 0–9 years). There were 285 males (57%) and 215 females (43%). Pineal calcifications were present in 5% ( n = 25; age range, 3.2–8.9 years; median, 7 years). Habenular calcifications were found in 10% ( n = 50; age range, 2.8–8.8 years; median, 7 years). Twelve percent ( n = 58) had choroid plexus calcifications, (age range, 0.1–8.8 years). Dural calcifications were rare, present in 1% ( n = 6; age range, 2.9–8.7 years). CONCLUSIONS: Physiologic intracranial calcifications may be found in the first decade, principally in children older than 5 years. Most epithalamic calcifications are habenular. Pineal and habenular calcifications were never present in children younger than 3 and 2 years, respectively. Choroid plexus calcifications may be present in the very young. Dural calcifications are rare.
Tortora, D.;Panara, V.;Mattei, P.A.;Tartaro, A.;Salomone, R.;Domizio, S.;Cotroneo, A.R.;Caulo, M.;
2015 American Journal of Neuroradiology
doi: 10.3174/ajnr.A4144pmid: 25376807
BACKGROUND AND PURPOSE: The loss of contrast on T1-weighted MR images at 3T may affect the detection of hyperintense punctate lesions indicative of periventricular leukomalacia in preterm neonates. The aim of the present study was to determine which 3T T1-weighted sequence identified the highest number of hyperintense punctate lesions and to explore the relationship between the number of hyperintense punctate lesions and clinical outcome. MATERIALS AND METHODS: The presence of hyperintense punctate lesions was retrospectively evaluated in 200 consecutive preterm neonates on 4 axial T1-weighted sequences: 3-mm inversion recovery and spin-echo and 1- and 3-mm reformatted 3D-fast-field echo. Statistically significant differences in the number of hyperintense punctate lesions were evaluated by using a linear mixed-model analysis. Logistic regression analysis was used to assess the relation between the number of hyperintense punctate lesions and neuromotor outcome at 3 months. RESULTS: Thirty-one neonates had at least 1 hyperintense punctate lesion indicative of periventricular leukomalacia in at least 1 of the 4 sequences. The 1-mm axial reformatted 3D-fast-field echo sequence identified the greatest number of hyperintense punctate lesions ( P < .001). No statistically significant differences were found among the 3-mm T1-weighted sequences. The greater number of hyperintense punctate lesions detected by the 1-mm reformatted T1 3D-fast-field echo sequence in the central region of the brain was associated with a worse clinical outcome. CONCLUSIONS: At 3T, the 1-mm axial reformatted T1 3D-fast-field echo sequence identified the greatest number of hyperintense punctate lesions in the central region of preterm neonate brains, and this number was associated with neuromotor outcome. ABBREVIATIONS: FFE fast-field echo IR inversion recovery HPL hyperintense punctate lesion ICC intraclass correlation coefficient PN preterm neonate PVL periventricular leukomalacia SE spin-echo
Diehn, F.E.;Rykken, J.B.;Wald, J.T.;Wood, C.P.;Eckel, L.J.;Hunt, C.H.;Schwartz, K.M.;Lingineni, R.K.;Carter, R.E.;Kaufmann, T.J.;
2015 American Journal of Neuroradiology
doi: 10.3174/ajnr.A4160pmid: 25395656
BACKGROUND AND PURPOSE: In patients with intramedullary spinal cord metastases, the impact of MR imaging and clinical characteristics on survival has not been elucidated. Our aim was to identify MR imaging and clinical features with prognostic value among patients with intramedullary spinal cord metastases from a large retrospective series. MATERIALS AND METHODS: The relevant MR imaging examination and baseline clinical data for each patient from a consecutive group of patients with intramedullary spinal cord metastases had previously been reviewed by 2 neuroradiologists. Additional relevant clinical data were extracted. The influence of clinical and imaging characteristics on survival was assessed by Kaplan-Meier survival curves and log-rank tests for categoric characteristics. RESULTS: Forty-nine patients had 70 intramedullary spinal cord metastases; 10 (20%) of these patients had multiple metastases. From the date of diagnosis, median survival for all patients was 104 days (95% CI, 48–156 days). One clinical feature was associated with decreased median survival: lung or breast primary malignancy (57 days) compared with all other malignancy types (308 days; P < .001). Three MR imaging features were associated with decreased median survival: multiple intramedullary spinal cord metastases (53 versus 121 days, P = .022), greater longitudinal extent of cord T2 hyperintensity (if ≥3 segments, 111 days; if ≤2, 184 days; P = .018), and ancillary visualization of the primary tumor and/or non-CNS metastases (96 versus 316 days, P = .012). CONCLUSIONS: Spinal cord edema spanning multiple segments, the presence of multifocal intramedullary spinal cord metastases, and ancillary evidence for non-CNS metastases and/or the primary tumor are MR imaging features associated with decreased survival and should be specifically sought. Patients with either a lung or breast primary malignancy are expected to have decreased survival compared with other primary tumor types. ABBREVIATION: ISCM intramedullary spinal cord metastasis
Shahgholi, L.;Yost, K.J.;Carter, R.E.;Geske, J.R.;Hagen, C.E.;Amrami, K.K.;Diehn, F.E.;Kaufmann, T.J.;Morris, J.M.;Murthy, N.S.;Wald, J.T.;Thielen, K.R.;Kallmes, D.F.;Maus, T.P.;
2015 American Journal of Neuroradiology
doi: 10.3174/ajnr.A4150pmid: 25614474
BACKGROUND AND PURPOSE: The Patient Reported Outcomes Measurement Information System is a newly developed outcomes measure promulgated by the National Institutes of Health. This study compares changes in pain and physical function–related measures of this system with changes on the Numeric Rating Pain Scale, Roland Morris Disability Index, and the European Quality of Life scale 5D questionnaire in patients undergoing transformational epidural steroid injections for radicular pain. MATERIALS AND METHODS: One hundred ninety-nine patients undergoing transforaminal epidural steroid injections for radicular pain were enrolled in the study. Before the procedure, they rated the intensity of their pain by using the 0–10 Numeric Rating Pain Scale, Roland Morris Disability Index, and European Quality of Life scale 5D questionnaire. Patients completed the Patient Reported Outcomes Measurement Information System Physical Function, Pain Behavior, and Pain Interference short forms before transforaminal epidural steroid injections and at 3 and 6 months. Seventy and 43 subjects replied at 3- and 6-month follow-up. Spearman rank correlations were used to assess the correlation between the instruments. The minimally important differences were calculated for each measurement tool as an indicator of meaningful change. RESULTS: All instruments were responsive in detecting changes at 3- and 6-month follow-up ( P < .0001). There was significant correlation between changes in Patient Reported Outcomes Measurement Information System scores and legacy questionnaires from baseline to 3 months ( P < .05). There were, however, no significant correlations in changes from 3 to 6 months with any of the instruments. CONCLUSIONS: The studied Patient Reported Outcomes Measurement Information System domains offered responsive and correlative psychometric properties compared with legacy instruments in a population of patients undergoing transforaminal epidural steroid injections for radicular pain. ABBREVIATIONS: EQ-5D European Quality of Life scale 5D questionnaire NRS Numeric Rating Pain Scale PROMIS Patient Reported Outcomes Measurement Information System RMDI Roland-Morris Disability Index TFESI transforaminal epidural steroid injection
Bellini, M.;Romano, D.G.;Leonini, S.;Grazzini, I.;Tabano, C.;Ferrara, M.;Piu, P.;Monti, L.;Cerase, A.;
2015 American Journal of Neuroradiology
doi: 10.3174/ajnr.A4166pmid: 25395657
BACKGROUND AND PURPOSE: Chemonucleolysis represents a minimally invasive percutaneous technique characterized by an intradiskal injection of materials under fluoroscopic or CT guidance. Recently, a substance based on radiopaque gelified ethanol has been introduced. The purpose of this study was to describe the indications, procedure, safety, and efficacy of radiopaque gelified ethanol in the percutaneous treatment of cervical and lumbar disk herniations. MATERIALS AND METHODS: Between September 2010 and August 2013, 80 patients (32 women and 48 men; age range, 18–75 years) were treated for 107 lumbar disk herniations (L2–L3, n = 1; L3–L4, n = 15; L4–L5, n = 53; and L5–S1, n = 38) and 9 cervical disk herniations (C4–C5, n = 2; C5–C6, n = 2; C6–C7, n = 3; and C7–D1, n = 2) by percutaneous intradiskal injection of radiopaque gelified ethanol under fluoroscopic guidance. Thirty-six patients underwent a simultaneous treatment of 2 disk herniations. Patient symptoms were resistant to conservative therapy, with little or no pain relief after 4–6 weeks of physical therapy and drugs. All patients were evaluated by the Visual Analog Scale and the Oswestry Disability Index. RESULTS: Sixty-two of 73 (85%) patients with lumbar disk herniations and 6/7 (83%) patients with cervical disk herniations obtained significant symptom improvement, with a Visual Analog Scale reduction of at least 4 points and an Oswestry Disability Index reduction of at least 40%. Leakage of radiopaque gelified ethanol in the surrounding tissues occurred in 19 patients, however without any clinical side effects. CONCLUSIONS: In our experience, percutaneous intradiskal injection of radiopaque gelified ethanol is safe and effective in reducing the period of recovery from disabling symptoms. ABBREVIATIONS: CDH cervical disk herniation LDH lumbar disk herniation ODI Oswestry Disability Index RGE radiopaque gelified ethanol VAS Visual Analog Scale
Menezes-Reis, R.;Salmon, C.E.G.;Carvalho, C.S.;Bonugli, G.P.;Chung, C.B.;Nogueira-Barbosa, M.H.;
2015 American Journal of Neuroradiology
doi: 10.3174/ajnr.A4125pmid: 25324494
BACKGROUND AND PURPOSE: Intervertebral disk biochemical composition could be accessed in vivo by T1ρ and T2 relaxometry. We found no studies in the literature comparing different segmentation methods for data extraction using these techniques. Our aim was to compare different manual segmentation methods used to extract T1ρ and T2 relaxation times of intervertebral disks from MR imaging. Seven different methods of partial-disk segmentation techniques were compared with whole-disk segmentation as the reference standard. MATERIALS AND METHODS: Sagittal T1ρ and T2 maps were generated by using a 1.5T MR imaging scanner in 57 asymptomatic volunteers 20–40 years of age. Two hundred eighty-five lumbar disks were separated into 2 groups: nondegenerated disk (Pfirrmann I and II) and degenerated disk (Pfirrmann III and IV). In whole-disk segmentation, the disk was segmented in its entirety on all sections. Partial-disk segmentation methods included segmentation of the disk into 6, 5, 4, 3, and 1 sagittal sections. Circular ROIs positioned in the nucleus pulposus and annulus fibrosus were also used to extract T1ρ and T2, and data were compared with whole-disk segmentation RESULTS: In the nondegenerated group, segmentation of ≥5 sagittal sections showed no statistical difference with whole-disk segmentation. All the remaining partial-disk segmentation methods and circular ROIs showed different results from whole-disk segmentation ( P < .001). In the degenerated disk group, all methods were statistically similar to whole-disk segmentation. All partial-segmentation methods, including circular ROIs, showed strong linear correlation with whole-disk segmentation in both the degenerated and nondegenerated disk groups. CONCLUSIONS: Manual segmentation showed strong reproducibility for T1ρ and T2 and strong linear correlation between partial- and whole-disk segmentation. Absolute T1ρ and T2 values extracted from different segmentation techniques were statistically different in disks with Pfirrmann grades I and II. ABBREVIATIONS: AAF anterior annulus fibrosus AF annulus fibrosus CROI circular ROIs ICC intraclass correlation coefficient NP nucleus pulposus PAF posterior annulus fibrosus PDS partial-disk segmentation WDS whole-disk segmentation