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Cerebral venous thrombosis is a less common but relevant cause of stroke in adults. The clinical manifestations are nonspecific leading frequently diagnostic delays, so imaging findings are is of vital importance. Conventional imaging modalities, namely computed tomography and magnetic resonance imaging (MRI), allow identification of the thrombus and parenchymal involvement due to venous congestion to a variable degree, but this entity may appears as a nonexpected finding in a nonvenographic study. computed tomography and MRI venographies allow noninvasive confirmation of the diagnosis and adequate characterization of the extent of the thrombus and acute complications, both of them being robust diagnostic techniques. MR venography also can be done without the use of contrast media, which is especially important in certain clinical situations. Cerebral venous thrombosis needs follow-up, and imaging plays a key role in detection of late complications of the disease, including dural arteriovenous fistulas and intracranial hypertension due to veno-occlusive disease. Knowledge of other diseases and conditions that may mimic a thrombus is needed to avoid wrong diagnosis. In this article, we conduct a pictorial comprehensive review of cerebral venous thrombosis, including also the technical aspects of different imaging modalities, diagnosis and acute complications, follow-up, late complications and potential imaging mimics.

Objective To describe a group of patients with suspected acute invasive fungal rhinosinusitis (AIFRS) diagnosis, and identify factors associated with a greater risk of presenting this disease. Design Non-concurrent cohort study. Setting A single-centre non-concurrent follow-up of patients with suspected AIFRS between August 2015 and July 2018. Participants 50 inpatients referred due to suspected AIFRS at Hospital Clinico Universidad Catolica based on the association of a predisposing factor (neutropenia/immunodeficiency/poorly controlled diabetes) with fever of unknown origin. Main outcome measure The primary outcome was AIFRS diagnosis, defined as a concordant tissue biopsy. Results Acute invasive fungal rhinosinusitis was confirmed in 18% (9/50) of the evaluated patients. AIFRS was significantly associated with a positive galactomannan (P = .04), and a paranasal sinus MRI with lack of contrast enhancement (LoCE) (P = .04) orbit compromise (P = .03) or global extrasinusal extension (P = .04). LoCE and extrasinusal extension in the paranasal sinus/brain MRI were risk factors for AIFRS (OR 16; CI 1.2-210.6 and OR 12.75; CI 1.3-128.8, respectively). Conversely, a nasal endoscopy showing healthy mucosa was identified as a protective factor for AIFRS (OR 0.06; CI 0.007-0.57). Conclusions In patients with suspected AIFRS, we identified laboratory and radiologic variables associated with the disease, which may help for a more accurate diagnostic algorithm and approach in this population.

Pituitary abscesses (PAs) are a rare clinical entity which may arise from normal pituitary tissue or underlying lesions within the gland. Rathke’s cleft cysts (RCCs) are not commonly associated with the development of PA. Retrospective chart review of three patients with PAs within RCCs at a single university center and review of the literature. Three cases are reported. The first case presented with fever and headache and a history of prior surgery due to RCC and a recent respiratory tract infection. The second case had a history of recent skin infections and presented with sudden onset headache and hypopituitarism. In the third case, chronic visual field impairment prompted an ophthalmologic evaluation resulting in a diagnosis of an adenoma and an infected RCC. In all three cases, an endoscopic endonasal approach was performed to drain infected tissue and allowed microbiological identification of gram-positive cocci, followed by treatment with antibiotics for at least three weeks. Cases in the literature are scarce and the diagnosis is usually made intraoperatively due to non-specific manifestations and imaging. PAs arising from underlying pituitary lesions are less common than primary PAs. Differential diagnosis should include pituitary apoplexy, hypophysitis and other cystic lesions. PAs occurring in RCCs are infrequent. Clinical manifestations are commonly subacute, without septic symptoms. Imaging is usually non-specific. Preoperative diagnosis is infrequent and a broad differential diagnosis should be considered. Empirical antimicrobial therapy should be initiated and adjusted after obtaining cultures to reduce the rate of recurrence and improve clinical outcomes.

Background Mechanical Thrombectomy (MT) is the standard of care for treatment of large vessel occlusion stroke. Until the beginning of 2020 MT was not funded nor widely implemented at the public healthcare level in Chile. Objective To describe the results of a pilot program created to provide access to public MT in Santiago - Chile. Methods Analysis from a prospectively collected database of MT cases performed between September 2017 and September 2019 in one center. A stroke network was developed with a single MT capable stroke center and five primary stroke centers. The primary efficacy endpoint was the rate of functional independence (mRS 0-2) at 90 days. Successful reperfusion was defined as 2 b-3 according to the thrombolysis in cerebral infarction scale. Safety outcomes include the rates of symptomatic intracranial hemorrhage and 90-day mortality. Results A total of 100 patients were treated over the study period. Their mean age was 62.8 ± 11.8 years and median baseline National Institute of Health Stroke Scale (NIHSS) measurement was 17. Seventy-seven percent of the patients received intra venous thrombolysis. Successful reperfusion was achieved in 95% of the cases. NIHSS at 24 hours showed a median drop of 7 points from baseline (p Conclusions We demonstrated the feasibility of a publicly funded MT program in Chile, with similar results as other international randomized control trials.

Hydrophilic polymer coatings on intravascular devices lower friction between the device and vasculature, thereby reducing trauma during interventional procedures. Polymer coating embolism-the detachment and downstream embolism of polymer particles-has been reported as an iatrogenic complication of coated interventional devices affecting the vasculature and various organs. The Food and Drug Administration (FDA) acknowledges this complication and continues to work with stakeholders to close gaps in performance testing and standards related to polymer coating integrity. Recent innovations within interventional technologies have led to development of new hydrophilic-coated devices with expanded indications for use. The 2018 FDA draft guidance for intravascular guidewires expands the application of particulate generation testing to most devices and recommends labeling changes to increase industry awareness. This article highlights current procedural trends where the phenomenon of polymer coating embolism may be more prevalent. It describes the mechanisms of polymer separation, reported clinical sequelae, and risk factors for relevant indications. These procedural trends and associated risk factors articulate the need for particulate testing and support the FDA's draft guidance recommendations for performance testing of applied coatings. If standardized, particulate assessments may allow characterization and comparisons of coating integrity among devices from various manufacturers, and are an important foundation for setting particulate limits. As hydrophilic coatings enable endovascular treatment for a range of patient populations, setting particulate limits or finding alternative solutions without compromise to device function may be essential. Particulate testing is relevant to physicians, regulators, and manufacturers for the purposes of product development and quality improvement of interventional devices.

Polymer coating emboli have been affiliated with persisting brain lesions after endovascular procedures.1–6 Patient symptoms include headaches, fevers, chills (ie, constitutional symptoms), neurological presentations of focal weakness, sensory and visual deficits, and seizures. Follow-up imaging highlights distinct areas of contrast enhancement in slightly different locations, with some lesions increasing in number and size (see figure 1). Polymer particles from various coating compositions have different rates of degradation, absorption, and metabolism or excretion (DAM/E). These varied rates of DAM/E may have impacts on persisting brain lesions, recurrent patient symptoms, and adverse event outcomes. Figure 1 Characteristic MRI of patients with persisting brain lesions. T1 postcontrast images highlighting an increase in the number and size of lesions (white arrows) over a 12 month period. Also note formation of new enhancing lesions. Images used with permission by Williams and Wilkins Co. (license ID: 1100407-1). Degradation is the chemical breakdown of a polymer by hydrolysis, oxidation, or enzymatic processes. A faster degradation rate may result in less obstruction within blood vessels or reduced presence …

Hypopituitarism after moderate or severe traumatic brain injury (TBI) is usually underdiagnosed and therefore undertreated. Its course can be divided in an acute phase during the first 14 days after TBI with 50 to 80% risk of hypopituitarism, and a chronic phase, beginning three months after the event, with a prevalence of hypopituitarism that ranges from 2 to 70%. Its pathophysiology has been addressed in several studies, suggesting that a vascular injury to the pituitary tissue is the most important mechanism during the acute phase, and an autoimmune one during chronic stages. In the acute phase, there are difficulties to correctly interpret pituitary axes. Hence, we propose a simple and cost-effective algorithm to detect and treat a potential hypothalamic-pituitary-adrenal axis impairment and alterations of sodium homeostasis, both of which can be life-threatening. In the chronic phase, post-concussion syndrome is the most important differential diagnosis. Given the high prevalence of hypopituitarism, we suggest that all pituitary axes should be assessed in all patients with moderate to severe TBI, between 3 to 6 months after the event, and then repeated at 12 months after trauma by a specialized team in pituitary disease.

Background Multiple sclerosis (MS) is a chronic immune mediated disease and the progressive phase appears to have significant neurodegenerative mechanisms. The classification of the course of progressive MS (PMS) has been re-organized into categories of active vs. not active inflammatory disease and the presence vs. absence of gradual disease progression. Clinical trial experience to date in PMS with anti-inflammatory medications has shown limited effect. Andrographolide is a new class of anti-inflammatory agent, that has been proposed as a potential drug for autoimmune disorders, including MS. In the present trial, we perform an exploratory pilot study on the efficacy and safety of andrographolide (AP) compared to placebo in not active PMS. Methods A pilot clinical trial using 140 mg oral AP or placebo twice daily for 24 months in patients with not active primary or secondary progressive MS was conducted. The primary efficacy endpoint was the mean percentage brain volume change (mPBVC). Secondary efficacy endpoints included 3-month confirmed disability progression (3-CDP) and mean EDSS change. Results Forty-four patients were randomized: 23 were assigned to the AP group, and 21 were assigned to the placebo group. The median baseline EDSS of both groups was 6.0. Annualized mPBVC was − 0.679% for the AP group and − 1.069% for the placebo group (mean difference: -0.39; 95% CI [− 0.836–0.055], p = 0.08, relative reduction: 36.5%). In the AP group, 30% had 3-CDP compared to 41% in the placebo group (HR: 0.596; 95% CI [0.200–1.777], p = 0.06). The mean EDSS change was − 0.025 in the AP group and + 0.352 in the placebo group (mean difference: 0.63, p = 0.042). Adverse events related to AP were mild rash and dysgeusia. Conclusions AP was well tolerated and showed a potential effect in reducing brain atrophy and disability progression, that need to be further evaluated in a larger clinical trial. Trial registration ClinicalTrials.gov NCT02273635 retrospectively registered on October 24th, 2014.

Background Context Differentiating osteoporotic vertebral fractures (OVFs) from metastatic vertebral fractures (MVFs) is an important clinical challenge. A novel magnetic resonance imaging (MRI)-based score (the META score) was described, aiming to differentiate OVF from MVF. This score showed an almost perfect agreement by the group developing it, but an independent agreement evaluation is pending. Purpose We aimed to perform an independent inter- and intraobserver agreement evaluation of the META score and to test the score's capability of differentiating OVF from MVF. Study design This is an agreement study of the META score. Methods Sixty-four patients with confirmed OVF or MVF were assessed by six independent evaluators (three spine surgeons and three fellowship-trained radiologists) using the META score. We used the intraclass correlation coefficient (ICC) to determine the overall inter-and intraobserver agreement, and the kappa statistic (κ) to express the agreement for each individual score criterion. The score accuracy was determined by calculating the area under the receiver operating characteristic curve. Finally, we used κ to evaluate the agreement among raters to determine whether the fracture was OVF or MVF. Results The overall interobserver agreement was poor [ICC=0.10 (0.02–0.20)]; spine surgeons [ICC=0.75 (0.66–0.83)] had better agreement than radiologists did [ICC=0.05 (−0.08 to 0.21)]. The intraobserver agreement was poor [ICC=0.17 (0.01–0.32)]; both spine surgeons [ICC=0.21 (0.05–0.41)] and radiologists had a poor agreement [ICC=0.03 (−0.29 to 0.27)]. The agreement for each specific criterion varied from κ=0.24 to κ=0.60. The area under the receiver operating characteristic curve was 0.58 (0.64 for spine surgeons and 0.52 for radiologists, p Conclusions The interobserver agreement using the META score was adequate for spine surgeons but not for other potential users (radiologists); the intraobserver agreement was poor. Further studies are thus necessary before the use of this score is recommended.

Multiple Sclerosis patients' clinical symptoms do not correlate strongly with structural assessment done with traditional magnetic resonance images. However, its diagnosis and evaluation of the disease's progression are based on a combination of this imaging analysis complemented with clinical examination. Therefore, other biomarkers are necessary to better understand the disease. In this paper, we capitalize on machine learning techniques to classify relapsing-remitting multiple sclerosis patients and healthy volunteers based on machine learning techniques, and to identify relevant brain areas and connectivity measures for characterizing patients. To this end, we acquired magnetic resonance imaging data from relapsing-remitting multiple sclerosis patients and healthy subjects. Fractional anisotropy maps, structural and functional connectivity were extracted from the scans. Each of them were used as separate input features to construct support vector machine classifiers. A fourth input feature was created by combining structural and functional connectivity. Patients were divided in two groups according to their degree of disability and, together with the control group, three group pairs were formed for comparison. Twelve separate classifiers were built from the combination of these four input features and three group pairs. The classifiers were able to distinguish between patients and healthy subjects, reaching accuracy levels as high as 89% ± 2%. In contrast, the performance was noticeably lower when comparing the two groups of patients with different levels of disability, reaching levels below 63% ± 5%. The brain regions that contributed the most to the classification were the right occipital, left frontal orbital, medial frontal cortices and lingual gyrus. The developed classifiers based on MRI data were able to distinguish multiple sclerosis patients and healthy subjects reliably. Moreover, the resulting classification models identified brain regions, and functional and structural connections relevant for better understanding of the disease. Keywords: Resting state, fMRI, DTI, SVM, Multiple sclerosis, Classification

Secondary paroxysmal dyskinesias (SPDs) are short, episodic, and recurrent movement disorders, classically related to multiple sclerosis (MS). Carbamazepine is effective, but with risk of adverse reactions. We identified 7 patients with SPD among 457 MS patients (1.53%). SPD occurred in face ( n = 1), leg ( n = 2), or arm +leg ( n = 4) several times during the day. Magnetic resonance imaging (MRI) showed new or enhancing lesions in thalamus ( n = 1), mesencephalic tegmentum ( n = 1), and cerebellar peduncles ( n = 5). Patients were treated with clonazepam and then acetazolamide ( n = 1), acetazolamide ( n = 5), or levetiracetam ( n = 1) with response within hours (acetazolamide) to days (levetiracetam). No recurrences or adverse events were reported after a median follow-up of 33 months.

We report the case of a 25-year-old woman who developed temporal lobe epilepsy associated with systemic lupus erythematosus (SLE). Serum and cerebrospinal fluid samples showed high titers of anti-ribosomal P (anti-P) antibodies with negative anti-NMDAR antibodies. She was receiving prednisone and azathioprine, with normalization of SLE serum markers, but without changes in titers of anti-P antibodies. No seizure control was achieved using valproic acid, levetiracetam and lamotrigine. However, she had a selective response to topiramate, an AMPAR blocker, maintained during 6 years of follow-up. We discuss the pathophysiology of this autoimmune epilepsy associated with high titer anti-P antibodies.

Modified (bioactive and hydrogel) coil embolization technologies were introduced to reduce aneurysm recurrence rates. The addition of bioactive polymers to bare platinum coils is designed to induce a tissue response and promote neoendothelialization. Hydrogel polymers on platinum coils swell in

Background: Multiple Sclerosis produces changes in the functional connectivity of the brain. Resting-State fMRI is a useful tool for the study of functional changes in the human brain, and its metrics can be related to clinical findings involved in clinical decline. Social cognition has focused increasing interest because patients are exposed to experiencing social disorganization during the progression of the disease. fMRI has proved to be a useful tool for studying brain connectivity and its relation with social cognition both in resting-state and during socio-cognitive tasks. Objective. to identify functional changes during rest in Relapsing-Remitting Multiple Sclerosis patients and look for a correlation with social cognition. Methods. 45 patients with Relapsing-Remitting Multiple Sclerosis and 47 control subjects were recruited to perform a neuropsychological evaluation of the social cognition performance and to acquire resting-state fMRI. Results. Patients exhibited lower performance in social cognition tasks, mostly related to face emotion recognition. Decreased functional connectivity in patients is seen concerning the right anterior insula, middle frontal, and occipital regions while increased connectivity is mostly related to the occipital and visual areas. The connectivity of the fusiform cortex and the amygdala is related to the performance in emotion recognition and Theory of Mind tasks respectively. Conclusion. Social cognition compromise was found in this sample. Functional connectivity changes during rest were detected and correlated with social cognition changes in patients.

We report six patients with anti-LGI1 associated epilepsy. Two patients presented with new-onset generalized tonic-clonic seizures, four developed faciobrachial dystonic seizures and two piloerection. All patients had significant cognitive complaints at the time of diagnosis. All patients described seizure reduction during the first week of carbamazepine, and seizure freedom was obtained at a median of 13 days (range 7–22), sustained after the initiation of immunosuppression. Median time from symptom onset to carbamazepine initiation was 164 days (range 38–206 days). We discuss the particular seizure response to sodium channel blocking antiepileptic drugs, alone or associated with immunosuppression in this antibody mediated seizures., Graphical abstract Unlabelled Image, Highlights • Anti-LGI1 associated epilepsy may particularly respond to sodium channel blocking AED. • Immunosuppression is usually needed to achieve sustained seizure freedom (SzF). • Carbamazepine and prednisone are affordable and available in developing countries. • We report 6 patients with SzF within two weeks of carbamazepine +/− immunotherapy. • Treatment was well tolerated and seems cost-effective.

Sciatic neuropathy is rare and difficult to diagnose in pediatrics, and its long-term course has not been completely understood. Objective: To analyze the clinical presentation and evolution of a group of pediatric patients with sciatic neuropathy. Patients and Method: Retrospective analysis of the clinical characteristics of pediatric patients with sciatic neuropathy treated in two hospitals of Santiago between 2014 and 2018. Locomotor examination, muscle trophism, deep tendon reflexes, gait, sensation, and pain were assessed. Sciatic nerve conduction study and electromyography (EMG) were performed, and magnetic resonance imaging (MRI) in three patients. Results: Six patients were included with an average age of 11.8 years. The etiologies were traumatic (N = 2), by compression (N = 2), vascular (N = 1), and tumor (N = 1). All of the 6 patients presented foot drop and Achilles tendon hyporeflexia/areflexia, and 5 patients presented severe neuropathic pain. The EMG showed involvement of the sciatic nerve rami and dependent muscles. In two patients, a pelvic girdle and lower limbs MRI was performed, showing selective muscle involvement in sciatic territory. One patient underwent a lumbosacral plexus MRI, and subsequently histological study showing a benign neural tumor. Out of the three patients who were followed-up longer than one year presented motor sequelae and gait disorder. Conclusion: Sciatic neuropathy in the study group was secondary to different causes, predominantly traumatic and compressive etiologies. The three patients that were in a long-term follow-up presented significant motor sequelae. In most of the cases, neural injury was associated with preventable causes, such as accidents and positioning in unconscious children, which is crucial in the prevention of a pathology with a high sequelae degree.

Background Cognitive impairment is a relevant contributor of the medical and social burden in Progressive MS. Social Cognition, the neurocognitive processes underlying social interaction, has been explored mainly in European and North American cohorts, influencing social aspects of quality of life (QOL) of early MS patients and families. Few studies have studied Social Cognition in Progressive MS and the literature on its neuroanatomical bases or brain atrophy measurements is still scarce. Objectives To explore the relationship between Social Cognition performance and its correlations with traditional cognitive domains, brain atrophy and QOL in primary and secondary Progressive MS patients. Methods Cross-sectional analysis including: mini-Social-Cognition-and-Emotional-Assessment (mini-SEA), neuropsychological battery, disability, depression, fatigue, QOL, and brain volume. Results Forty-three MS patients, 23 primary and 20 secondary Progressive, 65% women, mean age and disease duration of 57.2 and 15.7 years, respectively, with high levels of disability (median EDSS 6.0) and a widespread impairment in traditional domains (mostly episodic verbal/visual and working memories) were assessed. The Mini-SEA score was correlated with executive functions (cognitive shifts Rho:0.55; p = 0.001) analyzing the whole group, and with visual episodic memory (Rho:0.58, p = 0.009) in the primary Progressive MS group. Mini-SEA score was also correlated with total normalized grey matter volume (Rho:0.48; p = 0.004). Particularly, atrophy within bilateral cortical regions of orbitofrontal, insula and cerebellum, and right regions of fusiform gyrus and precuneus were significantly associated with higher Social Cognition impairment. In this cohort, QOL was not correlated with Social Cognition, but with EDSS, fatigue and depression. Conclusions In Progressive MS, Social Cognition is directly correlated with traditional cognitive domains such as executive function and episodic memory. It is also associated with global grey matter atrophy and regional atrophy within associative visual and executive cortical areas, but no correlations with QOL were found in this cohort. These findings may contribute to the understanding of the pathological bases behind Social Cognition in Progressive MS.

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.

Balloon kyphoplasty (BKP) has been proven to be safe and effective in the management of pathological vertebral compression fracture (VCF) due to metastatic spinal disease. The most common serious complications related to BKP include cement extravasation and new fractures at adjacent levels. Although the potential for “tumor extravasation” has been discussed as a potential iatrogenic complication, it has yet to be confirmed. The authors report on 2 cases of tumor extravasation following BKP, which they base on an observed unusual rapid tumor spread pattern into the adjacent tissues. They postulate that by increasing the vertebral body internal pressure and disrupting the tissues during balloon inflation and cement application, a soft-tissue tumor can be forced beyond the vertebral bony boundaries through pathological cortical defects. This phenomenon can manifest radiologically as subligamentous spread and/or extension into venous sinusoids, resulting in epidural venous plexus involvement, with subsequent tumor migration into the adjacent vertebral segments. Accordingly, the authors advise caution in using BKP when significant epidural tumor is present. The complication they encountered has caused them to modify their preference such that they now first use radiosurgery and subsequently BKP to ensure the target is appropriately treated, and they are currently developing possible modifications of procedural technique to reduce the risk.

Complications of endovascular therapy of aneurysms mainly include aneurysm rupture and thromboembolic events. The widespread use of MR imaging for follow-up of these patients revealed various nonvascular complications such as aseptic meningitis, hydrocephalus, and perianeurysmal brain edema. We present 7 patients from 5 different institutions that developed MR imaging-enhancing brain lesions after endovascular therapy of aneurysms, detected after a median time of 63 days. The number of lesions ranged from 4-46 (median of 10.5), sized 2-20 mm, and were mostly in the same vascular territory used for access. Three patients presented with symptoms attributable to these lesions. After a median follow-up of 21.5 months, the number of lesions increased in 2, was stable in 1, decreased in 3, and disappeared in 1. The imaging and clinical characteristics suggested a foreign body reaction. We could find no correlation to a specific device, but a possible source may be the generic hydrophilic coating.

Direct carotid-cavernous fistulas (CCFs) secondary to a ruptured intracavernous carotid aneurysm (ICCA) are usually high-flow lesions. On very rare occasions, a ruptured ICCA may present as a low-flow CCF, which poses a diagnostic and therapeutic dilemma whether the aneurysm and the observed fistula are causally related. Herein, we describe a rare case in which a ruptured ICCA resulted in a low-flow CCF. We demonstrated our approach to clarify this clinical scenario, and also propose a possible pathomechanism to explain the existence of low-flow direct CCF.

Dural arteriovenous fistulas (DAVFs) of the cavernous sinus are acquired arteriovenous shunts between the dural branches of the internal and external carotid arteries and the cavernous sinus. These fistulas may present with cortical venous reflux, but more commonly drain antegradely toward the superior ophthalmic vein (SOV). Transvenous embolization is the most common endovascular treatment, but in some cases transvenous access to the compartment of the shunt may not be possible. In cases with no corticovenous reflux, manual compression of the SOV is an excellent alternative treatment, which is well known but rarely reported in the literature. The authors describe a series of 3 cavernous DAVFs with anterior drainage treated successfully by intermittent manual compression of the SOV.

BACKGROUND AND PURPOSE: The PED is an FDS designed for the treatment of intracranial aneurysms. Data regarding the use of this device in acute or subacute aSAH is limited to a few case reports or small series. We aimed to demonstrate the feasibility of using an FDS, the PED, for the treatment of ruptured intracranial aneurysms with challenging morphologies. MATERIALS AND METHODS: We conducted a retrospective review of all known patients treated with the PED for aSAH at 4 institutions between June 2008 and January 2012. Pertinent clinical and radiologic information was submitted by individual centers for central collation. The decision to treat with the PED was made on a case-by-case basis by a multidisciplinary team under compassionate use. RESULTS: Twenty patients (15 women; median age, 54.5 years; IQR, 8.0 years) were found. There were 8 blister, 8 dissecting or dysplastic, 2 saccular, and 2 giant aneurysms. Median time to treatment was 4 days (range, 1–90 days; IQR, 12.75 days) from rupture. Three patients had previous failed treatment. Procedure-related symptomatic morbidity and mortality were 15%, with 1 (5%) procedure-related death. Two patients died relative to medical complications, and 1 patient was lost to follow-up. Sixteen patients were available for follow-up, 81% had a GOS of 5, and 13% had a GOS of 4 attributed to a poorer initial clinical presentation. One patient died of urosepsis at 4 months. Occlusion rates were 75% and 94% at 6 months and 12 months, respectively. There were 3 delayed complications (1 silent perforator infarct, 2 moderate asymptomatic in-stent stenoses). No symptomatic delayed complications or rehemorrhages occurred. CONCLUSIONS: The FDS may be a feasible treatment option in the acute or subacute setting of selected ruptured aneurysms, especially blister aneurysms. Ruptured giant aneurysms remain challenging for both surgical and endovascular techniques; at this stage, FDSs should be used with caution in this aneurysm subtype. aSAH : aneurysmal subarachnoid hemorrhage FDS : flow-diverting stent GOS : Glasgow Outcome Score IQR : interquartile range PED : Pipeline Embolization Device

BACKGROUND AND PURPOSE: The PED is a flow-diverting stent designed for the treatment of cerebral aneurysms. We report 4 cases of delayed ipsilateral IPH following the technically successful treatment of anterior circulation aneurysms with the PED. MATERIALS AND METHODS: Clinical and imaging data from all patients undergoing aneurysm treatment with the PED at 2 institutions were analyzed to assess the incidence of delayed IPH after treatment with the PED. RESULTS: A total of 66 patients (47 anterior circulation) with cerebral aneurysms underwent treatment with a PED between January 2008 and November 2010. Four patients experienced delayed periprocedural IPH, all after the treatment of anterior circulation aneurysms (8.5%, 4/47). The aneurysm size ranged from 5 to 21 mm. All IPHs occurred within the cerebral hemisphere, ipsilateral to the treated aneurysm, and were anatomically remote from the treated aneurysms. All procedures were uncomplicated, and patients emerged from general anesthesia at neurologic baseline. The hemorrhages became clinically evident between 1 and 6 days after the procedure. Two patients had unfavorable outcomes (mRS scores, 4 and 6). CONCLUSIONS: Delayed IPH may occur after the treatment of anterior circulation aneurysms with flow diverters. This complication does not seem to be restricted to a specific aneurysm subtype and does not seem to be related to an intraprocedural complication or solely attributable to DAT.

Portal biliopathy (PB) is a disorder characterized by biliary ductal and gallbladder wall abnormalities seen in patients with extrahepatic portal vein obstruction. These abnormalities consist mainly of bile duct compression and tethering, stenoses, fibrotic strictures and dilatation of both extrahepatic and intrahepatic bile ducts, as well as gallbladder varices. In this pictorial essay, we describe the imaging findings of PB, which allow differentiation of this entity from other diseases that may have similar imaging findings including cholangiocarcinoma, extrinsic compression of the bile duct caused by metastatic adenopathy or sclerosing cholangitis.

To evaluate the yield of digital subtraction angiography (DSA) and repeated follow-up imaging in patients with initial pattern of perimesencephalic subarachnoid hemorrhage (PSAH) and negative computed tomography angiography (CTA) in excluding an underlying aneurysm. We conducted a retrospective analysis of all nontraumatic SAH who underwent a DSA between January 2006 and January 2010 and selected those with a PSAH pattern on CT done within 72 h from ictus. All CTAs were performed with a 64-section multidetector row CT scanner, and findings were compared with DSA and to follow-up imaging. Forty-nine patients with initial PSAH pattern and negative CTA who underwent subsequent DSA were identified. Six patients were excluded because CTA was not available in hospitals or 72 h after ictus. Only one patient (2.4%) had a false negative CTA with a 1-mm left ICA aneurysm seen on DSA, considered not to be the source of hemorrhage. An average of 2.0 ± 1.2 follow-up exams per patient (range 0-5) revealed no source of bleeding. One patient had a procedure-related transient complication, but evolved with no sequels. In patients with PSAH, CTA is reliable for ruling out an underlying aneurysm. DSA and, especially, further follow-up imaging have no increased diagnostic yield compared to initial negative CTA.

Grading inter-vertebral disc degeneration (IDD) is important in the evaluation of many degenerative conditions, including patients with low back pain. Magnetic resonance imaging (MRI) is considered the best imaging instrument to evaluate IDD. The Pfirrmann classification is commonly used to grade IDD; the authors describing this classification showed an adequate agreement using it; however, there has been a paucity of independent agreement studies using this grading system. The aim of this study was to perform an independent inter- and intra-observer agreement study using the Pfirrmann classification. T2-weighted sagittal images of 79 patients consecutively studied with lumbar spine MRI were classified using the Pfirrmann grading system by six evaluators (three spine surgeons and three radiologists). After a 6-week interval, the 79 cases were presented to the same evaluators in a random sequence for repeat evaluation. The intra-class correlation coefficient (ICC) and the weighted kappa (wκ) were used to determine the inter- and intra-observer agreement. The inter-observer agreement was excellent, with an ICC = 0.94 (0.93–0.95) and wκ = 0.83 (0.74–0.91). There were no differences between spine surgeons and radiologists. Likewise, there were no differences in agreement evaluating the different lumbar discs. Most differences among observers were only of one grade. Intra-observer agreement was also excellent with ICC = 0.86 (0.83–0.89) and wκ = 0.89 (0.85–0.93). In this independent study, the Pfirrmann classification demonstrated an adequate agreement among different observers and by the same observer on separate occasions. Furthermore, it allows communication between radiologists and spine surgeons.

Purpose To compare the conventional CT and MR findings of DAVFs in relation to the venous drainage pattern on digital subtraction angiography (DSA). Materials and Methods Cross-sectional imaging findings (CT and/or MR) in 92 patients were compared to the presence of cortical venous reflux (CVR) on DSA. Results Imaging features significantly more prevalent in patients with CVR included: abnormally dilated and tortuous leptomeningeal vessels (92% vs. 4%, p 0.001) or medullary vessels (69% vs. 0%, p 0.001), venous ectasias (45% vs. 0%, p p 001). The following findings trended towards association but did not reach the p value established following Bonferroni correction: dilated external carotid artery branches (71% vs. 38%, p = 0.005 ), cluster of vessels surrounding dural venous sinus (50% vs. 19%, p = 0.009 ), presence of hemorrhage (33 vs. 12%, p =0.040), and parenchymal enhancement (21% vs. 0%, p =0.030). Conclusion In the appropriate clinical setting, recognition of ancillary signs presumably related to venous arterialization and congestion as well as arterial feeder hypertrophy should prompt DSA confirmation to identify DAVFs associated with CVR.

Resumen La enteroclisis por tomografia computarizada (TC) es una nueva tecnica que consiste en una TC helicoidal con multiples detectores realizada tras la administracion de agua a traves de una sonda nasoyeyunal y medio de contraste intravenoso, lo que permite una adecuada distension y visualizacion del intestino delgado. El uso de esta tecnica esta especialmente indicado en pacientes con enfermedad inflamatoria intestinal, hemorragia digestiva de causa no precisada, obstruccion parcial de intestino delgado y sospecha de neoplasia intestinal. Un total de 100 pacientes consecutivos se sometieron a una enteroclisis por TC (multiples detectores: 8, 16 o 64) debido a la sospecha de lesion en el intestino delgado. De ellos, 31 presentaron lesiones en esa localizacion: enfermedad de Crohn (n = 17), tumores (n = 8), obstruccion intestinal (n = 2), enteritis actinica (n = 1), enfermedad celiaca (n = 1), neumatosis cistoide (n = 1) y dilatacion de asas (n = 1); 28 de los 31 casos fueron confirmados por anatomia patologica, hallazgos endoscopicos o seguimiento clinico.

Neurovascular anatomy in interventional neuroradiology : , Neurovascular anatomy in interventional neuroradiology : , کتابخانه دیجیتال جندی شاپور اهواز