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BACKGROUND AND PURPOSE: Noninvasive angiography is commonly used to assess the outcome of surgical or endovascular treatment of intracranial aneurysms in clinical series or randomized trials. We sought to assess whether a standardized 3-grade classification system could be reliably used to compare the CTA and MRA results of both treatments. MATERIALS AND METHODS: An electronic portfolio composed of CTAs of 30 clipped and MRAs of 30 coiled aneurysms was independently evaluated by 24 raters of diverse experience and training backgrounds. Twenty raters performed a second evaluation 1 month later. Raters were asked which angiographic grade and management decision (retreatment; close or long-term follow-up) would be most appropriate for each case. Agreement was analyzed using the Krippendorff α (α(K)) statistic, and the relationship between angiographic grade and clinical management choice, using the Fisher exact and Cramer V tests. RESULTS: Interrater agreement was substantial (α(K) = 0.63; 95% CI, 0.55–0.70); results were slightly better for MRA results of coiling (α(K) = 0.69; 95% CI, 0.56–0.76) than for CTA results of clipping (α(K) = 0.58; 95% CI, 0.44–0.69). Intrarater agreement was substantial to almost perfect. Interrater agreement regarding clinical management was moderate for both clipped (α(K) = 0.49; 95% CI, 0.32–0.61) and coiled subgroups (α(K) = 0.47; 95% CI, 0.34–0.54). The choice of clinical management was strongly associated with the size of the residuum (mean Cramer V = 0.77 [SD, 0.14]), but complete occlusions (grade 1) were followed more closely after coiling than after clipping (P = .01). CONCLUSIONS: A standardized 3-grade scale was found to be a reliable and clinically meaningful tool to compare the results of clipping and coiling of aneurysms using CTA or MRA.

Hemorrhagic transformation is caused by extravasation of blood products from vessels after acute ischemic stroke. It is an undesirable and potentially devastating complication, which occurs in 10%-40% of clinical cases. Hemorrhagic transformation is classified into four subtypes based on European cooperative acute stroke study II. Predicting hemorrhagic complications at presentation can be useful life saving/altering decisions for the patient. Also, understanding the mechanisms of hemorrhagic transformation can lead to new treatments and intervention measures. We highlighted various imaging techniques that have been used to predict hemorrhagic transformation. Specifically, we looked at the usefulness of perfusion and permeability imaging for hemorrhagic transformation. Use of imaging to predict hemorrhagic transformation could change patient management that may lead to the prevention of hemorrhagic transformation before it occurs. We concluded that the current evidence is not strong enough to rely on these imaging parameters for predicting hemorrhagic transformation and more studies are required.

Background Orbital and peri-orbital venolymphatic malformations (VLM) are low flow vascular malformations. Intralesional bleomycin is now commonly being used to treat such malformations. Objective The purpose of this systematic review is to synthesize evidence on the safety and efficacy of bleomycin/pingyangmycin sclerotherapy for the treatment of orbital and peri-orbital VLM. Methods We searched Medline, Embase, Scopus and Cochrane database for studies reporting outcomes of bleomycin/pingyangmycin sclerotherapy for orbital and peri-orbital VLM between 1974 to April 5th, 2019. Nine retrospective cohort studies enrolling 132 patients were included. Two reviewers independently screened and extracted data and assessed the risk of bias. Predefined outcome measures were subjective and objective reduction of the lesion and associated complications. Results Subjective reduction of the lesions was seen in 96.2% of the studies. Objective reduction of the lesion and symptomatic improvement were reported in 91.6 and 95% of the studies respectively. Non responders were 9.0%. Minor adverse events were reported in 18.1% of the studies. Major complications like pulmonary toxicity or pulmonary fibrosis was not encountered in any of the included studies. Quality of evidence was generally low. Conclusion Bleomycin/pingyangmycin sclerotherapy is very effective and relatively safe for the treatment of orbital and periorbital VLM and is not associated with any major side effects including pulmonary fibrosis. Limitations: The systematic review is limited mainly due to low quality of the included studies with retrospective design.

Background and Purpose: Available data on the clinical course of patients with acute ischemic stroke due to medium vessel occlusion (MeVO) are mostly limited to those with M2 segment occlusions. Outcomes are generally better compared with more proximal occlusions, but many patients will still suffer from severe morbidity. We aimed to determine the clinical course of acute ischemic stroke due to MeVO with and without intravenous alteplase treatment. Methods: Patients with MeVO (M2/M3/A2/A3/P2/P3 occlusion) from the INTERRSeCT (The Identifying New Approaches to Optimize Thrombus Characterization for Predicting Early Recanalization and Reperfusion With IV Alteplase and Other Treatments Using Serial CT Angiography) and PRoveIT (Precise and Rapid Assessment of Collaterals Using Multi-Phase CTA in the Triage of Patients With Acute Ischemic Stroke for IA Therapy) studies were included. Baseline characteristics and clinical outcomes were summarized using descriptive statistics. The primary outcome was a modified Rankin Scale score of 0 to 1 at 90 days, describing excellent functional outcome. Secondary outcomes were the common odds ratio for a 1-point shift across the modified Rankin Scale and functional independence, defined as modified Rankin Scale score of 0 to 2. We compared outcomes between patients with versus without intravenous alteplase treatment and between patients who did and did not show recanalization on follow-up computed tomography angiography. Logistic regression was used to provide adjusted effect-size estimates. Results: Among 258 patients with MeVO, the median baseline National Institutes of Health Stroke Scale score was 7 (interquartile range: 5–12). A total of 72.1% (186/258) patients were treated with intravenous alteplase and in 41.8% (84/201), recanalization of the occlusion (revised arterial occlusive lesion score 2b/3) was seen on follow-up computed tomography angiography. Excellent functional outcome was achieved by 50.0% (129/258), and 67.4% (174/258) patients gained functional independence, while 8.9% (23/258) patients died within 90 days. Recanalization was observed in 21.4% (9/42) patients who were not treated with alteplase and 47.2% (75/159) patients treated with alteplase ( P =0.003). Early recanalization (adjusted odds ratio, 2.29 [95% CI, 1.23–4.28]) was significantly associated with excellent functional outcome, while intravenous alteplase was not (adjusted odds ratio, 1.70 [95% CI, 0.88–3.25]). Conclusions: One of every 2 patients with MeVO did not achieve excellent clinical outcome at 90 days with best medical management. Early recanalization was strongly associated with excellent outcome but occurred in

Purpose:Contrast-enhanced magnetic resonance imaging (CEMRI) of the head is frequently employed in investigations of sensorineural hearing loss (SNHL). The yield of these studies is perceptibly low and seemingly at odds with the aims of wise resource allocation and risk reduction within the Canadian healthcare system. The purpose of our study was to audit the use and diagnostic yield of CEMRI for the clinical indication of SNHL in our institution and to identify characteristics that may be leveraged to improve yield and optimize resource utilization.Materials and methods:The charts of 500 consecutive patients who underwent CEMRI of internal auditory canal for SNHL were categorized as cases with relevant positive findings on CEMRI and those without relevant findings. Demographics, presenting symptoms, interventions and responses, ordering physicians, and investigations performed prior to CEMRI testing were recorded. Chi-squared test and t-test were used to compare proportions and means, respectively.Results:CEMRI studies revealed relevant findings in 20 (6.2%) of 324 subjects meeting the inclusion criteria. Pre-CEMRI testing beyond audiometry was conducted in 35% of those with relevant positive findings compared to 7.3% of those without (p < 0.001). Auditory brainstem response/vestibular-evoked myogenic potentials were abnormal in 35% of those with relevant CEMRI findings compared to 6.3% of those without (p < 0.001).Conclusion:CEMRI is a valuable tool for assessing potential causes of SNHL, but small diagnostic yield at present needs justification for contrast injection for this indication. Our findings suggest preferred referral from otolaryngologists exclusively, and implementation of a non-contrast MRI for SNHL may be a better diagnostic tool.

Arterial recanalization to restore the blood supply and limit the brain damage is the primary goal in the management of acute ischemic stroke (AIS). Since the publication of pivotal randomized clinical trials in 2015, endovascular thrombectomy has become part of the standard of care in selected cases of AIS from large-vessel occlusions up to 6 hours after the onset of symptoms. However, the association between endovascular reperfusion and improved functional outcome is not strictly time dependent. Rather than on rigid time windows, candidates should be selected based on vascular and physiologic information. This approach places imaging data at the center of treatment decisions. Advances in imaging-based management of AIS provide crucial information about vessel occlusion, infarct core, ischemic penumbra, and degree of collaterals. This information is invaluable in identifying patients who are likely to benefit from reperfusion therapies and excluding those who are unlikely to benefit or are at risk of adverse effects. The approach to reperfusion therapies continues to evolve, and imaging is acquiring a greater role in the diagnostic work-up and treatment decisions as shown in recent clinical trials with extended time window. The 2018 American Heart Association/American Stroke Association guidelines reflect a paradigm shift in the management of AIS from "Time is Brain" to "Imaging is Brain." This review discusses the essential role of multimodal imaging developing from recent trials on therapy for AIS.

BACKGROUND Aneurysm recurrence after coiling has been associated with aneurysm growth, (re)hemorrhage, and a greater need for follow-up. The second-generation HydroCoil Embolic System (HES; MicroVention, Inc) consists of a platinum core with integrated hydrogel and was developed to reduce recurrence through enhancing packing density and healing within the aneurysm. OBJECTIVE To compare recurrence between the second-generation HES and bare platinum coil (BPC) in the new-generation Hydrogel Endovascular Aneurysm Treatment Trial (HEAT). METHODS HEAT is a randomized, controlled trial that enrolled subjects with ruptured or unruptured 3- to 14-mm intracranial aneurysms amenable to coiling. The primary endpoint was aneurysm recurrence using the Raymond-Roy scale. Secondary endpoints included minor and major recurrence, packing density, adverse events related to the procedure and/or device, mortality, initial complete occlusion, aneurysm retreatment, hemorrhage from target aneurysm during follow-up, aneurysm occlusion stability, and clinical outcome at final follow-up. RESULTS A total of 600 patients were randomized (HES, n = 297 and BPC, n = 303), including 28% with ruptured aneurysms. Recurrence occurred in 11 (4.4%) subjects in the HES arm and 44 (15.4%) subjects in the BPC arm (P = .002). While the initial occlusion rate was higher with BPC, the packing density and both major and minor recurrence rates were in favor of HES. Secondary endpoints including adverse events, retreatment, hemorrhage, mortality, and clinical outcome did not differ between arms. CONCLUSION Coiling of small-to-medium aneurysms with second-generation HES resulted in less recurrence when compared to BPC, without increased harm. These data further support the use of the second-generation HES for the embolization of intracranial aneurysms. VIDEO ABSTRACT

Background:Collateral status is an indicator of a favorable outcome in stroke. Leptomeningeal collaterals provide alternative routes for brain perfusion following an arterial occlusion or flow-limiting stenosis. Using a large cohort of ischemic stroke patients, we examined the relative contribution of various demographic, laboratory, and clinical variables in explaining variability in collateral status.Methods:Patients with acute ischemic stroke in the anterior circulation were enrolled in a multi-center hospital-based observational study. Intracranial occlusions and collateral status were identified and graded using multiphase computed tomography angiography. Based on the percentage of affected territory filled by collateral supply, collaterals were graded as either poor (0–49%), good (50–99%), or optimal (100%). Between-group differences in demographic, laboratory, and clinical factors were explored using ordinal regression models. Further, we explored the contribution of measured variables in explaining variance in collateral status.Results:386 patients with collateral status classified as poor (n = 64), good (n = 125), and optimal (n = 197) were included. Median time from symptom onset to CT was 120 (IQR: 78–246) minutes. In final multivariable model, male sex (OR 1.9, 95% CIs [1.2, 2.9], p = 0.005) and leukocytosis (OR 1.1, 95% CIs [1.1, 1.2], p = 0.001) were associated with poor collaterals. Measured variables only explained 44.8–53.0% of the observed between-patient variance in collaterals.Conclusion:Male sex and leukocytosis are associated with poorer collaterals. Nearly half of the variance in collateral flow remains unexplained and could be in part due to genetic differences.

Endovascular thrombectomy (EVT) has revolutionized the care of patients with acute ischemic stroke. The efficacy of EVT is dependent on the optimal setup of a stroke system. Extrapolating the results of clinical trials to any individual stroke center should be done with caution. This is more important for centers with suboptimal stroke systems of care. The Canadian registry has helped highlight the suboptimal outcome post EVT in Manitoba. This could potentially be optimized with the addition of an acute stroke unit in the near future. Our study will serve as a baseline for future improvement in acute stroke care.

Background:The T2 hypointensity has been suggested to be associated with intracranial metastatic adenocarcinomas (IMA). The purpose of our study was to determine the association of T2 hypointensity with IMA.Methods:All patients with pathologically confirmed metastatic brain tumors who had a magnetic resonance imaging (MRI) at our institution in the last 10 years were retrospectively assessed. Qualitative assessment of the lesions on MRI was done by two separate readers who were blinded to the pathological diagnosis. For qualitative assessment, the T2 hypointensity in the lesion was compared with the contralateral normal appearing white matter. Odds ratio, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated.Results:Of 107 patients with intracranial metastasis, only 73 (40 females; 33 males; mean age 61 years) had MRI available for review. Of these, only 46 (25 females; 21 males; mean age 61 years) had pathologically proven IMA. T2 hypointensity was seen in 20% of IMA. The odds ratio of T2 hypointensity in IMA was 3 compared to nonadenocarcinomas but was not statistically significant (p = 0.16). Intralesional hemorrhage was seen in 20. When controlled for hemorrhage, the odds ratio for T2 hypointensity in IMA was 4.7. The specificity, sensitivity, PPV, and NPV for T2 hypointensity to diagnose IMA were 92%, 19%, 81%, and 40%, respectively.Conclusion:T2 hypointensity was seen only in 20% of IMA with an odds ratio of 4.7. T2 hypointensity showed a high specificity and PPV for diagnosis of IMA.

Transorbital penetration accounts for one-quarter of the penetrating head injuries (PHIs) in adults and half of those in children. Injuries that traverse (with complete penetration of) the brainstem are often fatal, with survivors rarely seen in clinical practice. Here, the authors describe the case of a 16-year-old male who suffered and recovered from an accidental transorbital PHI traversing the brainstem—the first case of complete neurological recovery following such injury. Neuroimaging captured the trajectory of the initial injury. A delayed-onset carotid cavernous fistula and the subsequent development of internal carotid artery pseudoaneurysms were managed by endovascular embolization.The authors also review the relevant literature. Sixteen cases of imaging-confirmed PHI traversing the brainstem have been reported, 14 involving the pons and 12 penetrating via the transorbital route. Management and outcome of PHI are informed by object velocity, material, entry point, trajectory, relationship to neurovascular structures, and the presence of a retained foreign body. Trauma resuscitation is followed by a careful neurological examination and appropriate neuroimaging. Ophthalmological examination is performed if transorbital penetration is suspected, as injuries may be occult; the potential for neurovascular complications highlights the value of angiography. The featured case shows that complete recovery is possible following injury that traverses the brainstem.

Background and purpose Appropriate management of ruptured intracranial aneurysm (RIA) in patients eligible for surgical clipping but under-represented in or excluded from previous randomized trials remains undetermined. Methods The International Subarachnoid Aneurysm Trial-2 (ISAT-2) is a randomized care trial comparing surgical versus endovascular treatment (EVT) of RIA. All patients considered for surgical clipping but eligible for endovascular treatment can be included. The primary endpoint is death or dependency on modified Rankin score (mRS > 2) at 1 year. Secondary endpoints are 1 year angiographic results and length of hospital stay. Results An interim analysis was performed after 103 patients were treated from November 2012 to July 2017 in 4 active centers. Fifty-two of the 55 patients allocated to surgery were treated by clipping, and 45 of the 48 allocated to EVT were treated by coiling, with 3 crossovers in each arm. The main endpoint (1 year mRS > 2), available for 76 patients, was reached in 16/42 patients allocated to clipping (38%; 95%CI: 25%–53%), and 10/34 patients allocated to coiling (29%; 17%–46%). One year imaging results were available in 54 patients: complete aneurysm occlusion was found in 23/27 patients allocated to clipping (85%; 67%–94%), and 18/27 patients allocated to coiling (67%; 47%–81%). Hospital stay exceeding 20 days was more frequent in surgery (26/55 [47%; 34%–60%]) than EVT (9/48 [19%; 10%–31%]). Conclusion Ruptured aneurysm patients for whom surgical clipping may still be best can be managed in a randomized care trial, which is feasible in some centers. More participating centers are needed.

Endovascular thrombectomy (EVT) is efficacious for ischemic stroke caused by proximal intracranial large-vessel occlusion involving the anterior cerebral circulation. However, evidence of its cost-effectiveness, especially in a real-world setting, is limited. We assessed whether EVT ± tissue plasminogen activator (tPA) was cost-effective when compared with standard care ± tPA at our center.We identified patients treated with EVT ± tPA after the Endovascular treatment for Small Core and Anterior circulation Proximal occlusion with Emphasis on minimizing computed tomography to recanalization times trial from our prospective stroke registry from February 1, 2013 to January 31, 2017. Patients admitted before February 2013 and treated with standard care ± tPA constitute the controls. The sample size was 88. Cost-effectiveness was assessed using the net monetary benefit (NMB). Differences in average costs and quality-adjusted life years (QALYs) were estimated using the augmented inverse probability weighted estimator. We accounted for sampling and methodological uncertainty in sensitivity analyses.Patients treated with EVT ± tPA had a net gain of 2.89 [95% confidence interval (CI): 0.93-4.99] QALYs at an additional cost of $22,200 (95% CI: -28,902-78,244) per patient compared with the standard care ± tPA group. The NMB was $122,300 (95% CI: -4777-253,133) with a 0.85 probability of being cost-effective. The expected savings to the healthcare system would amount to $321,334 per year.EVT ± tPA had higher costs and higher QALYs compared with the control, and is likely to be cost-effective at a willingness-to-pay threshold of $50,000 per QALY.Analyse coût-efficacité de la thrombectomie endovasculaire dans un contexte réel. Objectif : La thrombectomie endovasculaire (TE) est efficace dans le cas d’accidents ischémiques cérébraux (AIC) causés par une occlusion proximale de l’artère cérébrale antérieure. Toutefois, les preuves d’un bon rapport coût-efficacité, particulièrement dans le cadre d’une pratique réelle, demeurent limitées. Nous avons ainsi évalué au sein de notre établissement dans quelle mesure la thrombectomie endovasculaire jumelée à un traitement au moyen d’un activateur tissulaire du plasminogène (t-PA) étaient davantage rentables en comparaison avec des soins usuels également jumelés à un traitement de t-PA. Méthodes : En consultant nos registres prospectifs, nous avons identifié des patients traités par une thrombectomie endovasculaire jumelée à un traitement de t-PA après avoir subi, du 1er février 2013 au 31 janvier 2017, un traitement endovasculaire destiné à un petit AVC central et ischémique à occlusion proximale avec un accent mis sur la minimisation du temps de recanalisation par tomodensitométrie. Les patients hospitalisés avant février 2013 et auxquels des soins usuels avaient été prodigués de concert avec l’administration d’un t-PA ont fait partie de notre groupe témoin. Au total, notre échantillon était formé de 88 patients. Nous avons évalué le rapport coût-efficacité au moyen du concept d’avantage monétaire net (AMN). Nous avons également estimé les différences en ce qui concerne les coûts moyens et l’indicateur QALY (quality-adjusted life years) en faisant appel à un estimateur pondéré par l’inverse de la probabilité inverse (augmented inverse probability weighted estimator). Enfin, nous avons tenu compte de l’incertitude de notre échantillonnage et de nos choix méthodologiques dans nos analyses de sensibilité. Résultats : Les patients traités par thrombectomie endovasculaire et l’administration d’un t-PA ont donné à voir un gain net de 2,89 années selon l’indicateur QALY (IC 95 % : 0,93 – 4,99) pour un coût additionnel de 22 200 $ (IC 95 % : −28,902 – 78,244) par patient si on les compare à notre groupe témoin. L’AMN s’est quant à lui élevé à 122 300 $ (IC 95 % : −4 777 – 253 133), sa probabilité d’être rentable atteignant 0,85. À cet égard, les économies annuelles pour le système de soins de santé pourraient atteindre les 321 334 $. Conclusion : Il appert que la thrombectomie endovasculaire jumelée à un traitement de t-PA entraînent des coûts plus élevés et un meilleur indicateur QALY en comparaison avec notre groupe témoin. Il est probable qu’une telle approche soit rentable en vertu d’un seuil de disposition à payer (willingness-to-pay threshold) avoisinant les 50 000 $ par année selon le QALY.

Although several studies have reported imaging findings associated with idiopathic intracranial hypertension (IIH), less is known about the correlation between imaging findings and IIH-related symptoms or signs. Our study aimed to determine if clinical features of IIH are correlated with magnetic resonance imaging (MRI) features. A retrospective chart review was conducted on consecutive patients presenting at the neuro-ophthalmology department over the last 15 years. All patients diagnosed with IIH were identified and those with available MRI were included in the final analysis. All MRI images were reviewed by a neuroradiologist blinded to the presenting symptoms and signs. Statistical analysis was performed to determine the correlation between the MRI findings with each clinical symptom or sign. Thirty-one out of 88 patients with the initial diagnosis of IIH had MRI available and were included in the study. Significant correlations were observed between colour vision and amount of perineural fluid around the optic nerve on MRI (r = − 0.382; p = 0.004), disc assessment and intraocular optic nerve protrusion (r = 0.364; p = 0.004), disc assessment and perineural fluid around the optic nerve (r = 0.276; p = 0.033) and disc assessment and venous sinus stenosis (r = 0.351; p = 0.009). Our study highlights correlations between imaging and clinical findings of IIH. MRI findings in IIH may be useful in ruling out ominous causes of intracranial pressure and risk stratifying ophthalmologic intervention and management of patients with headaches possibly due to IIH.

Clinical trials with percutaneous vertebral augmentation (PVA) for intractable pain from vertebral compression fractures (VCF) have shown variable results. Variation in the outcomes may be related to poor patient selection on imaging.To assess if PVA augmentation for osteoporotic VCF results in better improvement in pain when patients were selected based on clinical examination plus imaging vs clinical examination only.A systematic review and meta-analysis were performed. PubMed, Embase and Cochrane Library databases were searched from 2000 to May 2018. Two reviewers independently screened and extracted data to identify randomised control trials (RCTs) on PVA for osteoporotic VCF and assessed the risk of bias. Standard systematic review and meta-analysis methods were advocated by the Cochrane Collaboration and PRISMA Statement. A total of 12 RCTs with 1110 participants met the inclusion criteria. Eight of the 10 studies (938 participants) that used imaging to confirm oedema in the target vertebral bodies showed PVA (compared to nonsurgical treatment) was effective in reducing pain (immediate term: mean difference (MD) of -1.89; 95% confidence interval -1.93 to -1.85, p0.001; short term: MD of -1.68; 95% CI -1.82 to -1.54, p0.001; intermediate term: MD of -2.04; 95% CI -2.15 to -1.94, p0.001 and long term: MD of -1.88; 95% CI -1.95 to -1.80, p0.001).RCTs using imaging to confirm marrow oedema in the index vertebra showed an improved size effect compared to RCTs using no imaging. This benefit was observed in the immediate, short, intermediate and long term.Améliorer l’efficacité de la vertébroplastie au moyen de l’imagerie médicale : une revue systématique et une méta-analyse.Contexte: Des essais cliniques au cours desquels on a fait appel aux techniques percutanées de la vertébroplastie (vertebral augmentation) pour soulager des douleurs réfractaires produites par des fractures vertébrales par compression (FVC) ont donné à voir des résultats variables. Cette variabilité pourrait être liée à une mauvaise sélection des participants au moyen d’examens d’IRM. Objectif: Évaluer dans quelle mesure la vertébroplastie entraîne un soulagement accru de la douleur dans le cas de patients aux prises avec des FVC d’origine ostéoporotique. On a ainsi voulu comparer des patients choisis en fonction d’un examen clinique et d’un examen d’IRM avec d’autres patients choisis en fonction d’un seul examen clinique. Résultats: Nous avons mené une revue systématique ainsi qu’une méta-analyse. Pour ce faire, nous avons effectué des recherches dans les bases de données suivantes : PubMed, Embase et Cochrane, et ce, de l’année 2000 au mois de mai 2018. Deux examinateurs indépendants ont ensuite extrait et passé au crible des données afin d’identifier les essais cliniques randomisés (ECR) portant sur la vertébroplastie dans le cas de FVC d’origine ostéoporotique et d’évaluer les risques de biais. À noter que notre revue systématique et notre méta-analyse ont été effectuées en tenant compte des méthodes recommandées par Cochrane et PRISMA. Au total, douze ECR incluant 1110 participants ont satisfait à nos critères de sélection. Sur 10 ECR (938 participants) dans lesquels on a recouru à un examen d’IRM pour confirmer la présence d’un œdème dans les corps vertébraux ciblés, 8 d’entre eux ont révélé que le recours à la vertébroplastie était plus efficace qu’un traitement non-chirurgical dans le soulagement de la douleur (sur le champ : écart moyen de -1,89 ; IC 95 % -1,93 à -1,85 ; p0,001 ; à court terme : écart moyen de -1,68 ; IC 95 % -1,82 à -1,54 ; p0,001 ; à moyen terme : écart moyen de -2,04 ; IC 95 % -2,15 à -1,94 ; p0,001 ; et à long terme : écart moyen de -1,88 ; IC 95% -1,95 à -1,80 ; p0,001). Conclusions: En somme, les ECR utilisant des examens d’IRM pour confirmer la présence d’œdèmes de la moelle épinière dans une vertèbre de référence (index vertebra) ont révélé une taille d’effet améliorée si on les compare à des ECR n’utilisant pas ces examens. Cet avantage a été observé sur le champ mais aussi à court, moyen et long terme.

KEY POINTS • Computed tomographic perfusion (CTP) is increasingly being used in the characterization of brain ischemia.• Variations in post-processing protocols continue to be a challenge, resulting in a slight variation of CTP results.• We need to adopt a universal acquisition protocol to help optimize output of CTP.

IntroductionSevere traumatic brain injury (TBI) is a catastrophic neurological condition with significant economic burden. Early in-hospital mortality (Methods and analysisThe Early Diagnosis of Mortality using Admission CT Perfusion in Severe Traumatic Brain Injury Patients study, is a prospective cohort study in patients with severe TBI funded by a grant from the Canadian Institute of Health Research. Adults aged 18 or older, with evidence of a severe TBI (Glasgow Coma Scale score ≤8 before initial resuscitation) and, on mechanical ventilation at the time of imaging are eligible. Patients will undergo CTP at the time of first imaging on their hospital admission. Admission CTP compares with the reference standard of an accepted bedside clinical assessment for brainstem function. Deferred consent will be used. The primary outcome is a binary outcome of mortality (dead) or survival (not dead) in the first 48 hours of admission. The planned sample size for achieving a sensitivity of 75% and a specificity of 95% with a CI of ±5% is 200 patients.Ethics and disseminationThis study has been approved by the University of Manitoba Health Research Ethics Board. The findings from our study will be disseminated through peer-reviewed journals and presentations at local rounds, national and international conferences. The public will be informed through forums at the end of the study.Trial registration numberNCT04318665

BackgroundThe effectiveness and safety of endovascular thrombectomy (EVT) for medium vessel occlusions (MeVO) in the anterior intracranial circulation for patients with acute ischemic stroke (AIS) has yet to be definitively established. We compared outcomes in patients undergoing EVT for large vessel occlusion (LVO) versus those with MeVO.MethodsThis retrospective cohort study, using an intention to treat design, compared the 90-day modified Rankin Scale (mRS) score between 43 patients with MeVO and 199 with LVO in the anterior intracranial circulation. Secondary outcome measures included vessel recanalization using the Thrombolysis in Cerebral Infarction (TICI) score, procedural complications, post-EVT intracranial hemorrhage (ICH), and infarct size.ResultsThe rate of good functional outcome (90-day mRS 0–2) was higher in patients with LVO than in those with MeVO (32.9% vs 27%), but this was not statistically significant (p=0.19). The rate of EVT procedural complications was also not significantly different between the groups (p=0.10), nor was the rate of ICH (p=0.30). There was also no significant difference in TICI scores between groups (p=0.12). Infarct size was larger in the LVO group (pConclusionThe 90-day mRS and rate of periprocedural complications were not significantly different between patients treated for LVO and those treated for MeVO with EVT. Older age, not receiving r-tPA, and larger infarct size were independent predictors of poor outcome at 90 days.

Purpose:Endovascular thrombectomy (EVT) significantly improves outcomes for acute ischemic stroke patients with large vessel occlusion (LVO) who present in a time sensitive manner. Prolonged EVT access times may reduce benefits for eligible patients. We evaluated the efficiency of EVT services including EVT rates, onset-to-CTA time and onset-to-groin puncture time in our province.Materials and methods:Three areas were defined: zone I- urban region, zone II-areas within 1 h drive distance from the Comprehensive Stroke Center (CSC); and zone III-areas more than 1hr drive distance from the CSC. In this retrospective cohort study, EVT rate, onset-to-groin puncture time and onset-to-CTA time were compared among the three groups using Krustal–Wallis and Wilcoxon tests.Results:The EVT rate per 100,000 inhabitants for urban zone I was 8.6 as compared to 5.1 in zone II, and 7.5 in zone III. Compared to zone I (114 min; 95% CI (96, 132); n = 128), mean onset-to-CTA time was 19 min longer in zone II (133 min; 95% CI (77, 189); n = 23; p = 0.0459) and 103 min longer in zone III (217 min, 95% CI (162, 272); n = 44; p < 0.0001). Compared to zone I (209 min, 95% CI (181, 238)), mean onset-to-groin puncture time was 22 min longer in zone II (231 min, 95% CI (174, 288); p = 0.046) but 163 min longer in zone III (372 min, 95% CI (312, 432); p < 0.0001).Conclusion:EVT access in rural areas is considerably reduced with significantly longer onset-to-groin puncture times and onset-to-CTA times when compared to our urban area. This may help in modifying the patient transfer policy for EVT referral.

Cerebrovascular circulation; Ischemia; Ischemic stroke Circulació cerebrovascular; Isquèmia; Ictus isquèmic Circulación cerebrovascular; Isquemia; Ictus isquémico Background and Purpose Various imaging paradigms are used for endovascular treatment (EVT) decision-making and outcome estimation in acute ischemic stroke (AIS). We aim to compare how these imaging paradigms perform for EVT patient selection and outcome estimation. Methods Prospective multi-center cohort study of patients with AIS symptoms with multi-phase computed tomography angiography (mCTA) and computed tomography perfusion (CTP) baseline imaging. mCTA-based EVT-eligibility was defined as presence of large vessel occlusion (LVO) and moderate-to-good collaterals on mCTA. CTP-based eligibility was defined as presence of LVO, ischemic core (defined on relative cerebral blood flow, absolute cerebral blood flow, and cerebral blood volume maps) 1.8, absolute mismatch >15 mL. EVT-eligibility and adjusted rates of good outcome (modified Rankin Scale 0-2) based on these imaging paradigms were compared. Results Of 289/464 patients with LVO, 263 (91%) were EVT-eligible by mCTA-criteria versus 63 (22%), 19 (7%) and 103 (36%) by rCBF, aCBF, and CBV-CTP-criteria. CTP and mCTA-criteria were discordant in 40% to 53%. Estimated outcomes were best in patients who met both mCTA and CTP eligibility-criteria and were treated with EVT (62% to 87% good outcome). Patients eligible for EVT by mCTA-criteria and not by CTP-criteria receiving EVT achieved good outcome rates of 53% to 57%. Few patients met CTP-criteria and not mCTA-criteria for EVT. Conclusions Simpler imaging selection criteria that rely on little else than detection of the occluded blood vessel may be more sensitive and less specific, thus resulting in more patients being offered EVT and arguably benefiting from it. This study was supported by a grant from the Canadian Institute of Health Research. The authors are most grateful to all enrolling sites.

BACKGROUND According to the updated RANO criteria, MRI contrast enhancement and peritumoral edema during the initial 12 weeks within the radiation field following chemoradiation may be pseudoprogression (PP) or true progression (TP). This ambiguity results in diagnostic uncertainty and delays in effective therapies. MRI perfusion and permeability imaging markers, including relative blood volume (rBV), and volume transfer constant (Ktrans), may be useful in differentiating PP from TP. Both techniques rely on identification of a vascular input function (VIF) to produce reliable output maps. METHODS Perfusion and permeability maps were acquired from 7 patients on a Siemens 3T Verio MRI as part of an ongoing prospective study on glioblastoma multiforme. Patients received standard surgical resection with concurrent chemo-radiotherapy treatment and MRI follow-up at one and every 2 months. Maps were based on the follow-up MRI. The 3D contrast enhancing lesion (CEL) was segmented from the T1-Post-Gd MRI. VIF pixels were identified in the internal carotid artery (ICA), the M2 segment of the middle cerebral artery (MCA2), the superior sagittal sinus (SSS), automatically using software (Olea Sphere 3.0.22), and auto-edited (removed pixels from the auto VIF definition that were outside the brain). RESULTS For the different VIF pixel selections (ICA, MCA2, SSS, Auto, Auto-edited), mean Ktrans values from CEL were 0.32, 0.48, 0.05, 0.09, 0.08, respectively, showing a 10-fold variation. Mean rBV values from CEL were 2.70, 2.36, N/A, 3.10, 3.19, respectively, showing a 1.3-fold variation. CONCLUSIONS VIF pixel selection is a critical step in generating reliable perfusion and permeability MRI maps. Variation of up to a factor of 10 in the Ktrans values, depending on VIF selection, was observed. SSS for the permeability VIF resulted in maps that most closely matched literature values, whereas perfusion imaging showed less sensitivity to VIF selection.

Background:Venolymphatic malformations are rare benign vascular lesions of the head and neck. Sclerotherapy has become the first-line therapy of these lesions with bleomycin being a sclerosing agent commonly used.Purpose:To perform a systematic review of the published literature to synthesize evidence on the safety and efficacy of bleomycin for the treatment of head and neck venolymphatic malformations.Data sources:A systematic review of the literature (January 1995–May 2019) was performed in PubMed, Embase, and Cochrane Library databases to identify studies on sclerotherapy of venolymphatic malformations of the head and neck.Study selection:A total of 32 studies with participants met the inclusion criteria among which 1121 patients were included in the systematic review.Data analysis:Two reviewers independently screened and extracted data and assessed the risk of bias. The primary outcome was the subjective or objective reduction of lesion size as well as minor and major complications.Data synthesis:The bleomycin/pingyangmycin sclerotherapy achieved subjective or objective lesion size reduction in 96.3% (95% CI 94.1%–98.5%) of patients. Minor complications were observed in 16.2% and major complications in 1.1%.Conclusion:Bleomycin is a highly effective treatment of venolymphatic malformations of the head and neck with a low rate of major adverse events. This study represents an update on the “available” evidence, but only low-to-moderate quality studies were available.Limitations:This study reviewed 32 studies performed in different parts of the world, but there was heterogeneity of the study designs and interventions.

BackgroundSimulation training has been used in the aviation industry and surgical specialties for many years, but integration into neurointerventional practice is lagging behind.ObjectiveTo investigate how neurointerventionalists perceive the usefulness and limitations of simulation tools for the treatment of unruptured intracranial aneurysms (UIAs), and to identify simulation applications that were perceived to be most valuable for endovascular UIA treatment.MethodsA web-based international multidisciplinary survey was conducted among neurointerventionalists. Participants were asked for their perceptions on the usefulness of current simulation tools and the potential impact of future simulation tools in endovascular UIA treatment. They identified simulation applications that could add most value to endovascular UIA treatment and help to specifically reduce endovascular UIA treatment complications.Results233 neurointerventionalists from 38 countries completed the survey, most of whom (157/233 (67.4%)) had access to a simulator as a trainee, but only 15.3% used it frequently. Most participants (117/233 (50.2%)) considered currently available simulation tools relatively useful for endovascular UIA treatment, with greater value for trainees than for staff. Simulation of new devices (147/233 (63.1%)) and virtual practice runs in individual patient anatomy (119/233 (51.1%)) were considered most valuable for reducing endovascular UIA treatment complications.ConclusionAlthough neurointerventionalists perceived currently available simulation tools relatively useful, they did not use them regularly during their training. A priori testing of new devices and practice runs in individual patient anatomy in a virtual environment were thought to have the greatest potential for reducing endovascular UIA treatment complications.

In the absence of randomized evidence, the optimal management of patients with unruptured intracranial aneurysms (UIA) remains uncertain.Comprehensive Aneurysm Management (CAM) is an all-inclusive care trial combined with a registry. Any patient with a UIA (no history of intracranial hemorrhage within the previous 30 days) can be recruited, and treatment allocation will follow an algorithm combining clinical judgment and randomization. Patients eligible for at least 2 management options will be randomly allocated 1:1 to conservative or curative treatment. Minimization will be used to balance risk factors, using aneurysm size (≥7 mm), location (anterior or posterior circulation), and age60 years.The CAM primary outcome is survival without neurologic dependency (modified Rankin Scale [mRS] score3) at 10 years. Secondary outcome measures include the incidence of subarachnoid hemorrhage during follow-up and related morbidity and mortality; morbidity and mortality related to endovascular treatment or surgical treatment of the UIA at 1 year; overall morbidity and mortality at 1, 5, and 10 years; when relevant, duration of hospitalization; and, when relevant, discharge to a location other than home. The primary hypothesis for patients randomly allocated to at least 2 options, 1 of which is conservative management, is that active UIA treatment will reduce the 10-year combined neurologic morbidity and mortality (mRS score2) from 24% to 16%. At least 961 patients recruited from at least 20 centers over 4 years will be needed for the randomized portion of the study.Patients with unruptured intracranial aneurysms can be comprehensively managed within the context of an all-inclusive care trial.

Study design Retrospective cohort study. Objective To examine the relationship between preoperative Modic change (MC) and postoperative clinical assessment scores for patients receiving lumbar discectomy or transforaminal lumbar interbody fusion for lumbar disk herniation. Summary of background data Lumbar disk herniation is a risk factor for MC development. MC on spinal magnetic resonance imaging (MRI) has been associated with worse preoperative and postoperative clinical assessment scores. Materials and methods We reviewed data for 285 primary single-level surgeries. Preoperative and 12-month postoperative assessment scores were recorded using the visual analog scale leg pain, Oswestry Disability Index, and Short Form-36 Physical Component Summary. MC subgroup on preoperative MRI was recorded by a single neuroradiologist. Results One hundred seventy-nine patients (female, 56%; age-53±13 y) with preoperative MRI were included. Age and sex were similar across MC subgroups. The sample prevalence of MC on preoperative MRI was 62%, and MC2 was the most common subgroup (35%). No differences in preoperative assessment scores were identified, regardless of presence or absence of MC. For the overall cohort, improvement in assessment scores were observed: Short Form-36 improved an average of 8.2 points [95% CI (95% CI), 5.8-10.7], Oswestry Disability Index by 11.3 points (95% CI, 8.7-14.0), and visual analog scale by 2.8 points (95% CI, 2.1-3.5). In nearly all cases, MCID values were met, even when stratifying by MC subgroup. Few differences in postoperative assessment scores were identified when comparing across MC1, MC2, or no MC groups. Conclusions Statistically and clinically significant improvement in postoperative clinical assessment scores was observed for both lumbar discectomy and transforaminal lumbar interbody fusion groups. MC on preoperative MRI was not associated with worse preoperative or postoperative clinical assessment scores. Level of evidence Level III.

Spontaneous intracranial hypotension (SIH) is a significant cause of chronic, postural headaches. Spontaneous intracranial hypotension is generally believed to be associated with cerebrospinal fluid (CSF) leaks, and these leaks can be posttraumatic, iatrogenic, or idiopathic in origin. An integral part of the management of patients with this condition consists of localizing and stopping the leaks. Radiologists play a central role in the workup of this condition detecting leaks using computed tomography, magnetic resonance imaging, or nuclear imaging. In this article, we briefly review SIH and the various imaging modalities, which can be used to identify and localize a spontaneous CSF leak.

Purpose: Endovascular thrombectomy (EVT) treatment for acute ischemic stroke is now recommended as a standard of care. However, implementing EVT in routine clinical practice poses many challenges, even in countries with advanced health-care systems. The aim of the current study is to delineate if EVT at our institution is an effective treatment for acute ischemic stroke. Methods: All patients who underwent EVT at our institution between December 2011 and July 2017 were retrospectively assessed from our prospective registry. Clinical and imaging (including the Alberta Stroke Program Early CT [ASPECT] score, single-phase computed tomography angiography, and computed tomography perfusion) criteria were utilized to determine EVT suitability. Primary outcomes included modified Rankin score (mRS) at 90 days and recanalization determined by the modified Treatment in Cerebral Infarction score. Effectiveness was assessed by comparing our cohort with patients receiving EVT in the ESCAPE (Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke) trial. Results: Eighty-eight patients presented to our hospital after a median of 87 minutes last seen normal. Of these, median ASPECT score was 9. A majority (72%) also received intravenous alteplase. Successful recanalization (≥TICI 2b) was achieved in 79%. At 90 days, 48% (36/75) were functionally independent (mRS score of 0-2) and 28% (21/75) were disabled (mRS score of 3-5); 24% (18/75) died (mRS of 6) within 90 days. Conclusions: An audit of our initial experience with EVT for the treatment of acute ischemic stroke in a small tertiary care center yielded similar results compared to the ESCAPE trial, which is encouraging for implementing this treatment in routine clinical practice.

BackgroundThe efficacy of SILK flow diverters (SFD) in the management of cerebral aneurysms has been established. However, the risk of complications with parent artery occlusion (PAO) remains to be fully elucidated. The purpose of our study was to analyze intracranial aneurysms treated with SFDs and assess for occurrences and potential risk factors for PAO.Materials and methodsBetween September 2010 and September 2017, 34 patients were treated for intracranial aneurysms using SFDs at a Canadian institution. This database was retrospectively analyzed for frequency of PAOs and statistical analysis performed for potential contributing factors.ResultsFollowing treatment with SFDs, average clinical and imaging follow-ups were 31 and 22 months, respectively. PAOs were identified in 21% (7/34) of patients and occurred between 8 days and 1.5 years from intervention but only in 11.8% in those compliant to anti-platelet medications. These were all associated with anterior circulation aneurysms (P=0.131) and had no associated neurological deficits. Of these, 57% (4/7) had a fusiform morphology compared with only 19% (5/27) in non-occluded patients (P=0.039). The presence of clinical symptoms at the time of initial SFD intervention was significantly associated with PAO (P=0.021).ConclusionDelayed PAO is not an uncommon outcome of flow diverter deployment and could be seen up to 1.5 years after treatment with no associated neurological deficits. Anti-platelet non-adherence remains a risk factor for PAO. Fusiform morphology of the aneurysm and symptoms at the time of intervention were associated with subsequent occlusion.

Background and purpose Brain death determination (BDD) is primarily a clinical diagnosis, where death is defined as the permanent loss of brainstem function. In scenarios where clinical examinations are inaccurate, ancillary imaging tests are required. The choice of ancillary imaging test is variable, but the common denominator for all of them is to establish a lack of cerebral blood flow. The purpose of this study was to compare the diagnostic accuracy and interrater reliability of different ancillary imaging tests used for BDD. Methods Archival data were retrospectively analyzed for all patients who underwent any ancillary imaging test for BDD at our institution. The results of ancillary imaging tests were compared with, the reference standard, the clinical checklist for declaration of brain death. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of different ancillary imaging tests for BDD were performed. Interobserver agreement between two observers was measured using kappa statistics for each of the imaging modalities. Results A total of 74 patients underwent 41 computer tomography perfusion (CTP), 54 CT angiogram, 15 radionuclide scans, 1 cerebral angiogram, 3 magnetic resonance imaging, and 71 nonenhanced CT (NECT) head for BDD. All ancillary tests (except NECT head) showed 100% specificity and PPV. CTP had the highest sensitivity and NPV. All ancillary imaging tests demonstrated very high interrater reliability. Conclusions The uses of ancillary imaging tests for BDD are increasing. Within this study's limitations, CTP followed by radionuclide scan were found to be the most accurate and reliable ancillary imaging test for BDD.

Early assessment of the potential for neurologic recovery in comatose cardiac arrest patients (CCAP) has been a challenge despite significant evolution in management and imaging techniques. The purpose of study was to determine if the use of computed tomography perfusion (CTP) in CCAPs is feasible and if this technique can predict the likelihood that CCAPs will have a devastating outcome at hospital discharge. We prospectively enrolled 10 newly admitted comatose adults who had an out-of-hospital cardiac arrest and were treated with standard therapeutic hypothermia protocols. Patients underwent CTP of the head within 6 hours after finishing therapeutic hypothermia treatment. The imaging findings were compared with the results of a clinical assessment, as well as the modified Rankin Scale (mRS) score at hospital discharge. Sensitivity, specificity, and positive and negative predictive values for CTP were calculated to predict clinical outcome. Eight patients had an mRS score of ≥5, and 2 patients had an mRS score of ≤2 at hospital discharge. CTP predicted a good clinical outcome in both patients with an mRS score of ≤2. The area under the curve (AUC) for plain computed tomography of the head, computerized tomography angiogram 4-point scale, computerized tomography angiogram 7-point scale, CTP of the whole brain, and CTP of the brainstem for predicting the results of the immediate clinical assessment were 0.76, 0.83, 0.67, 0.83, and 1.0, respectively. The AUCs for predicting outcome at discharge were 0.69, 0.63, 0.56, 0.63, 0.63, and 0.69, respectively. In conclusion, our pilot study showed that CTP is feasible and had a very high AUC for predicting the results of immediate clinical assessment in CCAP.

BACKGROUND AND PURPOSE: The safety and efficacy of endovascular therapy for large-artery stroke in the extended time window is not yet well-established. We performed a subgroup analysis on subjects enrolled within an extended time window in the Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke (ESCAPE) trial. MATERIALS AND METHODS: Fifty-nine of 315 subjects (33 in the intervention group and 26 in the control group) were randomized in the ESCAPE trial between 5.5 and 12 hours after last seen healthy (likely to have groin puncture administered 6 hours after that). Treatment effect sizes for all relevant outcomes (90-day mRS shift, mRS 0–2, mRS 0–1, and 24-hour NIHSS scores and intracerebral hemorrhage) were reported using unadjusted and adjusted analyses. RESULTS: There was no evidence of treatment heterogeneity between subjects in the early and late windows. Treatment effect favoring intervention was seen across all clinical outcomes in the extended time window (absolute risk difference of 19.3% for mRS 0–2 at 90 days). There were more asymptomatic intracerebral hemorrhage events within the intervention arm (48.5% versus 11.5%, P = .004) but no difference in symptomatic intracerebral hemorrhage. CONCLUSIONS: Patients with an extended time window could potentially benefit from endovascular treatment. Ongoing randomized controlled trials using imaging to identify late presenters with favorable brain physiology will help cement the paradigm of using time windows to select the population for acute imaging and imaging to select individual patients for therapy.

BACKGROUND AND PURPOSE We have found DSA-Dynavision with multiplanar reconstruction very helpful in understanding the complex anatomy and planning of treatment of carotico-cavernous fistulas. The purpose of our study was to examine whether using DSA-Dynavision in pretreatment planning results in better outcome after endovascular treatment of dural arterio-venous fistulas (dAVFs). METHODS Patients with dAVF treated with endovascular embolization were retrospectively identified from our interventional neuroradiology database. Patients were assessed and divided into those with DSA-Dynavision and those without. They were compared for procedural time, angiographic evidence of cure, rates of resolution of cortical venous reflux (CVR), complications, and need for postembolization surgery. RESULTS Eighty-six percent of 28 patients (mean age 57 years, range 1.67-84 years) had Borden type 3 DAVF; 7% had Borden type 2; and 7% had Borden type 1. DSA-Dynavision was used in 14 of 28 (50%) patients. Fewer patients with DSA-Dynavision required postendovascular embolization surgery (7% vs. 50%, P = .01) and fewer DSA-Dynavision patients had CVR postprocedure (29% vs. 71%, P = .023). Mean procedural time (207 vs. 249 minutes; P = .40); permanent neurological complication rates (7% vs. 7%, P = 1.0); rate of immediate angiographic occlusion (64% vs. 29%, P = .061), and reported resolution of symptoms (79% vs. 53%, P = .18) were not significantly different. There was no significant difference in follow-up (mean: 75 vs 120 weeks, P = .47). CONCLUSION The use of DSA-Dynavision in planning of endovascular treatment of dAVF is associated with higher rates of elimination of CVR and less need for postembolization surgery.

Background and Purpose— Intracerebral hemorrhage is a feared complication of intravenous alteplase therapy in patients with acute ischemic stroke. We explore the use of multimodal computed tomography in predicting this complication. Methods— All patients were administered intravenous alteplase with/without intra-arterial therapy. An age- and sex-matched case–control design with classic and conditional logistic regression techniques was chosen for analyses. Outcome was parenchymal hemorrhage on 24- to 48-hour imaging. Exposure variables were imaging (noncontrast computed tomography hypoattenuation degree, relative volume of very low cerebral blood volume, relative volume of cerebral blood flow ≤7 mL/min·per 100 g, relative volume of T max ≥16 s with all volumes standardized to z axis coverage, mean permeability surface area product values within T max ≥8 s volume, and mean permeability surface area product values within ipsilesional hemisphere) and clinical variables (NIHSS [National Institutes of Health Stroke Scale], onset to imaging time, baseline systolic blood pressure, blood glucose, serum creatinine, treatment type, and reperfusion status). Results— One-hundred eighteen subjects (22 patients with parenchymal hemorrhage versus 96 without, median baseline NIHSS score of 15) were included in the final analysis. In multivariable regression, noncontrast computed tomography hypoattenuation grade ( P P =0.04) were the only significant variables associated with parenchymal hemorrhage on follow-up imaging (area under the curve, 0.73; 95% confidence interval, 0.63–0.83). Interrater reliability for noncontrast computed tomography hypoattenuation grade was moderate (κ=0.6). Conclusions— Baseline hypoattenuation on noncontrast computed tomography and very low cerebral blood volume on computerized tomography perfusion are associated with development of parenchymal hemorrhage in patients with acute ischemic stroke receiving intravenous alteplase.

Stroke is the second leading cause of mortality and the third leading cause of disability-adjusted life-years worldwide. For each minute of an ischemic stroke, an estimated 1.9 million brain cells die. The year 2015 saw the unprecedented publication of 5 multicentre, randomized, controlled trials. These studies showed that patients with acute ischemic stroke caused by large-vessel thrombus occlusion of the proximal anterior circulation had significantly reduced disability at 90 days when treated with endovascular thrombectomy and usual stroke care compared to usual stroke care alone. As a result, endovascular thrombectomy is now the new North American and European standard of care for suitable patients with acute ischemic stroke caused by large-vessel proximal anterior circulation occlusion. We review key take-home messages in this paradigm shift for radiologists, including the importance of time and workflow efficiency, what currently constitutes appropriate preimaging patient selection and imaging criteria, the use of newer generation thrombectomy devices, safety outcomes, as well as further areas still in need of elucidation.

Diffusion-weighted imaging provides image contrast that is different from that provided by conventional magnetic resonance imaging techniques. It is highly sensitive for detection of cytotoxic oedema, and as such has gained favor in the detection of acute infarcts. However, diffusion-weighted imaging is underrepresented in the characterisation of many other disease processes. Our objective is to differentiate diseases that manifest with various neurological disorders, based on diffusion contrast and apparent diffusion coefficient values and review of hyper- and hypointense lesions on diffusion-weighted imaging.

Radiologists may be the first to suggest the diagnosis of posterior reversible encephalopathy syndrome (PRES). PRES is associated with many diverse clinical entities, the most common of which are eclampsia, hypertension, and immunosuppressive treatment. Radiologists should be aware of the spectrum of imaging findings in PRES. When promptly recognized and treated, the symptoms and radiological abnormalities can be completely reversed. When unrecognized, patients can progress to ischemia, massive infarction, and death. In this review, we present an overview of the unique signs observed on computed tomography and magnetic resonance images in PRES that can help in the early diagnosis and treatment that is highly effective in this syndrome.

Although the efficacy of endovascular thrombectomy (EVT) for acute ischemic stroke caused by intracranial anterior circulation large vessel occlusion (LVO) is proven, demonstration of local effectiveness is critical for health system planning and resource allocation because of the complexity and cost of this treatment.Using our prospective registry, we identified all patients who underwent EVT for out-of-hospital LVO stroke from February 1, 2013 through January 31, 2017 (n = 44), and matched them 1:1 in a hierarchical fashion with control patients not treated with EVT based on age (±5 years), prehospital functional status, stroke syndrome, severity, and thrombolysis administration. Demographics, in-hospital mortality, discharge disposition from acute care, length of hospitalization, and functional status at discharge from acute care and at follow-up were compared between cases and controls.For EVT-treated patients (median age 66, 50% women), the median onset-to-recanalization interval was 247 min, and successful recanalization was achieved in 30/44 (91%). Alteplase was administered in 75% of cases and 57% of controls (p = 0.07). In-hospital mortality was 11% among the cases and 36% in the control group (p = 0.006); this survival benefit persisted during follow-up (p = 0.014). More EVT patients were discharged home from acute care (50% vs. 18%, p = 0.002). Among survivors, there were nonsignificant trends in favor of EVT for median length of hospitalization (14 vs. 41 days, p = 0.11) and functional independence at follow-up (51% vs. 32%, p = 0.079).EVT improved survival and decreased disability. This demonstration of single-center effectiveness may help facilitate expansion of EVT services in similar health-care jurisdictions.Étude cas-témoin portant sur la thrombectomie endovasculaire dans un centre canadien de prise en charge des AVC. Contexte : Bien qu’on ait prouvé l’efficacité de la thrombectomie endovasculaire dans le cas d’accidents ischémiques cérébraux aigus causés par l’occlusion de grosses artères affectant la circulation antérieure intracrânienne, la démonstration de son efficacité sur le terrain est essentielle à la planification du réseau la santé et à l’allocation des ressources en raison de la complexité de ce traitement et des coûts qui y sont associés. Méthodes : À l’aide d’un registre prospectif, nous avons identifié tous les patients ayant bénéficié (n = 44), du 1er février 2013 au 31 janvier 2017, d’une thrombectomie endovasculaire à la suite d’un AVC survenu en dehors d’un établissement de la santé, AVC causé par l’occlusion de grosses artères. De manière hiérarchique, nous avons fait correspondre nos patients dans un rapport de 1 à 1 à nos témoins non traités par thrombectomie endovasculaire, et ce, en nous basant sur leur âge (± 5 ans), sur leur situation fonctionnelle avant d’être admis, sur les signes cliniques et la gravité de leur AVC, et sur l’administration d’un traitement thrombolytique. Nous avons également comparé leurs caractéristiques démographiques, leur taux de mortalité hospitalière, les modalités d’obtention d’un congé des soins intensifs, la durée de leur hospitalisation et leur situation fonctionnelle au moment de quitter les soins intensifs et à l’occasion d’un suivi. Résultats : Dans le cas de nos patients traités par thrombectomie endovasculaire (âge médian : 66 ans ; 50 % de femmes), l’intervalle médian entre les premiers signes d’un AVC et la recanalisation a été de 247 minutes. Fait à souligner, une recanalisation réussie a été accomplie dans 30 cas sur 44 (91 %). L’altéplase a été administré dans 75 % des cas et chez 57 % des témoins (p = 0,07). En ce qui concerne le taux de mortalité hospitalière, il a été de 11 % parmi tous nos cas et de 36 % chez nos témoins (p = 0,006) ; À noter que cet avantage en termes de survie a persisté au moment des suivis (p = 0,014). Plus de patients traités par thrombectomie endovasculaire ont obtenu leur congé des soins intensifs et sont revenus à la maison (50 % contre 18 % ; p = 0,002). Parmi les survivants à ces AVC, on a noté des tendances non significatives en faveur des patients traités par thrombectomie endovasculaire pour ce qui est de la durée médiane d’hospitalisation (14 jours contre 41 jours ; p = 0,11) et de l’autonomie fonctionnelle au moment des suivis (51 % contre 32 % ; p = 0,079). Conclusion : En somme, la thrombectomie endovasculaire a permis d’améliorer le taux de survie des patients ainsi que leur niveau d’autonomie fonctionnelle. Effectuée dans un seul établissement hospitalier, cette démonstration de l’efficacité de ce traitement pourrait contribuer à faciliter l’essor des traitements de thrombectomie endovasculaire dans d’autres systèmes de santé similaires.

Although several studies have reported imaging findings associated with idiopathic intracranial hypertension (IIH), less is known about the correlation between imaging findings and IIH-related symptoms or signs. Our study aimed to determine if clinical features of IIH are correlated with magnetic resonance imaging (MRI) features.A retrospective chart review was conducted on consecutive patients presenting at the neuro-ophthalmology department over the last 15 years. All patients diagnosed with IIH were identified and those with available MRI were included in the final analysis. All MRI images were reviewed by a neuroradiologist blinded to the presenting symptoms and signs. Statistical analysis was performed to determine the correlation between the MRI findings with each clinical symptom or sign.Thirty-one out of 88 patients with the initial diagnosis of IIH had MRI available and were included in the study. Significant correlations were observed between colour vision and amount of perineural fluid around the optic nerve on MRI (r = - 0.382; p = 0.004), disc assessment and intraocular optic nerve protrusion (r = 0.364; p = 0.004), disc assessment and perineural fluid around the optic nerve (r = 0.276; p = 0.033) and disc assessment and venous sinus stenosis (r = 0.351; p = 0.009).Our study highlights correlations between imaging and clinical findings of IIH. MRI findings in IIH may be useful in ruling out ominous causes of intracranial pressure and risk stratifying ophthalmologic intervention and management of patients with headaches possibly due to IIH.

Objective Whether transverse venous sinus stenosis (TVSS) causes idiopathic intracranial hypertension (IIH) or is an effect of the increased intracranial pressures is controversial. The purpose of this study was to assess the feasibility of serial imaging in patients with IIH on medical management. Design and Participants Patients found to have IIH and TVSS on contrast-enhanced magnetic resonance venography (CEMRV) were recruited in a prospective cohort study. Patients were medically managed and followed with a CEMRV immediately after lumbar puncture, 3–6 months after diagnosis with resolution of IIH symptoms, and 1 year after diagnosis. Ophthalmological data were collected at the time of diagnosis, 3–6 months after diagnosis, and 1 year after diagnosis. Feasibility data, including patient recruitment rate, barriers, and logistical issues, were recorded. Results Twenty patients with suspected IIH were screened, and 5 of 7 (71.4%; 95% confidence interval: 36.21–100) eligible patients were enrolled in 1 year, at completion. All recruited patients had clinical resolution of their IIH on medical therapy, and none of them had any obvious change in their TVSS. Conclusions Prospective examination of TVSS with serial magnetic resonance imaging in patients with IIH is feasible. TVSS in patients with IIH did not show any change, despite clinical improvement on medical management in all participants.