Diagnostic Errors in Cerebrovascular Pathology: Retrospective Analysis of a Neuroradiology Database at a Large Tertiary Academic Medical Center.

BACKGROUND AND PURPOSE: Diagnostic errors affect 2%-8% of neuroradiology studies, resulting in significant potential morbidity and mortality. This retrospective analysis of a large database at a single tertiary academic institution focuses on diagnostic misses in cerebrovascular pathology and suggests error-reduction strategies. MATERIALS AND METHODS: CT and MR imaging reports from a consecutive database spanning 2015-2020 were searched for errors of attending physicians in cerebrovascular pathology. Data were collected on missed findings, study types, and interpretation settings. Errors were categorized as ischemic, arterial, venous, hemorrhagic, and "other." RESULTS: A total of 245,762 CT and MR imaging neuroradiology examinations were interpreted during the study period. Vascular diagnostic errors were present in 165 reports, with a mean of 49.6 (SD, 23.3) studies on the shifts when an error was made, compared with 34.9 (SD, 19.2) on shifts without detected errors (P < .0001). Seventy percent of examinations occurred in the hospital setting; 93.3% of errors were perceptual; 6.7% were interpretive; and 93.9% (n = 155) were clinically significant (RADPEER 2B or 3B). The distribution of errors was arterial and ischemic each with 33.3%, hemorrhagic with 21.8%, and venous with 7.5%. Most errors involved brain MR imaging (30.3%) followed by head CTA (27.9%) and noncontrast head CT (26.1%). The most common misses were acute/subacute infarcts (25.1%), followed by aneurysms (13.7%) and subdural hematomas (9.7%). CONCLUSIONS: Most cerebrovascular diagnostic errors were perceptual and clinically significant, occurred in the emergency/inpatient setting, and were associated with higher-volume shifts. Diagnostic errors could be minimized by adjusting search patterns to ensure vigilance on the sites of the frequently missed pathologies.

Neuroradiology diagnostic errors at a tertiary academic centre: effect of participation in tumour boards and physician experience.

AIM: To quantify and correlate the diagnostic error rates in radiological interpretation with the experience of the attending neuroradiologist at a tertiary academic medical centre. MATERIALS AND METHODS: The institution's Neuroradiology Quality Assurance Database of diagnostic errors was searched for misses from 2014-2020. Attendance at Head and Neck (H&N), Brain, and Paediatric Neuroradiology (PN) tumour boards (TB) as the presenting radiologist was recorded. Number of post-fellowship years of clinical practice (CPY) and frequency of TB attendance were considered separate metrics of a radiologist's experience. Radiological errors were categorised as Total, H&N, Skull Base (SKB), Brain, or PN diagnostic errors. Diagnostic error rates per attending neuroradiologist within each category were correlated with the frequency of TB participation and CPY using Spearman's rank correlation coefficients. RESULTS: A total 607 examinations contained a diagnostic error. Spearman's rank correlation coefficients between Total TB participation and Total, H&N, SKB, Brain error rates were: -0.89 (p=0.0002); -0.81 (p=0.002); -0.66 (p=0.03); -0.82 (p=0.002); respectively. Spearman's rank correlation coefficients between CPY and Total, H&N, SKB, Brain and PN error rates were: 0.05 (p=0.88); 0.08 (p=0.82); 0.28 (p=0.41); -0.10 (p=0.77); -0.16 (p=0.63), respectively. Spearman's rank correlation coefficients between H&N TB and H&N, SKB error rates; and between Brain TB attendance and Brain error rates were statistically significant (p<0.05). CONCLUSION: The present study shows a strong correlation between high TB participation rates and low diagnostic error rates. The number of years in practice did not appear to influence error rate.

COVID-19 Neurologic Complication with CNS Vasculitis-Like Pattern.

Coronavirus disease 2019 (COVID-19) is a viral infection caused by the Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2), which spreads rapidly from person to person and manifests in most symptomatic patients as a respiratory illness, similar to prior SARS viruses. Neurologic manifestations of COVID-19 are uncommon; those so far reported include encephalopathy, stroke from large-vessel occlusion, and polyneuropathy. We report a unique neurologic complication of COVID-19 in a patient who had extensive cerebral small-vessel ischemic lesions resembling cerebral vasculitis in a characteristic combined imaging pattern of ischemia, hemorrhage, and punctuate postcontrast enhancement. Also, a characteristic lower extremity skin rash was present in our patient. Our observation lends support to the increasingly suspected mechanism of "endotheliitis" associated with this novel coronavirus.

Follow-Up MRI for Small Brain AVMs Treated by Radiosurgery: Is Gadolinium Really Necessary?

BACKGROUND AND PURPOSE: Follow-up MR imaging of brain AVMs currently relies on contrast-enhanced sequences. Noncontrast techniques, including arterial spin-labeling and TOF, may have value in detecting a residual nidus after radiosurgery. The aim of this study was to compare noncontrast with contrast-enhanced MR imaging for the differentiation of residual-versus-obliterated brain AVMs in radiosurgically treated patients. MATERIALS AND METHODS: Twenty-eight consecutive patients with small brain AVMs (<20 mm) treated by radiosurgery were followed with the same MR imaging protocol. Three neuroradiologists, blinded to the results, independently reviewed the following: 1) postcontrast images alone (4D contrast-enhanced MRA and postcontrast 3D T1 gradient recalled-echo), 2) arterial spin-labeling and TOF images alone, and 3) all MR images combined. The primary end point was the detection of residual brain AVMs using a 5-point scale, with DSA as the reference standard. RESULTS: The highest interobserver agreement was for arterial spin-labeling/TOF (κ = 0.81; 95% confidence interval, 0.66-0.93). Regarding brain AVM detection, arterial spin-labeling/TOF had higher sensitivity (sensitivity, 85%; specificity, 100%; 95% CI, 62-97) than contrast-enhanced MR imaging (sensitivity, 55%; specificity, 100%; 95% CI, 27-73) and all MR images combined (sensitivity, 75%; specificity, 100%; 95% CI, 51-91) (P = .008). All nidus obliterations on DSA were detected on MR imaging. In 6 patients, a residual brain AVM present on DSA was only detected with arterial spin-labeling/TOF, including 3 based solely on arterial spin-labeling images. CONCLUSIONS: In this study of radiosurgically treated patients with small brain AVMs, arterial spin-labeling/TOF was found to be superior to gadolinium-enhanced MR imaging in detecting residual AVMs.

Pedunculated basilar terminus aneurysm with pseudo-septation due to anterior herniation through a perforated membrane of Liliequist.

Septations within cerebral arteries or aneurysms are exceedingly rare in the absence of associated fenestrations. We report an unusual unruptured pedunculated basilar apex aneurysm, with a "pseudoseptation" between the main aneurysmal sac and an anterior compartment, which was, in fact, represented by a perforation in the membrane of Liliequist, permitting anterior aneurysmal herniation into the carotid-chiasmatic cistern. The patient was successfully treated with detachable coils. This case is unusual on 2 accounts: 1) the aneurysm's appearance, and 2) the presence of a large fenestration in the membrane of Liliequist, of which anatomic features are herein reviewed.

Reversal of delayed vasospasm by TS-011 in the dual hemorrhage dog model of subarachnoid hemorrhage.

PURPOSE: Arachidonic acid is avidly metabolized to a potent vasoconstrictor, 20-hydroxyeicosatetraenoic acid (20-HETE), in the cerebral circulation. 20-HETE has been reported to contribute to the acute fall in cerebral blood flow following subarachnoid hemorrhage (SAH), but its role in the development of delayed vasospasm is unknown. The present study examined whether delayed vasospasm is associated with elevations in 20-HETE in CSF in the dual hemorrhage model of SAH in dogs and if blockade of the synthesis of 20-HETE with N-(3-chloro-4-morpholin-4-yl)phenyl-N'-hydroxyimido formamide (TS-011) can reverse delayed vasospasm in this model. MATERIALS AND METHODS: Delayed vasospasm was induced in 22 adult beagle dogs by dual injection of blood (0.5 mL/kg) into the cisterna magna on days 1 and 4. Sequential samples of CSF were collected before intracisternal injections of blood on days 1 and 4 and after the development of delayed vasospasm on day 7. Sequential angiograms were obtained before and after intracisternal injection of blood on days 1 and 4 and before and 1 hour after administration of TS-011 (1 mg/kg IV) on day 7. RESULTS: The dogs consistently developed delayed vasospasm, and the diameter of the basilar artery fell to 68 +/- 3% (n = 15), 3 days after the second intracisternal injection of blood. The levels of 20-HETE in CSF increased from 4 +/- 2 to 39 +/- 16 pg/mL. In 9 dogs with delayed vasospasm, acute blockade of the synthesis of 20-HETE with TS011 (1 mg/kg IV) significantly increased the diameter of the basilar artery by 39%. Chronic administration of TS-011 (1 mg/kg per day) attenuated the development of delayed vasospasm, and the diameter of the basilar artery fell by 17 +/- 1% versus the 33 +/- 3% decrease in diameter seen in control animals 3 days following the second injection of blood into the cisterna magna. CONCLUSIONS: These results indicate that the development of delayed vasospasm in dogs is associated with an increase in 20-HETE levels in CSF, and acute blockade of the synthesis of 20-HETE with TS-011 reverses delayed vasospasm in this model.

Standardized protocols increase organ and tissue donation rates in the neurocritical care unit.

The authors tested the effect of uncoupling and removal of the treating physician from organ and tissue donation requests on consent rates for donation in the neurocritical care unit. After a neurointensivist-led policy change, consent rates increased from 23.1 to 36.5% (odds ratio = 1.9, p = 0.01), whereas there was no change in other hospital units. This supports such a policy change and shows a positive effect of a neurointensivist on organ and tissue procurement.

Emergent EEG: indications and diagnostic yield.

The authors reviewed the reports of all emergent EEG (EmEEG) performed in our hospital within 1 hour of the test being ordered over a period of 52 months. Two hundred sixty-one EmEEG (12.8% of all EEG) were performed. The most common reason to order the test was a change in mental status or coma (17.6%). Although EmEEG was ordered to rule out status epilepticus (SE) in 60.2% of cases, this diagnosis was made in only 10.7% of patients. The only independent predictor for SE was a history of cardiac or respiratory arrest (odds [95% CI], 6.8 [2.7 to 16.9]).

Anticoagulation and induced hypertension after endovascular treatment for ruptured intracranial aneurysms.

OBJECTIVE: Guglielmi detachable coil (GDC) embolization may be used to prevent early rebleeding after aneurysmal subarachnoid hemorrhage, but anticoagulation and induced hypertension may increase this risk. We sought to determine retrospectively the relationship between levels of induced hypertension and anticoagulation and incidence of rebleeding in GDC-treated patients. METHODS: Twenty-five consecutive patients with acute (<14 days) subarachnoid hemorrhage who underwent GDC embolization were retrospectively analyzed with regard to percent obliteration of an aneurysm on postprocedure angiogram, the duration and intensity of anticoagulation, the duration and level of induced hypertension, and the frequency of thromboembolic and rebleeding complications. RESULTS: Complete angiographic obliteration of the aneurysm was achieved in five cases (20%). In some cases (n = 2), only the dome of the aneurysm was coiled to allow eventual surgical clipping. Heparin was given to 23 patients (92%) for an average of 6 days (range, 8 hrs to 22 days); the mean dose was 588 units/hr, and the mean partial thromboplastin time was 37 secs. Seven patients (28%) were treated with vasopressors for symptomatic vasospasm for a mean duration of 5 days (range, 8 hrs to 9 days); mean arterial blood pressure averaged 118 mm Hg, and peak systolic blood pressures ranged from 195 to 250 mm Hg. There were no episodes of aneurysm rebleeding. Three patients (12%) suffered intraoperative thromboembolic complications, which in one instance was fatal; two of these cases were associated with subtherapeutic partial thromboplastin time values. CONCLUSION: Induced hypertension (mean arterial blood pressure, 120 mm Hg) and heparinization do not appear to increase the risk of early rebleeding after GDC embolization. In a select group of patients, use of anticoagulation in the immediate perioperative period to prevent thromboembolic complications appears to be safe.

Effect of intracarotid papaverine on human cerebral blood flow and vascular resistance during acute hemispheric arterial hypotension.

This study assessed the feasibility of augmenting cerebral blood flow (CBF) and decreasing hemispheric cerebrovascular resistance (CVR) by intracarotid papaverine during acute cerebral hypotension. Awake patients (n = 10) undergoing transfemoral balloon occlusion of an internal carotid artery (ICA) with nitroprusside (SNP)-induced systemic hypotension (10% reduction of mean arterial pressure) were studied. We measured mean femoral artery pressure (MAP), mean distal ICA pressure (P(ica)), and CBF (intracarotid 133Xe) at two time points: before and after intracarotid papaverine infusion (1 or 7 mg/min). Two patients became symptomatic immediately after ICA occlusion and were excluded. One patient developed a focal seizure during papaverine infusion. In another, the occlusion balloon deflated prematurely. Of the remaining six patients, two of the three patients who received high-dose papaverine (7 mg/min) developed transient obtundation. The remaining three patients, who received low-dose papaverine (1 mg/min), did not develop any neurologic symptoms. There was a trend for intracarotid papaverine to increase hemispheric CBF by 36% (33 +/- 10 versus 45 +/- 22 ml x 100 g(-1) x min(-1), P = .084, n = 6); papaverine decreased CVR from 1.3 +/- 0.4 to 1.0 +/- 0.3 mm Hg x ml(-1) x 100 g(-1) x min(-1) (P = .049). There was no significant change in heart rate, MAP, or P(ica) during experimental protocol. Manipulation of CVR by intracarotid papaverine during acute hemispheric arterial hypotension appears to be feasible. Further studies are needed to establish safety and efficacy.

Giant cell tumors of the jugular foramen.

PURPOSE: To review the diagnosis and treatment of giant cell tumors of the jugular foramen. MATERIALS AND METHODS: A typical case is reported. Symptoms, signs, and diagnostic studies are reviewed. Photomicrographs and angiographic studies showing the differences between these and glomus jugulare tumors are provided. A coherent approach to their management is presented. RESULTS: These hypervascular, traditionally radioresistant tumors may cause pulsatile tinnitus, conductive hearing loss, and lower cranial nerve paresis. Angiographic studies showed a hypervascular lesion supplied by numerous small branches of the external carotid artery, making embolization difficult. Complete resection was achieved by an infratemporal fossa approach with preoperative embolization. CONCLUSION: Giant cell tumors of the temporal bone may mimic glomus jugulare tumors with respect to anatomic location, cranial nerve deficits, and vascularity.

Higher cerebral function and hemispheric blood flow during awake carotid artery balloon test occlusions.

OBJECTIVES: Measures capable of detecting early alterations of brain function during acute cerebral ischaemia have not been adequately defined. Internal carotid artery (ICA) test occlusions provide a well controlled environment to investigate the effects of reversible acute hemispheric hypoperfusion on brain function. A continuous time estimation task was developed that reliably demonstrated alterations in higher cerebral function before development of any deficits in elementary neurological function during ICA balloon catheter test occlusions. In the present study, we hypothesised that alterations in our behavioural task would correlate significantly with absolute level of ipsilateral CBF. METHODS: Twenty five patients underwent awake ICA test occlusions during which sustained attention and ipsilateral CBF were measured simultaneously using our time estimation task and the intracarotid 133Xe washout method. Alteration in sustained attention was correlated with CBF after occlusion using Fisher's exact test. RESULTS: Deterioration in sustained attention was significantly associated with ipsilateral CBF below 30 ml/g/min (Fisher's exact test, p=0.047). Changes in individual patients' performance on the behavioural task correlated in real time with changes occurring either at the point of occlusion or at a specific threshold of induced hypotension. Sensitivity for our behavioural test in predicting CBF was 75%; specificity 70%. CONCLUSIONS: Monitoring sustained attention during carotid balloon test occlusions seems to be a sensitive means to detect decreases in CBF as measured by 133Xe washout. Correlation between higher cerebral function and CBF can allow more detailed investigations of physiological relations between cerebral haemodynamics and brain function in human conditions of cerebral ischaemia.

Developmental deficits in adult patients with arteriovenous malformations.

BACKGROUND: Cerebral arteriovenous malformations (AVMs) are congenital masses of arteries and veins that appear to undergo an unclear "maturation" for many years. Using structured interviews, we compared developmental history of adult patients with AVM with a comparison group of patients with cerebral tumor or aneurysm. OBJECTIVE: To determine whether a remote history of developmental abnormality in adult patients with AVM might be an early marker of cerebral status. DESIGN: Adult patients with AVM and a comparison group of patients with cerebral aneurysm or low-grade tumor participated in a survey. SETTING: Urban medical school-based tertiary care center. PATIENTS: Forty-four randomly selected patients with AVM from the Columbia-Presbyterian AVM Database. There were 32 comparison patients:15 randomly chosen patients from the institution's Cerebral Aneurysm Database and all 17 patients who underwent a biopsy from 1990 to 1995 with a diagnosis of low-grade tumor and who could be contacted. MAIN OUTCOME MEASURES: A brief, structured interview adapted from the Centers for Disease Control and Prevention for its 1994 study of the prevalence of learning disabilities in American children. We defined the positive occurrence of a condition as an affirmative answer to the question, " Did have (condition) during his/her school-age years?" Each patient was also asked if there had been any problems in the following skill areas: reading, writing, listening, speaking, attention, impulsivity, organization, mathematics, or drawing. The AVM size was calculated on the angiographic film by measuring its longest diameter in any dimension. RESULTS: Patients with AVM were significantly more likely to report a positive occurrence to any survey question (P<.05). Two thirds of all patients with AVM (66%) reported at least 1 skill difficulty during their school years, significantly more than the comparison group (P<.001). Neither the maximum AVM diameter nor the occurrence of hemorrhage as an adult differed between patients with AVM with and without early skill difficulty. CONCLUSIONS: Patients with AVM are more likely to report a developmental learning disorder than patients with tumor or aneurysm despite the absence of other neurologic symptoms of diseases not diagnosed for another 20 years. These data support the notion that disorders of behavioral and intellectual function are sensitive markers of early cerebral status.

Hemodynamic perturbations in cerebral arteriovenous malformations and management implications.

Cerebral AVMs have high flow, low resistance shunts that induce regional hemodynamic disturbances and possibly neural derangements. A better understanding of these mechanisms may help treatment planning and the management of complications after endovascular or surgical treatment. Although the precise mechanisms of hemodynamic perturbation are still relatively unclear, the presence of chronic cerebral hypoperfusion is central and widely believed to be associated with both neurological deficits at presentation ('steal') and 'hyperemic' complications following shunt obliteration. The 'normal perfusion pressure breakthrough' (NPPB) theory states that chronic hypoperfusion around AVMs induces the loss of autoregulatory capability; following AVM shunt obliteration, perfusion pressure elevation induces an increase in flow, due to 'vasomotor paralysis', which can cause hemorrhage. The 'dissociative vasoparalysis' theory suggests that vasodilation is preserved but not vasoconstriction. However, pharmacologic exploration of cerebral autoregulation with induced vasoconstriction (phenylephrine) and vasodilatation (acetazolamide) helps identify 3 patterns of autoregulatory behavior. The vast majority of AVM patients appear to retain autoregulatory capability, despite low arterial feeding pressures, consistent with a "shift to the left" of the autoregulation curve. Pronounced hypotension may "exhaust" cerebrovascular reserve in some patients, predisposing to hemorrhagic complications in the post-operative period. Lastly, "vasoparalysis" may coexist with a combination of vascular insult and marked hypotension. Clinical presentation, AVM angioarchitecture and peri-operative physiologic data (especially feeding artery and venous outflow pressures) may assist patient management. Patients can be identified in whom staged treatment is recommended initially. Following AVM obliteration, the patient's hemodynamic response, which may range from a minimal increase in A-V pressure gradient to significant CBF increase may be predicted, and blood pressure, fluid and lCP management adjusted accordingly, as the monitoring of post-operative cerebral hemodynamics remains difficult. Extreme attention to endovascular and operative technique must be exercised, as technical problems can be devastating. Although incompletely understood, hemodynamic derangements associated with cerebralAVMs increasingly appear to be associated with intact cerebral autoregulation in most patients. As cerebral hemodynamics monitoring remains challenging, clinical, angiographic and physiologic data from interventional/operative monitoring must be used to guide patient management.

Complex intracranial aneurysms: combined operative and endovascular approaches.

OBJECTIVE: Endovascular management of complex intracranial aneurysms is increasingly being considered as an alternative to standard surgical clipping. However, little attention has been paid to the complementary nature of surgery and endovascular therapy. METHODS: Between September 1992 and May 1997, 12 patients with complex intracranial aneurysms were treated with combined operative and endovascular methods. Seven patients demonstrated subarachnoid hemorrhage (two of Grade II, two of Grade III, and three of Grade IV). Five patients demonstrated unruptured aneurysms, i.e., three giant aneurysms (one vertebrobasilar junction aneurysm, one middle cerebral artery bifurcation aneurysm, and one internal carotid artery-ophthalmic artery aneurysm), one large internal carotid artery-ophthalmic artery aneurysm, and one middle cerebral artery serpentine aneurysm. Management strategies involved either surgery followed by endovascular therapy (S-E; n = 5) or endovascular therapy followed by surgery (E-S; n = 7). S-E paradigms included aneurysm exploration followed by endovascular treatment (S-E1; n = 3), partial aneurysm clipping followed by endovascular aneurysm packing (S-E2; n = 1), and extracranial-to-intracranial bypass followed by endovascular parent vessel occlusion (S-E3; n = 1). E-S paradigms included superselective angiography followed by surgical clipping (E-S1; n = 2), Guglielmi detachable coil partial dome packing followed by delayed surgical clipping (E-S2; n = 2), proximal temporary vessel balloon occlusion followed by aneurysm clipping (E-S3; n = 2), and proximal permanent vessel occlusion followed by surgical aneurysm decompression for mass effect treatment (E-S4; n = 1). RESULTS: Eleven aneurysms (92%) were completely eliminated. The remaining aneurysm was 90% obliterated and remained quiescent at the 34-month follow-up examination, despite presenting with subarachnoid hemorrhage. No patient experienced repeat bleeding (follow-up period, 23+/-28 mo). There were no deaths. One patient achieved a fair outcome (Glasgow Outcome Scale score of III); all other patients experienced excellent outcomes (Glasgow Outcome Scale score of I). In all cases, the aneurysm management paradigm chosen had a positive effect on definitive therapy. CONCLUSION: Several factors can contribute to the complexity of intracranial aneurysms. Management strategies that combine operative and endovascular techniques in a complementary way, for the best possible outcomes for these patients, can be designed accordingly.

The feasibility of intracarotid adenosine for the manipulation of human cerebrovascular resistance.

UNLABELLED: To assess the feasibility of manipulating human cerebrovascular resistance with adenosine, we measured cerebral blood flow (CBF) by determining the initial slope (IS) of tracer washout 20-80 s after intracarotid 133Xe injection (standard IS) during sequential 3-min intracarotid infusions of (a) saline; (b) adenosine 1.2-mg bolus followed by an infusion of 1 mg/min (bolus + infusion); (c) saline; and (d) nicardipine (0.1 mg/min). During 133Xe washout, adenosine caused a rapidly clearing compartment. Therefore, tracer washout was also analyzed 5-25 s after injection (early IS). Nicardipine (n = 8) increased both standard IS (from 39+/-12 to 53+/-16 mL 100g.min(-1); P < 0.005) and early IS (from 40+/-9 to 55+/-20 arbitrary units; P < 0.02) to a similar degree. Adenosine bolus + infusion increased early IS (from 33+/-6 to 82+/-43 arbitrary units; P < 0.02) but did not increase standard IS (from 41+/-12 to 43 +/-16 mL 100g(-1) min(-1)). Standard and early IS values were then determined before and after adenosine delivered either by infusion alone (2 mg/min for 3 min, n = 5) or bolus alone (2 mg in 1 s, n = 3). Neither standard nor early IS changed after adenosine infusion alone. Early IS increased after adenosine bolus alone. Increase in early IS, but not standard IS, suggests a transient (<30 s) increase in CBF. IMPLICATIONS: Intracarotid adenosine, in the 1- to 2-mg dose range, may cause a transient, but not a sustained, increase in cerebral blood flow. Intracarotid adenosine in such a dose range does not seem to be an appropriate drug for sustained manipulation of cerebrovascular resistance.