Endovascular treatment of intracranial arteriovenous malformations using detachable-tip microcatheters and Onyx 18®.

PURPOSE: To evaluate clinical and imaging features before embolization, data of embolization procedure and outcome in patients with ruptured or unruptured intracranial arteriovenous malformation (AVM) who were treated by endovascular embolization using detachable-tip microcatheters and Onyx 18®. MATERIAL AND METHODS: Forty-three patients treated with endovascular embolization using a detachable-tip microcatheter and Onyx18® between January 2008 and April 2016 were evaluated. There were 27 men and 16 women with a mean age of 35.9±14.1years (range: 10-68years). Clinical and imaging features, embolization details and post-treatment findings were analyzed. Patients were divided into ruptured AVM and unruptured AVM groups. Death, complications and total embolization rates of each group were assessed. RESULTS: Fifty-one embolization sessions were performed in 43 patients. Total embolization rate was 40% (17/43). There were significant relationships between AVM diameter and total embolization success and AVM diameter and complication rates. The degree of embolization was partial in all patients who had complications. Catheter retention and iatrogenic rupture were not observed in any procedure. No major neurologic deficit was seen in patients who had unruptured AVM and complications after treatment. CONCLUSIONS: Our results show the efficacy of endovascular embolization of AVM using detachable-tip microcatheters and Onyx 18®. A new AVM classification system based on AVM diameter for this embolization technique may be more predictive in terms of total embolization success and complication development.

Effectiveness of percutaneous vertebroplasty in cases of vertebral metastases.

PURPOSE AND OBJECTIVES: To assess the effectiveness of percutaneous vertebroplasty (PV) in patients with vertebral collapse due to metastases. MATERIALS AND METHODS: PV procedures performed on 95 vertebras in 52 patients with primary malignancy were retrospectively evaluated. Vertebral metastases, primary malignancies of the patients, pain before and after PV on a visual analogue scale (VAS), amount of polymethylmethacrylate (PMMA) cement applied to the vertebral body during PV, PMMA cement leakage and vertebral approaches were evaluated. RESULTS: VAS scores of 43 patients (in total 79 vertebras) were evaluated. Median VAS scores of patients declined from 8 (4-10) before PV to 3 (0-7) within one day after the procedure, to 2 (0-9) one week after the procedure and eventually to 2 (0-9) 3months after the procedure (p<0.001). PMMA amount applied to the vertebral body during PV varied between 1.5-9mL (average±SD 4.91±1.61). There was no significant statistical correlation between PMMA amounts and VAS scores within one day after, 1week after and 3months after the PV procedure (p>0.05). CONCLUSION: PV is a simple, effective, reliable, easy to perform and minimally invasive procedure in patients with painful vertebral metastases.

Anatomical correlation between existence of concha bullosa and maxillary sinus volume.

PURPOSE: The objective of this study was to assess the effects of concha bullosa variation on maxillary sinus volume and uncinate angle. METHOD: The study group included 169 patients (338 sides) who underwent either surgical or medical treatment with the diagnosis of chronic rhinosinusitis. The paranasal sinus computed tomography of these patients was analyzed to measure maxillary sinus volume, uncinate angle and existence of concha bullosa. Subsequently, these variables were evaluated to find out possible relationship inbetween. RESULTS: Mean maxillary sinus volume and uncinate angle at right and left sides were 15.21 ± 0.47 and 15.51 ± 0.48 mm(3), 30.57 ± 0.62° and 30.20 ± 0.68°, respectively. There was no difference between patients with or without concha bullosa in regard to maxillary sinus volume and uncinate angle at both sides. Maxillary sinus volume and degree of uncinate angle did not show any significant correlation at both sides; r = -0.124, p = 0.107 and r = -0.136, p = 0.078. CONCLUSION: In conclusion, concha bullosa is a common anatomical variation at nasal cavity. The existence of concha bullosa does not have any association with the volume of maxillary sinus and angle of uncinate process.

Assesment of perfusion in glial tumors with arterial spin labeling; comparison with dynamic susceptibility contrast method.

PURPOSE: Arterial spin labeling perfusion imaging (ASL-PI) is a non-invasive perfusion imaging method that can be used for evaluation and quantification of cerebral blood flow (CBF). Aim of our study was to evaluating the efficiency of ASL in histopathological grade estimation of glial tumors and comparing findings with dynamic susceptibility contrast perfusion imaging (DSC-PI) method. METHODS: This study involved 33 patients (20 high-grade and 13 low-grade gliomas). Multiphase multislice pulsed ASL MRI sequence and a first-passage gadopentetate dimeglumine T2*-weighted gradient-echo single-shot echo-planar sequence were acquired for all the patients. For each patient, perfusion relative signal intensity (rSI), CBF and relative CBF (rCBF) on ASL-PI and relative cerebral blood volume (rCBV) and relative cerebral blood flow (rCBF) values on DSC-PI were determined. The relative signal intensity of each tumor was determined as the maximal SI within the tumor divided by SI within symetric region in the contralateral hemisphere on ASL-PI. rCBV and rCBF were calculated by deconvolution of an arterial input function. Relative values of the lesions were obtained by dividing the values to the normal appearing symmetric region on the contralateral hemisphere. For statistical analysis, Mann-Whitney ranksum test was carried out. Receiver operating characteristic curve (ROC) analysis was performed to assess the relationship between the rCBF-ASL, rSI-ASL, rCBV and rCBF ratios and grade of gliomas. Their cut-off values permitting best discrimination was calculated. The correlation between rCBV, rCBF, rSI-ASL and rCBF-ASL and glioma grade was assessed using Spearman correlation analysis. RESULTS: There was a statistically significant difference between low and high-grade tumors for all parameters. Correlation analyses revealed significant positive correlations between rCBV and rCBF-ASL (r=0.81, p<0.001). However correlation between rCBF and rCBF-ASL was weaker (r=0.64, p<0.001). CONCLUSION: Arterial spin labeling is an employable imaging technique for evaluating tumor perfusion non-invasively and may be useful in differentiating high and low grade gliomas.

A mucormycosis case treated with a combination of caspofungin and amphotericin B.

Mucormycosis is a rare, invasive and fatal disease that occurs mainly in diabetes mellitus patients with uncontrolled blood glucose levels or in immunocompromised patients. The mortality rate of this disease is as high as 25 to 80%, despite aggressive surgical treatment and antifungal therapy. This high mortality requires alternative treatment approaches. The accepted treatment modality of invasive mucormycosis are amphotericin B lipid formulations. Although echinocandins generally show no activity against Mucorales, it was shown that Rhizopus oryzae expressed the target enzyme for echinocandins, 1,3-beta-glucan synthase. Additionally, there are some experimental studies in a diabetic mouse model and case reports regarding the effects of caspofungin. In this report, we present a rhinocerebral mucormycosis case treated with liposomal amphotericin B and caspofungin. There was regression of the patient's clinical and radiological condition with the addition of caspofungin, but she died due to discontinuation of her treatment and reasons other than mucormycosis.

Correlation between hippocampal volume and excessive daytime sleepiness in obstructive sleep apnea syndrome.

BACKGROUND/AIM: The limbic system, specifically the hippocampus, plays a key role in controlling the sleep-wake cycle. Changes in these particular structures of the central nervous system have been suggested to be related to obstructive sleep apnea syndrome (OSAS). We hypothesized that reduced hippocampal volume is a risk factor for excessive daytime sleepiness (EDS) in OSAS. PATIENTS AND METHODS: Twenty-two patients with newly diagnosed OSAS and 20 healthy controls were included in the present study. Polysomnography was performed for each participant to determine the presence of OSAS. EDS was defined based on the Epworth sleepiness scale (ESS) score, and patients were grouped as sleepy or non-sleepy according to this score. The hippocampal volume was calculated by MR volumetry using a manual tracing technique. RESULTS: There was no significant difference between groups in demographic variables. The hippocampus was markedly smaller in the OSAS groups than in controls (p < 0.001 Hippocampal volume was negatively correlated with the ESS score (r = -0.631, p = 0.002). CONCLUSIONS: Our findings suggest that EDS is associated with reduced hippocampal volume in OSAS.

Phase-contrast MRI and 3D-CISS versus contrast-enhanced MR cisternography for the detection of spontaneous third ventriculostomy.

PURPOSE: To compare the diagnostic efficacies of phase-contrast MRI (PC-MRI) and three-dimensional constructive interference in steady-state (3D-CISS) sequence for the detection of spontaneous third ventriculostomy (STV) on the basis of contrast-enhanced MR cisternography (MRC). PATIENTS AND METHODS: Eleven obstructive hydrocephalus patients with clinically-radiologically suspected STV and ten controls were examined by PC-MRI, 3D-CISS and MRC. PC-MRI and 3D-CISS sequence were applied to view the third ventricle and basal cisterns. Following injection of 0.5-1ml intrathecal Gd-DTPA injection, postcontrast MRC images were obtained in three planes. Presence of STV was scored as follows: grade 0, no existence of STV; grade 1, STV present. Results of PC-MRI and 3D-CISS were compared with the MRC findings. RESULTS: In PC-MRI, five patients were assessed as grade 0 and six cases grade 1. As a result of 3D-CISS sequence, eight cases were evaluated as grade 0 and three cases grade 1. Based on MRC, nine cases were assessed as grade 0 and two cases grade 1. False positivity was found in four cases by PC-MRI and in one case by 3D-CISS. The sensitivity, specificity and accuracy of PC-MRI and 3D-CISS sequence regarding demonstration of STV, were 100, 100, 56, 89, 64, and 91% respectively. DISCUSSION: PC-MRI and 3D-CISS are helpful in confirming the STV. PC-MRI and 3D-CISS should be the first preference. If PC-MRI and 3D-CISS give negative results, then MRC is not required. MRC should be performed on patients who demonstrate suspected STV findings on PC-MRI and 3D-CISS sequences. MRC may prevent false positive results.

Proton MR spectroscopy and white matter hyperintensities in idiopathic normal pressure hydrocephalus and other dementias.

The differentiation of idiopathic normal-pressure hydrocephalus (INPH) from other types of dementia is a clinical challenge. The aim of this prospective study was to evaluate the role of proton MR spectroscopy (MRS) and white matter hyperintensities (WMH) in the diagnosis of INPH, predicting response to therapy and differentiating INPH from other dementias. The study included 18 patients with INPH (Group 1), 11 patients with other types of dementia (Group 2) and 20 control patients (Group 3). The value of WMH scores and MRS findings in diagnosis, evaluation of response to therapy and in the differentiation of INPH from other dementias was statistically evaluated. The level of statistical significance was set at p<0.05 (Kruskal-Wallis and Mann-Whitney U-test). In both Groups 1 and 2, N-acetylaspartate (NAA)/choline-NAA/creatine ratios were significantly less than in the control group (p<0.05). The WMH and MRS findings of Groups 1 and 2 demonstrated no statistically significant correlation (p>0.05). No correlation was found between the outcome of shunt operations and WMH and MRS findings (p>0.05). In conclusion, neither WMH nor MRS were useful in differentiating INPH from other types of dementia. WMH and MRS showed no additional benefit in identifying INPH patients who will better respond to shunt therapy.

Solitary metastases and high-grade gliomas: radiological differentiation by morphometric analysis and perfusion-weighted MRI.

AIM: To evaluate the value of morphometric analysis and perfusion-weighted magnetic resonance imaging (MRI) in differentiating solitary metastases from high-grade gliomas. MATERIALS AND METHODS: Forty-eight tumours (22 high-grade gliomas and 26 solitary hemispheric metastases) were evaluated using conventional and perfusion-weighted MRI. T2-weighted, gradient-echo, echo-planar sequences were used for perfusion-weighted MRI. Relative cerebral blood volume (rCBV) ratios were calculated by dividing the rCBV of the intratumoural and peritumoural areas with the average CBV value of the normal white matter areas. Morphometric analysis was carried out by proportioning the area of peritumoural oedema to the mass area. Mann-Whitney U test and ROC curve analysis were applied for statistical analysis. P<0.05 was accepted as statistically significant. RESULTS: Mean rCBV ratios of intratumoural areas of high-grade gliomas and metastases were 5.02+/-2.47 and 4.62+/-2.46, respectively. No statistically significant difference was found (p=0.515). rCBV ratios of peritumoural oedema were 0.89+/-0.51 in high-grade gliomas and 0.31+/-0.12 in metastases. The difference was statistically significant (p<0.001). According to the results of morphometric analysis, a statistically significant difference was present between the two tumour types (p<0.001). CONCLUSION: Measuring the oedema: mass and rCBV ratios of the oedema surrounding the tumour prior to operation in solitary masses proved to be useful for differentiating metastases from high-grade gliomas.

Multiple intracranial abscesses due to Cryptococcus neoformans: an unusual clinical feature in an immunocompetent patient and a short review of reported cases.

We present a case of multiple intracranial abscesses caused by Cryptococcus neoformans in a patient who presented with no symptoms of immunodeficiency.

The contribution of 3D-CISS and contrast-enhanced MR cisternography in detecting cerebrospinal fluid leak in patients with rhinorrhoea.

The aim of this prospective study was to evaluate the value of unenhanced (three-dimensional constructive interference in steady state (3D-CISS)) and contrast-enhanced MR cisternography (CE-MRC) in detecting the localisation of cerebrospinal fluid (CSF) leak in patients with rhinorrhoea. 17 patients with active or suspected CSF rhinorrhoea were included in the study. 3D-CISS sequences in coronal and sagittal planes and fat-suppressed T1-weighted spin-echo sequences in three planes before and after intrathecal contrast media administration were obtained. Images were obtained of the cribriform plate and sphenoid sinus. In addition, high-resolution CT (HRCT) was performed in order to evaluate the bony elements. The leak was present in 9/17 patients with 3D-CISS and 10/17 patients with CE-MRC. The leak from the cribriform plate to the nasal cavity in six patients and from the sphenoid sinus in four patients was nicely shown by CE-MRC. Eight of those patients were surgically treated, but spontaneous regression of the symptoms in two precluded any intervention. The leak localisations shown with CE-MRC were fully compatible with surgical results. The sensitivities of HRCT, 3D-CISS and CE-MRC for showing CSF leakage were 88%, 76% and 100%, respectively. In conclusion, 3D-CISS is a non-invasive and reliable technique, and should be the first-choice method to localise CSF leak. CE-MRC is helpful in conditions when there is no leak or in complicated cases with a positive beta2-transferrin measurement.

Dilatation of Virchow-Robin perivascular spaces: report of 3 cases with different localizations.

We report on three different cases with Virchow-Robin spaces, including one with extreme widening causing hydrocephalus. In one patient we have performed neuroendoscopic cyst fenestration to resolve the problem.

Foramen of Monro meningioma with atypical appearance: CT and conventional MR findings.

Intraventricular meningiomas have often been reported; however, literature reveals very few cases localized within foramen of Monro. Herein we report a 57-year-old woman admitted with obstructive hydrocephalus-related symptoms. Strikingly, the lesion was completely calcified in CT and had no marked solid component on MRI. The lesion was completely removed by surgical resection with a transfrontal intraventricular approach. The resected mass was histopathologically diagnosed as meningioma. The patient's symptoms resolved immediately after the operation.