Radiological and Clinical Significance of Cervical Dynamic Magnetic Resonance Imaging for Cervical Spondylotic Myelopathy.

OBJECTIVE: The study compared the morphometric changes of the cervical spinal cord using dynamic magnetic resonance imaging (MRI) in patients with cervical spondylotic myelopathy (CSM) and assessed the correlation with kinematic changes, cord cross-sectional area (CSA), and high signal intensity (SI) on T2-weighted imaging (T2WI). METHODS: Patients with CSM were evaluated through dynamic MRI for sagittal and axial CSA changes of the cervical cord, cerebrospinal fluid (CSF) reserve ratio, degree of cord impingement, cord compression rate, range of motion (ROM), and severity of SI on T2WI. The degree of cord impingement was evaluated using the Muhle grading system. Clinical outcomes were assessed using Japanese Orthopaedic Association scoring and Nurick grade. RESULTS: The study included 191 patients (113 males) with a mean age of 55.34 ± 12.09 years. The lowest sagittal CSF reserve ratio and cord occupation rate were observed during extension. Cord impingement and SI change were more prevalent in extension-positioned MRI. There was no difference between ROM on dynamic radiographs and dynamic MRI. Preoperative cervical ROM was greater in patients with intensely high SI change. CONCLUSION: Dynamic MRI is useful for evaluating neck movement. Patients with high SI had greater ROM before surgery but worse outcomes after. Neck extension exacerbated cervical stenosis and cord compression compared to flexion, and cervical spinal motion contributed to the severity of CSM. Cervical spinal motion should be carefully evaluated, particularly in hyperextension, to prevent worsening of CSM.

Is a small coil more effective as a finishing coil for the embolization of intracranial aneurysms? Outcomes using GALAXY G3™ MINI micro-coils as finishing coils in a single center.

OBJECTIVE: The purpose of this study was to compare the outcomes of coil embolization using a 0.009 inches primary outer diameter coil as finishing coil (FC) to that of 0.01 inches. METHODS: From February and August 2020, 131 aneurysms that performed coil embolization using FC with a second loop diameter of 1 mm, were reviewed retrospectively, conducting propensity score matching and logistic regression analysis. Angiographic results such as, occlusion grade, packing density, failure and event were compared between 0.009 inches coil of GALAXY G3™ MINI microcoil (n = 54) and 0.01 inches coils (n = 77). RESULTS: There were no statistically significant differences between two groups, but more events occurred in the 0.009 group. (Odds ratio, 3.65; 95% CI, 1.06-12.55; P = 0.031) In the results of coil embolization, successful occlusion occlusion (complete occlusion and residual neck) was identified more in the 0.01 group. After propensity score matching, the variables in each group were similar, but the successful occlusion was higher in the 0.01 group as in the total population. Events tended to occur more frequently in the 0.009 inch group, and logistic regression analysis showed slightly higher events in the angled microcatheter. (48.3% versus 76.9%., P = 0.075), Also, the 0.009 inch FC is an independent risk factor. (Odds ratio, 3.84; 95% CI, 1.07-13.80; P = 0.039). CONCLUSIONS: Using 0.01 inches coils as FC increased the packing density after the procedure, and showed more successful occlusion than using a 0.009 inches coil. The probability of unexpected events was observed more than three times in the 0.009 inch group.

Increased Glucose Variability During Long-Term Therapeutic Hypothermia as a Predictor of Poor Neurological Outcomes and Mortality: A Retrospective Study.

Therapeutic hypothermia (TH) is considered as a treatment option in patients with stroke and brain injury for controlling intracranial pressure. A relatively longer duration of TH is required in such patients than in cardiac arrest patients. We aimed to investigate blood glucose parameters during TH that predict unfavorable neurological outcomes and mortality in patients admitted to the neurological or neurosurgical intensive care unit (ICU). This retrospective study evaluated electronic medical records of patients admitted to the ICU from January 1, 2012, to May 20, 2017. A total of 103 patients were included in the analyses. Multivariable analyses revealed that age and glycemic variability (GV) index were significantly associated with poor neurological outcomes (odds ratio [OR] 1.09, 95% confidence interval [CI] 1.03-1.15, p = 0.002, and OR 1.04, 95% CI 1.02-1.06, p < 0.001, respectively); furthermore, cumulative input-output balance, sequential organ failure assessment score, and glucose variability index were associated with 90-day mortality (hazard ratio [HR] 1.13, 95% CI 1.05-1.21, p < 0.001; HR 1.20, 95% CI 1.04-1.38, p = 0.010; and HR 1.01, 95% CI 1.01-1.02, p < 0.001, respectively). Receiver operating characteristic curve analyses of the GV index for prediction of 90-day mortality and poor neurological outcomes revealed that the areas under the curves were 0.747 (95% CI 0.65-0.85) and 0.826 (95% CI 0.75-0.91), respectively. In conclusion, variability in glucose levels may be valuable for predicting 90-day mortality and poor neurological outcomes in patients undergoing long-term TH.

Incidental Microaneurysms During Microvascular Surgery: Incidence, Treatment, and Significance.

BACKGROUND: Although new imaging tools have been developed for the detection of smaller aneurysms, angiographically negative microaneurysms are still encountered during cerebral microsurgery. Currently, only limited information regarding incidence and efficacy of treatment of these microaneurysms is available. METHODS: We investigated the incidence and treatment of incidental microaneurysms (IMAs) in the last 5 years. IMAs are unidentifiable and invisible on preoperative angiography, but are detected during microvascular surgery. The inclusion criteria were aneurysm cases treated with microsurgery via transsylvian approaches, and those undergoing preoperative digital subtraction angiography. RESULTS: This study enrolled 484 surgical cases (248 cases of subarachnoid hemorrhage and 236 cases of unruptured aneurysms) in 460 patients, and 33 tiny aneurysms were found in 31 operative cases (6.4% incidence per operation). The most typical type was located on another branching site of the middle cerebral artery found during neck clipping of the middle cerebral artery bifurcation aneurysm. A patient with multiple aneurysms presented a statistically significant risk (375/78 vs. 15/16; P < 0.001) of IMA identification. IMAs were treated by clipping and wrapping in 18 and 15 cases, respectively, without complications. CONCLUSIONS: This study revealed a 6.4% incidence of IMAs; however, this could be underestimated because of the limited range of inspection. Early detection of an IMA through careful inspection during microvascular surgery could be beneficial, especially in patients with multiple aneurysms.

Long-term outcomes of treatment for unruptured intracranial aneurysms in South Korea: clipping versus coiling.

BACKGROUND: The long-term outcomes of endovascular coiling and surgical clipping for the treatment of unruptured intracranial aneurysms are unclear. METHODS: We performed a nationwide retrospective cohort study using claims data from the Korean Health Insurance Review and Assessment Service on patients undergoing surgical clipping or endovascular coiling from 2008 to 2014. Inverse probability treatment weighting for average treatment effect on the treated and the multiple imputation method were used to balance covariates and handle missing values. The primary outcome was all-cause mortality at 7 years. RESULTS: We identified 26 411 patients of whom 11 777 underwent surgical clipping and 14 634 underwent endovascular coiling. After adjustment with the use of inverse probability treatment weighting for average treatment effect on the treated, all-cause mortality rates at 7 years were 3.8% in the endovascular coiling group and 3.6% in the surgical clipping group (HR 1.05; 95% CI 0.86 to 1.28; P=0.60, log-rank test). The adjusted probabilities of aneurysm rupture at 7 years were 0.9% after endovascular coiling and 0.7% after surgical clipping (HR 0.9; 95% CI 0.61 to 1.34; P=0.63, log-rank test). The probabilities of retreatment at 7 years after adjustment were 4.9% in the endovascular coiling group and 3.2% in the surgical clipping group (HR 1.52; 95% CI 1.28 to 1.81; P<0.001, log-rank test). CONCLUSIONS: All-cause mortality at 7 years was similar between the elective surgical clipping and endovascular coiling groups in patients with unruptured aneurysms who had no history of subarachnoid hemorrhage due to aneurysm rupture.

Radiologic Measurement of Brain Swelling in Patients with Large Hemispheric Infarctions During Targeted Temperature Management.

Brain herniation is most often the result of severe brain swelling and can rapidly lead to death or brain death. We retrospectively identified radiologic indicators to evaluate the effects of targeted temperature management (TTM) on the extent of cerebral edema and determine the cutoff values that best predict TTM outcomes in patients with large hemispheric infarction. We retrospectively reviewed brain computed tomography (CT) scans of 21 patients with large hemispheric infarctions, who were treated with TTM. We excluded 4 patients whose CT scans were inadequate for evaluation, which left 17 patients. We divided the patients into success and failure groups. TTM failure was defined as death or the need for decompressive hemicraniectomy (DHC) after TTM. Infarction size was measured as the total restricted area in diffusion-weighted imaging that was performed on admission. CT scans were obtained on the first and second days after TTM initiation and then every 2 days. We measured septum pellucidum shifts (SPS) and pineal gland shifts (PGS) on CT scans. The median time from symptom onset to TTM initiation was 14.5 hours. Ten patients were successfully treated with TTM, six patients died, and one patient underwent a DHC. Initial infarction sizes were not significantly different between the success and failure groups (p = 0.529), but the SPS and PGS at 36-72 hours after TTM initiation were (mean SPS: 5.0 vs. 14.9 mm, p = 0.001; mean PGS: 2.3 vs. 7.9 mm, p = 0.001). The sensitivity and negative predictive value for TTM failure caused by cerebral edema (SPS ≥9.25 mm and PGS ≥3.70 mm) at 36-72 hours after TTM initiation were both 100%. The SPS and PGS on CT scans taken 36-72 hours after TTM initiation may help to estimate the effect of TTM on cerebral edema and guide further treatment.

Effect of statin on progression of symptomatic basilar artery stenosis and subsequent ischemic stroke.

BACKGROUND AND OBJECTIVE: Symptomatic basilar artery stenosis (BAS) is associated with high risk of ischemic stroke recurrence. We aimed to investigate whether statin therapy might prevent the progression of symptomatic BAS and stroke recurrence. METHODS: We retrospectively analyzed the data of patients with acute ischemia with symptomatic BAS, which was assessed using magnetic resonance angiogram (MRA) imaging on admission day, and 1 year later (or the day of the clinical event). The clinical endpoints were recurrent ischemic stroke and its composites, transient ischemic attack, coronary disease, and vascular death. RESULTS: Of the 153 patients with symptomatic BAS, 114 (74.5%) were treated with a statin after experiencing a stroke. Statin therapy significantly prevented the progression of symptomatic BAS (7.0% vs 28.2%) and induced regression (22.8% vs 15.4%) compared to non-statin users (p = 0.002). There were 31 ischemic stroke incidences and 38 composite vascular events. Statin users showed significantly lower stroke recurrence (14.9% vs 35.9%, p = 0.05) and composite vascular events (17.5% vs 46.2%; odds ratio [OR], 0.29; 95% confidence interval [CI], 0.13-0.64) than those not using statins did. Recurrent stroke in the basilar territory and composite vascular events were more common in patients with progression of BAS than they were in other patients (OR, 5.16; 95% CI, 1.63-16.25 vs OR, 4.2; 95% CI, 1.56-11.34). CONCLUSION: Our study suggests that statin therapy may prevent the progression of symptomatic BAS and decrease the risk of subsequent ischemic stroke. Large randomized trials are needed to confirm this result.

Efficacy and Safety of Fractionated Stereotactic Radiosurgery for Large Brain Metastases.

OBJECTIVE: To investigate the efficacy and safety of fractionated stereotactic radiosurgery for large brain metastases (BMs). METHODS: Between June 2011 and December 2013, a total of 38 large BMs >3.0 cm in 37 patients were treated with fractionated Cyberknife radiosurgery. These patients comprised 16 men (43.2%) and 21 women, with a median age of 60 years (range, 38-75 years). BMs originated from the lung (n=19, 51.4%), the gastrointestinal tract (n=10, 27.0%), the breast (n=5, 13.5%), and other tissues (n=3, 8.1%). The median tumor volume was 17.6 cc (range, 9.4-49.6 cc). For Cyberknife treatment, a median peripheral dose of 35 Gy (range, 30-41 Gy) was delivered in 3 to 5 fractions. RESULTS: With a median follow-up of 10 months (range, 1-37 months), the crude local tumor control (LTC) rate was 86.8% and the estimated LTC rates at 12 and 24 months were 87.0% and 65.2%, respectively. The median overall survival (OS) and progression-free survival (PFS) rates were 16 and 11 months, respectively. The estimated OS and PFS rates at 6, 12, and 18 months were 81.1% and 65.5%, 56.8% and 44.9%, and 40.7% and 25.7%, respectively. Patient performance status and preoperative focal neurologic deficits improved in 20 of 35 (57.1%) and 12 of 17 patients (70.6%), respectively. Radiation necrosis with a toxicity grade of 2 or 3 occurred in 6 lesions (15.8%). CONCLUSION: These results suggest a promising role of fractionated stereotactic radiosurgery in treating large BMs in terms of both efficacy and safety.

Thoracic Extradural Cavernous Hemangioma Mimicking a Dumbbell-Shaped Tumor.

Dumbbell-shaped spinal extradural cavernous hemangioma is rare. The differential diagnosis of dumbbell-shaped spinal tumors based on magnetic resonance imaging includes schwannoma and lymphoma. Here, we report a dumbbell-shaped spinal extradural cavernous hemangioma with intrathoracic growth on T2-3 in a 64-year-old man complaining of right side infrascapular area back pain with no neurologic deficit. The cavernous hemangioma was resected through combined video-assisted thoracoscopy and laminectomy without a fusion procedure. The patient had tolerable operative wound pain with no neurologic deficit after surgery. Based on magnetic resonance imaging findings and a review of the literature, we discuss cavernous hemangioma among the differential diagnosis of paravertebral dumbbell-shaped spinal tumors and the importance of complete resection.