Highly Visible Wall-Timer to Reduce Endovascular Treatment Time for Stroke.

BACKGROUND: Endovascular therapy for acute ischemic stroke has revolutionized clinical care for patients with stroke and large vessel occlusion, but treatment remains time sensitive. At our stroke center, up to half of the door-to-groin time is accounted for after the patient arrives in the angio-suite. Here, we apply the concept of a highly visible timer in the angio-suite to quantify the impact on endovascular treatment time. METHODS: This was a single-center prospective pseudorandomized study conducted over a 32-week period. Pseudorandomization was achieved by turning the timer on and off in 2-week intervals. The primary outcome was angio-suite-to-groin time, and secondary outcomes were angio-suite-to-intubation time, groin-to-recanalization time, and 90-day modified Rankin scale. A stratified analysis was performed based on type of anesthesia (ie, endotracheal intubation versus not). RESULTS: During the 32-week study period, 97 mechanical thrombectomies were performed. The timer was on and off for 38 and 59 cases, respectively. The timer resulted in faster angio-suite-to-groin time (28 versus 33 minutes; P=0.02). The 5-minute reduction in angio-suite-to-groin was maintained after adjusting for intubation status in a multivariate regression (P=0.02). There was no difference in the 90-day modified Rankin scale between groups. The timer impact was consistent across the 32-week study period. CONCLUSIONS: A highly visible timer in the angio-suite achieved a meaningful, albeit modest, reduction in endovascular treatment time for patients with stroke. Given the lack of risk and low cost, it is reasonable for stroke centers to consider a highly visible timer in the angio-suite to improve treatment times.

Computed tomography-guided transforaminal lumbar puncture using local anesthesia and a straight 22-gauge spinal needle for intrathecal nusinersen in adults: Findings in 77 procedures.

BACKGROUND: Intrathecal nusinersen is the first Food and Drug Administration-approved treatment for spinal muscular atrophy. Reliable intrathecal access is critical for initial and maintenance therapy; however, this can be challenging in older patients with spinal muscular atrophy many of whom have had prior lumbar instrumentation and osseous fusion. Transforaminal lumbar punctures have emerged as a technique for intrathecal access that avoids the hazards of cervical punctures. We describe our technique for transforaminal lumbar punctures under computed tomography guidance using local anesthesia and a straight 22-gauge needle. METHODS: Following local institutional review board approval, medical records of all patients undergoing computed tomography-guided transforaminal lumbar puncture for intrathecal nusinersen injection were obtained and analyzed. The rate of technical success and immediate complications were recorded. Any delayed complications noted in a 3-day follow-up phone call and future office visit were also recorded. Data collation and analysis were performed using Excel. RESULTS: A total of 77 transforaminal lumbar punctures were performed with intrathecal administration of nusinersen, for a 100% technical success rate. Local anesthesia was used in 76 cases, with conscious sedation used in one case. General anesthesia was not used in any case. There were no major complications. One patient had a postdural puncture headache that resolved completely after a transforaminal epidural blood patch performed 4 days later. CONCLUSIONS: Intrathecal administration of nusinersen is critical for treatment of patients with spinal muscular atrophy. Our described technique allows for reliable access to the intrathecal space using local anesthesia and a straight 22-gauge spinal needle under computed tomography guidance, and is easily reproducible.

Phase Ib Clinical Trial of IGV-001 for Patients with Newly Diagnosed Glioblastoma.

PURPOSE: Despite standard of care (SOC) established by Stupp, glioblastoma remains a uniformly poor prognosis. We evaluated IGV-001, which combines autologous glioblastoma tumor cells and an antisense oligonucleotide against IGF type 1 receptor (IMV-001), in newly diagnosed glioblastoma. PATIENTS AND METHODS: This open-label protocol was approved by the Institutional Review Board at Thomas Jefferson University. Tumor cells collected during resection were treated ex vivo with IMV-001, encapsulated in biodiffusion chambers with additional IMV-001, irradiated, then implanted in abdominal acceptor sites. Patients were randomized to four exposure levels, and SOC was initiated 4-6 weeks later. On the basis of clinical improvements, randomization was halted after patient 23, and subsequent patients received only the highest exposure. Safety and tumor progression were primary and secondary objectives, respectively. Time-to-event outcomes were compared with the SOC arms of published studies. RESULTS: Thirty-three patients were enrolled, and median follow-up was 3.1 years. Six patients had adverse events (grade ≤3) possibly related to IGV-001. Median progression-free survival (PFS) was 9.8 months in the intent-to-treat population (vs. SOC, 6.5 months; P = 0.0003). In IGV-001-treated patients who met Stupp-eligible criteria, PFS was 11.6 months overall (n = 22; P = 0.001) and 17.1 months at the highest exposure (n = 10; P = 0.0025). The greatest overall survival was observed in Stupp-eligible patients receiving the highest exposure (median, 38.2 months; P = 0.044). Stupp-eligible patients with methylated O6-methylguanine-DNA methyltransferase promoter (n = 10) demonstrated median PFS of 38.4 months (P = 0.0008). Evidence of immune activation was noted. CONCLUSIONS: IGV-001 was well tolerated, PFS compared favorably with SOC, and evidence suggested an immune-mediated mechanism (ClinicalTrials.gov: NCT02507583).

Imaging endpoints of intracranial atherosclerosis using vessel wall MR imaging: a systematic review.

PURPOSE: The vessel wall MR imaging (VWI) literature was systematically reviewed to assess the criteria and measurement methods of VWI-related imaging endpoints for symptomatic intracranial plaque in patients with ischemic events. METHODS: PubMed, Scopus, Web of Science, EMBASE, and Cochrane databases were searched up to October 2019. Two independent reviewers extracted data from 47 studies. A modified Guideline for Reporting Reliability and Agreement Studies was used to assess completeness of reporting. RESULTS: The specific VWI-pulse sequence used to identify plaque was reported in 51% of studies. A VWI-based criterion to define plaque was reported in 38% of studies. A definition for culprit plaque was reported in 40% of studies. Frequently scored qualitative imaging endpoints were plaque quadrant (21%) and enhancement (21%). Frequently measured quantitative imaging endpoints were stenosis (19%), lumen area (15%), and remodeling index (14%). Reproducibility for all endpoints ranged from good to excellent (range: ICCT1 hyperintensity = 0.451 to ICCstenosis = 0.983). However, rater specialty and years of experience varied among studies. CONCLUSIONS: Investigators are using different criteria to identify and measure VWI-imaging endpoints for culprit intracranial plaque. Early awareness of these differences to address methods of acquisition and measurement will help focus research resources and efforts in technique optimization and measurement reproducibility. Consensual definitions to detect plaque will be important to develop automatic lesion detection tools particularly in the era of radiomics.

Vascular imaging of the spine in the US Medicare population: Catheter and MR angiography volumes from 2004 to 2016.

AIMS: The purpose of our study was to analyze utilization trends and physician specialty distribution in spinal catheter angiography and magnetic resonance angiography in the Medicare fee-for-service population. METHODS: Data from the CMS Physician/Supplier Procedure Summary Master Files for 2004 to 2016 were used for this study. The Current Procedural Terminology version 4 codes for spinal magnetic resonance angiography (72159) and spinal catheter angiography (75705) were used to analyze the volumes of these procedures. Using Medicare's 108 specialty code, we compared procedure volumes among physician specialties. Data analysis was performed using SAS version 9.3 for Windows. RESULTS: The volume of spinal catheter angiography performed was 4758 in 2004, peaked at 6869 in 2012, and dropped to 6656 in 2016. Overall, the volume of spinal catheter angiography increased by 40% from 2004 to 2016. Radiologists performed the majority of these procedures (3736 or 56.1%) in 2016, followed by neurosurgeons (2456 or 36.9%), and neurologists (346 or 5.2%). The spinal magnetic resonance angiography volume fluctuated between 0 and 1 from 2004 to 2009, then precipitously increased to 40 in 2010, peaked at 133 in 2011, and declined to 81 in 2016. The volume of spinal magnetic resonance angiography procedures increased by 8000% from 2004 to 2016, with radiologists performing the majority of them. CONCLUSION: Our results show that spinal catheter angiography volumes continue to rise in the Medicare fee-for-service population, and are largely performed by radiologists, neurosurgeons, and neurologists. Although spinal magnetic resonance angiography volumes have started to increase, they comprise only a small fraction of studies performed for vascular evaluation of the spine.

Intracranial vessel wall MR imaging of an intradural vertebral artery dissection.

Diagnosis of intracranial arterial dissections can be challenging due to the wide spectrum of imaging presentations. High-resolution vessel wall MR imaging can be a useful adjunct to conventional lumen-based imaging techniques for diagnosing arterial dissections. We present a case of a 37-year-old male with a history of a Wolff-Parkinson-White syndrome presenting with acute onset of nausea, vertigo, and left body hemisensory loss of pain and temperature. A conventional brain MRI identified an acute infarct in the right lateral medulla, concordant with clinical symptoms of Wallenberg syndrome. CT angiogram of the head and neck showed lack of opacification of the right intradural vertebral artery. Intracranial vessel wall MR imaging showed findings suggestive of an intimal dissection flap with both intramural and intraluminal thrombus. Intracranial vessel wall MR imaging can provide complementary information to conventional lumen-based imaging to diagnose a vertebral dissection.

Advanced Imaging Interpretation by Radiologists and Nonradiologist Physicians: A Training Issue.

OBJECTIVE. The purpose of this study was to examine the degree to which nonradiologist physicians provide formal interpretations for advanced imaging and to consider whether adequate training can be achieved for those physicians. This investigation assumed that hospitals are the only places where formal imaging training occurs. MATERIALS AND METHODS. The CMS Physician/Supplier Procedure Summary Master Files (PSPSMFs) of the Medicare Part B datasets for 2015 were reviewed. We selected the Current Procedural Terminology (CPT) codes for four categories of noninvasive diagnostic imaging: CT, MRI, PET, and general nuclear imaging. Medicare place-of-service codes allowed us to determine the location of each study interpretation. We narrowed our analysis to data from the three major hospital places of service: inpatient facilities, hospital outpatient departments, and emergency departments. Provider specialties were determined using Medicare's 108 specialty codes. Procedure volumes among nonradiologist physicians were compared with those among radiologists. RESULTS. Of the 17,824,297 hospital-based CT examinations performed in the Medicare fee-for-service population, radiologists interpreted 17,698,360 (99.29%) and nonradiologists interpreted 125,937 (0.71%). Of the 4,512,627 MRI examinations performed, radiologists interpreted 4,469,275 (99.04%) and nonradiologist physicians interpreted 43,352 (0.96%). Of 391,688 PET studies performed, radiologists interpreted 368,913 (94.19%) and nonradiologist physicians interpreted 22,775 (5.81%). Of the 2,070,861 general nuclear medicine studies performed, radiologists interpreted 1,307,543 (63.14%) and nonradiologist physicians interpreted 763,318 (36.86%). Cardiologists had the largest involvement of nonradiologist physicians, contributing approximately 3% of all advanced imaging interpretations. All other nonradiologist physicians interpreted a tiny fraction of advanced imaging studies. CONCLUSION. Besides radiologists and cardiologists, no other medical specialty provides sufficient education for their trainees and practitioners in advanced imaging interpretation to justify allowing them to interpret these studies in practice, except under carefully controlled circumstances.

The utility of whole spine survey MRI in blunt trauma patients sustaining single level or contiguous spinal fractures.

PURPOSE: To determine the utility of obtaining whole-spine survey MRI after a whole-spine CT diagnoses single level or contiguous fractures. METHODS: A retrospective search from 2015 to 2017 was performed using an institutional PACS database for consecutive patients who sustained spinal fractures from blunt injury. Only patients who received whole-spine CT followed by whole-spine MRI were included in the study. All cases had sagittal T2-weighted and Short TI (Tau) inversion recovery (STIR) imaging of the entire spine with additional T1 and T2-weighted axial imaging covering the known injury. Reports from the whole-spine CTs were compared to the reports of the whole-spine MRI to determine if additional bony and soft tissue injury were identified on subsequent MRI. RESULTS: A total of 156 patients met the inclusion criteria, with an average age of 59.5 ± 20.6 years. Twenty-nine patients (18.5%) had a whole-spine MRI that demonstrated an additional bony ± soft tissue injury. A 95.1% of the additional injuries were osseous contusions or vertebral body compression fractures without significant loss of height. The distance between the original injury on CT and the additional injury on MR ranged from 1 to 13 vertebrae. A 82.8% of the additional injuries occurred within 1 to 8 vertebrae levels of the primary injury and most commonly in the thoracic spine. CONCLUSIONS: Most additional bony injuries detected on MRI are bone contusions and mild compression fractures, which are unlikely to alter management. However, if screening MRI is performed for additional bony injuries, we posit that a targeted regional spinal MRI is adequate.

Neurointerventional Radiology for the Aspiring Radiology Resident: Current State of the Field and Future Directions.

OBJECTIVE: The purposes of this study were to document recent trends in stroke intervention at a tertiary-care facility with a comprehensive stroke center and to analyze current procedure volumes and the employment of specialty providers in neurointerventional radiology (NIR). MATERIALS AND METHODS: Institutional trends in the volume of mechanical thrombectomy were analyzed on the basis of the number of patients who underwent mechanical thrombectomy from 2013 to 2017. To evaluate the current status of mechanical thrombectomy volumes in the United States, the number of patients in the Medicare fee-for-service database who underwent mechanical thrombectomy in 2016 was assessed. The specialty backgrounds of the various providers who performed mechanical thrombectomy were analyzed. Procedure volumes for intracranial stenting, embolization, and vertebral augmentation procedures were assessed. RESULTS: From 2013 to 2017, the total numbers of mechanical thrombectomy procedures for acute ischemic stroke were 19 in 2013 and 111 in 2017. The total volume of mechanical thrombectomy procedures in the Medicare fee-for-service population in 2016 was 7479. For intracranial endovascular procedures, 20,850 were performed in the U.S. Medicare population in 2015 and 22,511 in 2016. Radiologists performed 45% of procedures in 2016; neurosurgeons, 41%; and neurologists, 11%. When the total numbers of percutaneous brain and spine procedures were combined, radiologists performed 41%; neurosurgeons, 23%; and neurologists, 3%. In 2016, there were a total of 220 active NIR staff at the NIR programs with rotating residents or fellows. In these programs, 49% of staff members were neuroradiologists, 41% were neurosurgeons, and 10% were neurologists. Of the 72 NIR departments with confirmed rotating fellows or residents, 14 had only neuroradiologists on staff, six had only neurosurgeons, and one had only neurologists. CONCLUSION: Increasing radiology resident interest and participation in NIR should ensure a steady influx of radiologists into the field, continuing the strong tradition of radiology participation, leadership, and innovation in NIR.

JOURNAL CLUB: Longitudinal Qualitative Characterization of MRI Features After Laser Interstitial Thermal Therapy in Drug-Resistant Epilepsy.

OBJECTIVE: Laser interstitial thermal therapy (LITT), a method for ablating brain tissue under real-time MR thermometry, has been used more frequently in recent years to treat nonmalignant lesions. The purpose of this study is to longitudinally characterize MRI features after LITT in patients with drug-resistant epilepsy, primarily in the setting of mesial temporal sclerosis. MATERIALS AND METHODS: MR images from 23 consecutive patients who underwent LITT were retrospectively reviewed. All patients had images obtained immediately after the ablation. Multiple patients had follow-up imaging at various time points after treatment, from postoperative days 7 through 1539. A total of 54 MRI studies were reviewed. RESULTS: Immediately after LITT, MR images showed a ring-enhancing lesion at the ablation site with minimal surrounding edema. Seven images showed increased enhancement of the ipsilateral choroid plexus. Images in the subacute phase showed a mild increase in edema with similar enhancement. Images in the transitional phase showed a decrease in edema with variable enhancement. Images in the chronic phase showed minimal gliosis with or without cavity formation or cavity formation alone, with either decreased or no enhancement. CONCLUSION: This report describes the time course of the imaging findings after LITT for drug-resistant epilepsy. The typical stages include rim-enhancing lesion with minimal edema, followed by an increase in edema, to eventual gliosis and nonenhancing cavity formation. Radiologists need to be familiar with the postablation findings to minimize misdiagnosis and prevent unnecessary workup.

Lumbar paraganglioma.

Spinal paragangliomas (SP) are benign and overall rare extra-adrenal neuroendocrine tumors often diagnosed during workup for lower back pain. Complete surgical resection achieves both symptomatic relief and cure. We present a 32-year-old man with a longstanding history of lumbago and bilateral lower extremity pain found to have a lumbar paraganglioma at the level of the L3 vertebrae. The clinical, histopathological, and radiological characteristics are described, including the rare finding of superficial siderosis on MRI of the brain. A laminectomy with microscopic dissection of the intradural mass achieved complete debulking without evidence of residual tumor. Excellent prognosis can be achieved with complete surgical resection of SP without the need for adjuvant therapy. Therefore, care should be taken to distinguish these spinal tumors from those that appear similar but are more aggressive. As such, the radiological finding of superficial siderosis should raise the suspicion for SP when a vascular intradural extramedullary spinal tumor is observed.

Novel delivery strategies for glioblastoma.

Brain tumors--particularly glioblastoma multiforme--pose an important public health problem in the United States. Despite surgical and medical advances, the prognosis for patients with malignant gliomas remains grim: current therapy is insufficient with nearly universal recurrence. A major reason for this failure is the difficulty of delivering therapeutic agents to the brain: better delivery approaches are needed to improve treatment. In this article, we summarize recent progress in drug delivery to the brain, with an emphasis on convection-enhanced delivery of nanocarriers. We examine the potential of new delivery methods to permit novel drug- and gene-based therapies that target brain cancer stem cells and discuss the use of nanomaterials for imaging of tumors and drug delivery.