Longitudinal radiological follow-up of individual level non-ischemic cerebral enhancing lesions following endovascular aneurysm treatment.

BACKGROUND: Non-ischemic cerebral enhancing (NICE) lesions following aneurysm endovascular therapy are exceptionally rare, with unknown longitudinal evolution. OBJECTIVE: To evaluate the radiological behavior of individual NICE lesions over time. METHODS: Patients included in a retrospective national multicentric inception cohort were analyzed. NICE lesions were defined, using MRI, as delayed onset punctate, nodular, or annular foci enhancements with peri-lesion edema, distributed in the vascular territory of the aneurysm treatment, with no other confounding disease. Lesion burden and the longitudinal behavior of individual lesions were assessed. RESULTS: Twenty-two patients were included, with a median initial lesion burden of 36 (IQR 17-54) on the first MRI scan. Of the 22 patients with at least one follow-up MRI scan, 16 (73%) had new lesions occurring mainly within the first 200 weeks after the date of the procedure. The median number of new lesions per MRI was 6 (IQR 2-16). Among the same 22 patients, 7 (32%) had recurrent lesions. The median persistent enhancement of a NICE lesion was 13 weeks (IQR 6-30). No factor was predictive of early regression of enhancement activity with lesion regression kinetics mainly being patient-dependent. CONCLUSIONS: The behavior of individual NICE lesions was found to be highly variable with an overall patient-dependent regression velocity.

Antithrombotic therapies for neurointerventional surgery: a 2021 French comprehensive national survey.

BACKGROUND: Neurointerventionists lack guidelines for the use of antithrombotic therapies in their clinical practice; consequently, there is likely to be significant heterogeneity in antithrombotic use between centers. Through a nationwide survey, we aimed to obtain an exhaustive cross-sectional overview of antithrombotic use in neurointerventional procedures in France. METHODS: In April 2021, French neurointerventional surgery centers were invited to participate in a nationwide 51-question survey disseminated through an active trainee-led research collaborative network (the JENI-RC). RESULTS: All 40 centers answered the survey. Fifty-one percent of centers reported using ticagrelor and 43% used clopidogrel as premedication before intracranial stenting. For flow diversion treatment, dual antiplatelet therapy was maintained for 3 or 6 months in 39% and 53% of centers, respectively, and aspirin was prescribed for 12 months or more than 12 months in 63% and 26% of centers, respectively. For unruptured aneurysms, the most common heparin bolus dose was 50 IU/kg (59%), and only 35% of centers monitored heparin activity for dose adjustment. Tirofiban was used in 64% of centers to treat thromboembolic complications. Fifteen percent of these comprehensive stroke centers reported using tenecteplase to treat acute ischemic strokes. Cangrelor appeared as an emergent drug in specific indications. CONCLUSION: This nationwide survey highlights the important heterogeneity in clinical practices across centers. There is a pressing need for trials and guidelines to further evaluate and harmonize antithrombotic regimens in the neurointerventional field.

Non-ischemic cerebral enhancing lesions after intracranial aneurysm endovascular repair: a retrospective French national registry.

BACKGROUND: Non-ischemic cerebral enhancing (NICE) lesions are exceptionally rare following aneurysm endovascular therapy (EVT). OBJECTIVE: To investigate the presenting features and longitudinal follow-up of patients with NICE lesions following aneurysm EVT. METHODS: Patients included in a retrospective national multicentre inception cohort were analysed. NICE lesions were defined, using MRI, as delayed onset punctate, nodular or annular foci enhancements with peri-lesion edema, distributed in the vascular territory of the aneurysm EVT, with no other confounding disease. RESULTS: From a pool of 58 815 aneurysm endovascular treatment procedures during the study sampling period (2006-2019), 21/37 centres identified 31 patients with 32 aneurysms of the anterior circulation who developed NICE lesions (mean age 45±10 years). Mean delay to diagnosis was 5±9 months, with onset occurring a month or less after the index EVT procedure in 10 out of 31 patients (32%). NICE lesions were symptomatic at time of onset in 23 of 31 patients (74%). After a mean follow-up of 25±26 months, 25 patients (81%) were asymptomatic or minimally symptomatic without disability (modified Rankin Scale (mRS) score 0-1) at last follow-up while 4 (13%) presented with mild disability (mRS score 2). Clinical follow-up data were unavailable for two patients. Follow-up MRI (available in 27 patients; mean time interval after onset of 22±22 months) demonstrated persistent enhancement in 71% of cases. CONCLUSIONS: The clinical spectrum of NICE lesions following aneurysm EVT therapy spans a wide range of neurological symptoms. Clinical course is most commonly benign, although persistent long-term enhancement is frequent.

Rate of Rebleed and Retreatment of Previously Treated Intracranial Aneurysms.

BACKGROUND: Intracranial aneurysms (IAs) can be treated through endovascular treatment (EVT) or microsurgery (MS). Treated IAs can recanalize, which can lead to rupture or retreatment. OBJECTIVE: The aim of our study was to evaluate the natural history of previously treated IA, by evaluating the risk of rupture and the risk of retreatment. METHODS: All patients treated for an IA between 2007 and 2017 in 4 hospitals were included. The rate of (recurrent) hemorrhage and the rate of prophylactic retreatment were retrospectively evaluated. Kaplan-Meier survival analysis with log-rank tests was used to compare the rates of rupture or retreatment. Patients with ruptured and unruptured aneurysms were separated, and we compared the risk of retreatment between EVT and the surgical treatment. RESULTS: A total of 4997 IAs were included in the study, corresponding to 20,489 patient-years. Overall, 28 (0.6%) aneurysms that had been previously treated demonstrated hemorrhage. Moreover, 237 (4.7%) aneurysms were retreated for recanalization without hemorrhage. The rate of retreatment was higher in the EVT-treated IAs as compared with the MS-treated IAs (LogRank: P < 0.0001) and higher in the previously ruptured IAs versus unruptured IAs (LogRank: P < 0.0001). However, the rate of posttreatment hemorrhage/IA rupture was similar for both groups. CONCLUSIONS: The rate of IA retreatment is low; however, the rate of hemorrhage/rupture from treated IAs is even lower. A higher rate of retreatment was noted in EVT-treated IAs versus MS-treated IAs and in ruptured IAs versus unruptured IAs; however, the rate of hemorrhage or rerupture was comparable between the groups.

Why We Should Still Treat by Neurosurgery Patients With Cushing Disease and a Normal or Inconclusive Pituitary MRI.

CONTEXT: In patients with Cushing disease (CD) and a typical image of adenoma at MRI, transsphenoidal surgery is consensual. However, when MRI is inconclusive or normal, some authors now advocate medical treatment instead. The implicit assumption is that modern MRI should miss only very small microadenomas that are too difficult to visualize at surgery. OBJECTIVE: To analyze the evolution with time of the performances of MRI and the outcomes of surgery in patients with CD with a typical image of adenoma vs an inconclusive or normal MRI. DESIGN AND PATIENTS: Retrospective single center study of 195 patients with CD treated by transsphenoidal surgery between 1992 and 2018, using first a translabial microscopic and then a transnasal endoscopic approach. Patients with inconclusive or normal MRI were explored by bilateral inferior petrosal sinus sampling. Four MRI groups were defined: microadenomas (n = 89), macroadenomas (n = 18), or MRI either inconclusive (n = 44) or normal (n = 44). RESULTS: The proportion of inconclusive/normal MRI decreased with time, from 60% (21/35) in 1992 to 1996 to 27% (14/51) in 2012 to 2018 (P = 0.037). In the four MRI groups, the per-operatory adenoma visualization rate was only slightly lower when MRI was normal (95%, 100%, 86%, 79%; P = 0.012) and postoperative remission rates were not different (85%, 94%, 73%, 75%; P = 0.11). CONCLUSION: The diagnostic performances of MRI have improved but remain inferior to the eye of an expert neurosurgeon, best assisted by endoscopy. We propose that patients with CD and an inconclusive/normal MRI be addressed by an expert neurosurgeon for transsphenoidal surgery rather than being treated medically.

Which Protocol for Milrinone to Treat Cerebral Vasospasm Associated With Subarachnoid Hemorrhage?

BACKGROUND: Milrinone has emerged as an option to treat delayed cerebral ischemia after subarachnoid hemorrhage. However, substantial variation exists in the administration of this drug. We retrospectively assessed the effectiveness of 2 protocols in patients with angiographically proven cerebral vasospasm. METHODS: During 2 successive periods, milrinone was administered using either a combination of intra-arterial milrinone infusion followed by intravenous administration until day 14 after initial bleeding (IA+IV protocol), or a continuous intravenous milrinone infusion for at least 7 days (IV protocol). The primary endpoint was the reversion rate of vasospastic arterial segments following the first IA infusion of milrinone (IA+IV protocol) compared with the reversion rate during the first week of IV infusion (IV protocol). RESULTS: There were 24 and 77 consecutive patients in IA+IV and IV protocols, respectively. The reversion rate was comparable between the 2 protocols: 71% (95% confidence interval [CI], 59%-83%) in the IA+IV protocol versus 64% (95% CI, 58%-71%) in the IV protocol (P=0.36). Rescue procedures for persistence or recurrence of vasospasm, that is, mechanical angioplasty and/or IA milrinone infusion, were similar between the 2 protocols. Patients with a good neurological outcome at 1 year, that is, modified Rankin Scale scores 0-2, were comparable between the 2 protocols. Side effects of milrinone were uncommon and equally distributed within the 2 protocols. CONCLUSIONS: These findings indicate that a continuous IV infusion of milrinone was as efficient as combined IA+IV infusion and suggest that this modality could be considered as a first easy-to-use option to treat patients with CVS.

Facet joint syndrome: from diagnosis to interventional management.

Low back pain (LBP) is the most common pain syndrome, and is an enormous burden and cost generator for society. Lumbar facet joints (FJ) constitute a common source of pain, accounting for 15-45% of LBP. Facet joint degenerative osteoarthritis is the most frequent form of facet joint pain. History and physical examination may suggest but not confirm facet joint syndrome. Although imaging (radiographs, MRI, CT, SPECT) for back pain syndrome is very commonly performed, there are no effective correlations between clinical symptoms and degenerative spinal changes. Diagnostic positive facet joint block can indicate facet joints as the source of chronic spinal pain. These patients may benefit from specific interventions to eliminate facet joint pain such as neurolysis, by radiofrequency or cryoablation. The purpose of this review is to describe the anatomy, epidemiology, clinical presentation, and radiologic findings of facet joint syndrome. Specific interventional facet joint management will also be described in detail. TEACHING POINTS: • Lumbar facet joints constitute a common source of pain accounting of 15-45%. • Facet arthrosis is the most frequent form of facet pathology. • There are no effective correlations between clinical symptoms, physical examination and degenerative spinal changes. • Diagnostic positive facet joint block can indicate facet joints as the source of pain. • After selection processing, patients may benefit from facet joint neurolysis, notably by radiofrequency or cryoablation.

Greater occipital nerve MR tractography: Feasibility and anatomical considerations.

BACKGROUND AND PURPOSE: To assess the feasibility of greater occipital nerve (GON) tractography using a fully automated tractography technique on the whole-neck volume, in comparison with anatomical knowledge. METHODS: Healthy subjects were consecutively included in this study if they had no history or symptoms of headache or brain disorder. A 3T MRI scanner with a 32 channel head coil was used. The following parameters for Diffusion Weighed (DWI) were used: b value of 1000 s/mm2, 32 directions, acquired voxel size: 2 mm isotropic. High-Order tractography with the Constrained Spherical Deconvolution (CSD) model was generated. Track-Weighted Imaging (TWI) maps were generated with MRTrix. Two radiologists performed blind evaluations of the GON pathways on TWI maps. RESULTS: A total of 20 healthy subjects were included (12 males and eight females, mean age 53.8 years old). In comparison with anatomical atlas, GON complete visualization (from C1-C2 origin to muscular emergence) was possible in 18 out of 20 healthy subjects. In two cases, GON was not visible in the cervical spine foramen. CONCLUSION: Tractography through TWI is a feasible technique to accurately depict GON. This technique may appear as a promising technique for therapeutic management of patients with occipital neuralgia.

Potentially stress-induced acute splanchnic segmental arterial mediolysis with a favorable spontaneous outcome.

A 62-year-old woman presented with hemithoracic anesthesia and acute abdominal pain following a violent psychological stress. Magnetic resonance imaging showed a thoracic hematoma with arachnoiditis of the spinal cord. Tomography revealed a typical aspect of segmental arterial mediolysis with multiple aneurysms and stenoses of the splanchnic arteries, confirmed by abdominal arteriography. There was no argument for hereditary, traumatic, atherosclerotic, infectious, or inflammatory arterial disease. Segmental arterial mediolysis was diagnosed on the basis of the radiologic data and probably involved both medullary and splanchnic arteries. The patient spontaneously recovered and was in good health 18 months later.

Cerebral imaging in infectious endocarditis: A clinical study.

BACKGROUND: Because neurological failure is the most frequent extra-cardiac complication in Infectious Endocarditis (IE), a brain computerised tomography (CT) scan is usually performed. The benefits of magnetic resonance imaging (MRI) have not been clearly established. This study aims to clarify the prevalence and type of cerebral lesions in IE detected using MRI and to compare them with those detected using CT scans. METHODS: In the Grenoble University Hospital, patients diagnosed with definite or possible endocarditis according to Duke's criteria were screened from 2010-2012. Brain CT and MRI were performed as soon as possible after diagnosis. RESULTS: Of the 62 patients with IE who underwent at least one cerebral imaging within 3 weeks of diagnosis, Streptococcus (29) and Staphylococcus (14) were the main micro-organisms present. Twenty-eight (45%) patients underwent cardiac surgery. Eight (13%) died before discharge. Twenty (32%) had neurological symptoms. A brain CT-scan was performed on 53 (85%) patients and a MRI was performed on 43 (69%) patients. CT was pathological in 26 (49%) patients, whereas 32 (74%) MRI demonstrated abnormalities. The MRI lesions were classified as follows: ischaemia (48%), microbleeds (34%), haemorrhages (16%), abscesses (9%) and microbial aneurysms (4%). Of the 37 patients who underwent both MRI and CT examinations, ischaemia (48% vs 35%) and microbleeds (34%) demonstrated the difference between the two imaging methods. CONCLUSION: Through the early diagnosis of cerebral damage, even in asymptomatic cases, MRI may have a role in the IE management, influence any surgical decision and assist in prognosis assessment.

Reduced CMRO2 and cerebrovascular reserve in patients with severe intracranial arterial stenosis: a combined multiparametric qBOLD oxygenation and BOLD fMRI study.

Multiparametric quantitative blood oxygenation level dependent (mqBOLD) magnetic resonance Imaging (MRI) approach allows mapping tissular oxygen saturation (StO2 ) and cerebral metabolic rate of oxygen (CMRO2 ). To identify hemodynamic alteration related to severe intracranial arterial stenosis (SIAS), functional MRI of cerebrovascular reserve (CVR BOLD fMRI) to hypercapnia has been proposed. Diffusion imaging suggests chronic low grade ischemia in patients with impaired CVR. The aim of the present study was to evaluate how oxygen parameters (StO2 and CMRO2 ), assessed with mqBOLD approach, correlate with CVR in patients (n = 12) with SIAS and without arterial occlusion. The perfusion (dynamic susceptibility contrast), oxygenation, and CVR were compared. The MRI protocol conducted at 3T lasted approximately 1 h. Regions of interest measures on maps were delineated on segmented gray matter (GM) of middle cerebral artery territories. We have shown that decreased CVR is spatially associated with decreased CMRO2 in GM of patients with SIAS. Further, the degree of ipsilateral CVR reduction was well-correlated with the amplitude of the CMRO2 deficit. The altered CMRO2 suggests the presence of a moderate ischemia explained by both a decrease in perfusion and in CVR. CVR and mqBOLD method may be helpful in the selection of patients with SIAS to advocate for medical therapy or percutaneous transluminal angioplasty-stenting.

Normalization of cerebral vasoreactivity using BOLD MRI after intravascular stenting.

BACKGROUND AND PURPOSE: Intravascular angioplasty and stenting of intracranial arterial stenosis provided controversial results. Besides the expertise of the practitioners, the selection of the patients remains challenging. BOLD MRI of the cerebral vasoreactivity (BOLD MRI CVR) to hypercapnia provides reproducible maps of the entire brain of the vascular reserve, and could be helpful to assess the best therapeutic strategy. CASE HISTORY: We report the case of a 63-year-old woman referred for a severe stenosis of the proximal portion of the left middle cerebral artery, revealed by a lenticulostriate and precentral infarction. Despite an aggressive medical treatment during 5 months, the occurrence of iterative transient ischemic attacks motivated intravascular stenting. Functional MRI of the vasoreactivity to hypercapnia using both Blood Oxygen Level Dependent (BOLD) and arterial spin labeling sequences showed normal basal perfusion and impaired vasoreactivity in the left middle cerebral artery territory. Three months after stenting, the BOLD MRI CVR showed vasoreactivity normalization. Since, the patient remains free of ischemic disorders one year after stenting. CONCLUSION: BOLD MRI of the CVR to hypercapnia may be helpful to optimize the treatment of patients with intracranial arterial stenosis, and could be performed in future therapeutic trials.

Perfusion magnetic resonance imaging: comparison of semiologic characteristics in first-pass perfusion of brain tumors at 1.5 and 3 Tesla.

OBJECTIVES: To investigate whether using 3 Tesla (T) instead of 1.5T modifies the data obtained from first-pass perfusion in relation to the quantitative values of cerebral blood volume (CBV) and estimation of micro-vascular leakage (MVL). To describe the differences in data in the setting of neuro-oncology cases and propose explanations based on the discrepancies. MATERIAL AND METHODS: In total, 21 patients presenting an intracranial intra-axial space-occupying lesion underwent two MRI explorations, one at 1.5T and another at 3T, including a first-pass perfusion sequence using sequence parameters, defined by the manufacturer Philips. Using a gamma variate analysis, the ratio of cerebral blood volume (rCBV) in tumor, peritumoral, and normal appearing areas was first assessed. After a global analysis, a subgroup analysis was conducted according to the rCBV value measured at 1.5T. Lastly, MVL was assessed based on the signal intensity recorded above baseline after the passage of the contrast medium. RESULTS: At 3T, compared to 1.5T data that are currently the reference, rCBV was constantly and significantly over-evaluated (P=0.0041 for all tumors), while MVL was constantly and significantly under-evaluated (P<0.0001 for all tumors). DISCUSSION: The increase in magnetic field strength along with the associated modifications in sequence parameters led to variations in rCBV and MVL when measured using first-pass perfusion. In some cases, such as lymphomas, there was a loss of diagnostic information. It therefore appears necessary to optimize the acquisition parameters to allow for radiologic semiology to become relevant again.

Recovery of third nerve palsy after endovascular treatment of posterior communicating artery aneurysms.

BACKGROUND: High recovery rates after endovascular treatment of TNP-inducing PcomA aneurysms have been reported. However, only few and often small series were reported. The results of the 2 available comparative studies are controversial. Choosing clipping or coiling as treatment modality nowadays is still a matter of debate. We report the ophthalmologic outcome of 20 consecutive patients treated by coiling of TNP-inducing PcomA aneurysms. METHODS: The third nerve function before and after endovascular treatment was assessed and studied retrospectively. Predictive recovery factors known from literature including treatment timing, the degree of preoperative nerve deficit, the association with SAH, coil type, cardiovascular risk factors, and age were analyzed. A review of the literature was performed. RESULTS: Eight patients presented initially with complete nerve palsy (40%) and 12 with partial palsy (60%). Eleven patients had SAH. The mean aneurysm size was 7.14 mm; there were no partially thrombosed aneurysms. Of the 20 patients, 19 (95%) recovered. Recovery was complete in 7 patients (35%), partial in 12 patients (60%), and 1 patient remained unchanged (5%). The mean duration of follow-up was 24.7 months. One patient with complete TNP recovered completely after 5 months of coiling. One case of late complete nerve recovery was observed at 20 months. No cases of reoccurrences or worsening of the partial TNP were observed, including patients who developed recanalization of the aneurysmal sac. Clinical presentation with SAH and early management were statistically significant factors that positively influenced nerve recovery (P = .006549 and P = .015718, respectively). Initial partial TNP seems to influence recovery but did not reach significance (P = .079899). CONCLUSION: Coiling of PcomA aneurysms is associated with high rates of third nerve function recovery. Complete recovery can be expected even after long periods and in cases of initial complete nerve palsy. The early treatment and the association with SAH seem to promote the nerve recovery.

Stenting of symptomatic basilar and vertebral artery stenosis in patients resistant to optimal medical prevention: the lyon stroke unit experience.

UNLABELLED: Intracranial angioplasty stenting may be an efficient therapy in patients with intracranial atherosclerotic symptomatic vertebrobasilar artery stenosis unresponsive to optimal medical therapy. We present our experience in this setting. RESULTS: The study included 12 cases (8 men, 4 women), with an age range of 43-78 years (mean 62.6 years). Intracranial stenosis that resulted in qualifying stroke or transient ischemic attack involved the vertebral artery (n = 4), lower basilar artery (n = 1) and mid basilar artery (n = 5). Tandem stenosis included the intracranial vertebral artery and basilar artery (n = 1) and both intracranial vertebral arteries (n = 1). The degree of stenosis ranged between 70 and 90% in the basilar and vertebral arteries. Angioplasty + stenting was performed in all lesions. A successful procedure resulting in 30% of residual stenosis was found in 14 vessels. A periprocedural adverse event occurred in 1 case and was related to a brain hemorrhage. The mean patient follow-up was 15 +/- 3 months; 10 patients remained symptom free. All patients underwent a percutaneous endovascular balloon angioplasty and stent placement. CONCLUSIONS: This study supports the safety and the potential efficiency of stent-assisted angioplasty in patients resistant to optimal prevention. Randomized larger prospective trials are needed to confirm the benefit of this approach.

Dural arteriovenous fistula of the anterior fossa treated with the Onyx liquid embolic system and the Sonic microcatheter.

We report an association of new technologies (the Onyx liquid embolic system and the Sonic microcatheter) for transarterial embolization through the anterior branch of the middle meningeal artery of a dural arteriovenous fistula (DAVF) of the anterior fossa. The place of endovascular treatment in anterior fossa DAVFs is reviewed, and its clinical implications discussed in light of the case of a patient whose management was modified by this association of new technologies.

Exogenous lipoid pneumonia with unusual CT pattern and FDG positron emission tomography scan findings.

We report a case of an exogenous lipoid pneumonia that appeared as a spiculated calcified mass on CT scan in which a positron emission tomography (PET) scan was performed before histological analysis. The F-18 fluoro-deoxy-D-glucose (FDG) PET showed a pattern highly suggestive of malignancy which, to our knowledge, has not yet been described. Similar to inflammatory and infectious lung diseases, lipoid pneumonia may be a false-positive case of F-18 FDG uptake.