Extra-axial cranial nerve enhancement: a pattern-based approach.

Cranial nerve enhancement is a common and challenging MRI finding that requires a meticulous and systematic evaluation to identify the correct diagnosis. Literature mainly describes the various pathologies with the associated clinic-radiological characteristics, while the radiologist often needs a reverse approach that starts from the radiological findings to reach the diagnosis. Therefore, our aim is to provide a new and practical pattern-based approach to cranial nerve enhancement, which starts from the radiological findings and follows pattern-driven pipelines to navigate through multiple differential diagnoses, guiding the radiologist to reach the proper diagnosis. Firstly, we reviewed the literature and identified four patterns to categorize the main pathologies presenting with cranial nerve enhancement: unilateral linear pattern, bilateral linear pattern, unilateral thickened pattern, and bilateral thickened pattern. For each pattern, we describe the underlying pathogenic origin, and the main radiological features are displayed through high-quality MRI images and illustrative panels. A suggested MRI protocol for studying cranial nerve enhancement is also provided. In conclusion, our approach for cranial nerve enhancement aims to be an easy tool immediately applicable to clinical practice for converting challenging findings into specific pathological patterns.

An epidural arteriovenous fistula studied with time-resolved imaging of contrast kinetics (TRICKS) sequence.

We describe the use of time-resolved MR angiography in the diagnosis of cervical epidural arteriovenous fistula before final diagnosis and embolization was achieved by digital subtraction angiography. A 42-year-old woman was referred to us because of headache and dizziness, in addition to radiculopathy of the right superior limb. Angiographic examinations documented a direct high-flow arteriovenous fistula between the right vertebral artery and the cervical epidural venous plexus. The point of fistula was located in the upper third of the cervical segment below the C2 arch. Time-resolved MR angiography might add important information in case of suspected arteriovenous fistula, helpful both for therapeutic decisions and follow-up.

Wingspan experience in the treatment of symptomatic intracranial atherosclerotic disease after antithrombotic failure.

BACKGROUND AND PURPOSE: Intracranial stenting with the Wingspan system has been used as a revascularization strategy in symptomatic patients with intracranial atherosclerotic disease (ICAD). The latest results of the Stenting versus Aggressive Medical Therapy for Intracranial Artery Stenosis (SAMMPRIS) trial challenge this approach. Our experience in the treatment of symptomatic ICAD with the Wingspan system is reported. MATERIALS AND METHODS: Patients who underwent stenting for symptomatic ICAD were included in the analysis. Demographic data, periprocedural complications, long term radiological and clinical outcomes are reported. RESULTS: 46 lesions were treated in 45 patients. 13 patients (29%) presented with a transient ischemic attack and 32 (71%) with a stroke. 43 patients (95.5%) failed antithrombotic therapy at presentation. One (2%) symptomatic periprocedural (24 h) complication occurred. The 30 day incidence of stroke and vascular death was 6.6%--a fatal hemorrhagic stroke and two non-fatal hemorrhagic strokes. In-stent stenosis (≥50%) was seen in nine (42.8%) lesions, two were symptomatic. CONCLUSIONS: This cohort of patients with symptomatic ICAD who failed antithrombotic medications benefited from angioplasty and stenting with the Wingspan system.

Postpartum cerebral angiopathy treated with intra-arterial nicardipine and intravenous immunoglobulin.

Postpartum cerebral angiopathy (PCA) is a rare vasoconstriction syndrome that can lead to severe disability and death. The pathophysiology of PCA is unknown. A case of a 39-year-old woman who developed PCA 3 days after twin delivery is reported. She presented with right hemiparesis, aphasia and lethargy. Imaging studies demonstrated severe segmental narrowing of multiple cerebral arteries comprising the anterior and posterior circulations. She continued to deteriorate despite induced hypertension, immunosuppression, intravenous magnesium and oral nimodipine. Intra-arterial administration of nicardipine on three consecutive occasions reversed the angiographic vasospasm and led to symptom resolution. Definite improvement occurred after a 5 day course of intravenous immunoglobulin (IVIg). The patient described in this report developed recalcitrant PCA-induced vasospasm which resolved with endovascular administration of nicardipine and immunotherapy with IVIg.

Current indications and results of thrombolysis by intravenous recombinant tissue plasminogen activator.

A number of landmark trials have proven the efficacy of thrombolysis by intravenous recombinant tissue plasminogen activator in the acute phase of the ischemic stroke. Despite the recently extended time window of 4.5 hours, the number of people who are being treated in most centers is low. Several reasons seem to account for this, including poor recognition of symptoms, delays in emergency transport, low levels of public awareness, or age limits originally imposed by drug regulatory rules. Trials are ongoing to possibly extend the indications to the treatment. A major effort is to extend the time window by bridging the treatment with neuroprotective approaches, or by identifying subgroups that may particularly benefit from recanalization and reperfusion. Procedures using ultrasounds or alternative intravenous compounds are also being investigated with promising results.

Spinal arteriovenous malformation associated with spinal metameric syndrome: a treatable cause of long-term paraplegia?

Cutaneomeningospinal angiomatosis, or Cobb syndrome, is a rare metameric developmental disorder presenting as an extradural-intradural vascular malformation that involves bone, muscle, skin, spinal cord, and nerve roots. A 14-year-old girl with a red nevus involving the T6-9 dermatomes on the left side of her back presented with a 5-year history of bowel and bladder incontinence, paraplegia, and lower-extremity sensory loss. Magnetic resonance imaging demonstrated a hemangioma in the T-8 and T-9 vertebral bodies and a spinal cord AVM nidus extending from T-6 to T-9. The AVM was successfully embolized and the patient regained lower-extremity strength, ambulation, and normal sphincter functions after 5 years of having been wheelchair bound. The authors report the restoration of ambulation after endovascular embolization of a large spinal AVM in a patient with long-standing paraplegia due to Cobb syndrome.

Stroke prediction after transient ischemic attacks in patients admitted to a stroke unit.

BACKGROUND: Transient ischemic attacks (TIAs) bear a presumed high risk of early recurrence of stroke. Data in the literature, however, are inconsistent, as recurrence rates range from 9.5 to 20%, at 90 days. AIMS: The study was designed to determine the risk of stroke after TIA. METHODS: 94 consecutive patients referred to a Stroke Unit for TIA or minor stroke, within 24 h of symptom onset, were recruited. Eleven of the 94 patients (12%, 95% CI: 7-20%) had a relapse within 90 days. The relapse consisted of a TIA for 9 patients (10%, 95% CI: 5-17%), or of a stroke for 2 subjects (1%, 95% CI: 0-8%). More than a quarter of the relapses occurred within 1 week from the first TIA. ABCD(2), ABCD(2)-I and ABCD-E+ scores were similar among people with or without relapse. CONCLUSIONS: The data seem to confirm previous reports on the relatively low relapse rate for stroke, when TIA patients are promptly assisted in dedicated structures. The findings stress the potential benefit of early intervention in subjects with TIA.

Reduced insulin-induced phosphatidylinositol-3-kinase activation in peripheral blood mononuclear leucocytes from patients with Alzheimer's disease.

The epidemiological finding of an increased risk of dementia in patients with diabetes mellitus has raised the hypothesis that a dysfunction of the insulin receptors plays a role in the pathogenesis of Alzheimer's disease (AD). A possible link is suggested by the evidence that the insulin-stimulated phosphatidylinositol-3-kinase (PI-3-K)/phospho-Akt pathway negatively controls the glycogen synthase kinase-3beta. The activation of this enzyme mediates the hyperphosphorylation of the tau protein, a relevant step in the formation of the neurofibrillary tangles associated with AD. We hypothesized that the neurodegeneration associated with AD is related to an impairment of the intracellular signalling stimulated by insulin receptors. To test this hypothesis we assessed the PI-3-K/phospho-Akt pathway following in-vitro challenge with insulin in peripheral blood mononuclear cells from subjects with AD (n = 20) and controls (n = 20). We found that the stimulation of PI-3-K is blunted in patients with AD with respect to control. The reduction did not correlate with the extent of cognitive decline or with scores at neuropsychological tests exploring attention, memory, language or visuospatial abilities. The study supports the hypothesis that an impaired control of glycogen synthase kinase-3beta activity by insulin receptor-mediated signalling plays a role in the pathogenesis of AD, facilitating tau protein phosphorylation and neurofibrillary tangle formation.