Clinical and Anatomical Characteristics of Perforator Aneurysms of the Posterior Cerebral Artery: A Single-Center Experience.

INTRODUCTION: Posterior cerebral artery (PCA) aneurysms represent up to 1% of all cerebral aneurysms. P1-P2 perforator aneurysms are thought to be even less prevalent and often require complex treatment strategies due to their anatomical and morphological characteristics, with risk of a perforator infarct. We studied the treatment of P1-P2 perforator aneurysms in a single-center cohort from a high-volume tertiary center, reporting clinical and anatomical characteristics, treatment strategies, and outcomes. METHODS: A retrospective analysis of adult patients with a P1-P2 perforator aneurysm who presented at our institution between January 2000 and January 2023 was performed. The patients were analyzed for demographics, clinical presentation, imaging findings, treatment techniques, outcomes, and complications. Subgroup analyses between ruptured versus non-ruptured cases were included. RESULTS: Out of 2733 patients with a cerebral aneurysm, 14 patients (0.5%) presented with a P1-P2 perforator aneurysm. All six patients with a ruptured aneurysm were treated by endovascular coiling, of whom one patient (16.7%) required surgical clipping of a recurrence. One out of eight (12.5%) patients with unruptured aneurysms was treated by surgical clipping. P1-P2 perforator aneurysms predominantly affected middle-aged individuals (median 59.5 years), with 10/14 (71.4%) being female. Endovascular coiling was the primary treatment modality overall, yielding favorable technical outcomes, however, it was complicated by a perforator infarct in two patients (33.3%) without new permanent morbidity or mortality secondary to treatment. CONCLUSIONS: P1-P2 perforator aneurysms are a rare subtype of intracranial aneurysm. Endovascular coiling could present an effective treatment modality; however, care should be taken for ischemic complications in the dependent perforator territory. Larger studies are required to provide more insights.

Periventricular nodular heterotopia associated with a "transmantle band sign" in patients with epilepsy.

OBJECTIVE: Previous studies using advanced magnetic resonance imaging (MRI) techniques have documented abnormal transmantle bands connecting ectopic nodules to overlying cortex in patients with periventricular nodular heterotopia (PNH). We describe a similar finding using conventional MRI techniques. METHODS: Patients were identified by means of a full-text search of radiological reports. All scanning was performed using conventional sequences at 3 Tesla (3T). Scans were reviewed by three neuroradiologists, and we characterized imaging features based on type of PNH and cortical irregularities associated with the transmantle band. RESULTS: A total 57 PNH patients were reviewed, of whom 41 demonstrated a "transmantle band" connecting the nodule to the overlying cortex. One or more periventricular heterotopic nodules was present in all 41 patients-this was bilateral in 29 of 41 (71%) and unilateral in the remaining 29%. In many cases there was more than one such band, and in some cases this band was nodular. In 19 of the cases, the cortex to which the band connected was abnormal, showing thinning in 4 cases, thickening in 5 cases, and polymicrogyria in another 10. SIGNIFICANCE: The transmantle band can be seen frequently in both unilateral and bilateral cases of PNH and can be visualized with conventional 3T MRI sequences. The band highlights the underlying neuronal migration issues at play in the pathogenesis of this disorder, but its underlying role in the complex, patient-specific epileptogenic networks in this cohort has yet to be determined and warrants further investigation.

The presence of pachymeningeal hyperintensity on non-contrast flair imaging in patients with spontaneous intracranial hypotension.

PURPOSE: Traditionally, in the work-up of patients for spontaneous intracranial hypotension, T1 post-contrast imaging is performed in order to assess for pachymeningeal enhancement. The aim of this study is to assess whether pachymeningeal hyperintensity can be identified on a non-contrast FLAIR sequence in these patients as a surrogate sign for pachymeningeal enhancement. METHODS: The patient cohort was identified from a prospectively maintained database of patients with a clinical diagnosis of intracranial hypotension. Patients who had both a post-contrast T1 sequence brain as well as non-contrast FLAR sequence of the brain were reviewed. Imaging was retrospectively reviewed by three independent neuroradiologists. Each study was assessed for the presence or absence of pachymeningeal hyperintensity on the FLAIR sequence. RESULTS: From January 2010 to July 2022, 177 patients were diagnosed with spontaneous intracranial hypotension. In total, 121 were excluded as post-contrast imaging was not performed during their work-up. Twenty-four were excluded as the FLAIR sequence was performed after administration of contrast. Six were excluded as there was no pachymeningeal thickening present on T1 post-contrast imaging, although there were other signs of intracranial hypotension. The study group therefore consisted of 26 patients. Pachymeningeal thickening was correctly identified on the non-contrast FLAIR sequence in all patients (100%). CONCLUSION: Where present, diffuse pachymeningeal hyperintensity can be accurately identified on a non-contrast FLAIR sequence in patients with spontaneous intracranial hypotension. This potentially obviates the need for gadolinium base contrast agents in the work-up of these patients.

Intradural spinal varix: the "doughnut" sign on T 2 weighted MR and confirmation with gadolinium-enhanced arterial and blood pool MR angiography.

Intradural spinal varices are rare lesions, with only three cases being previously reported in the literature. Previously described patients underwent MRI for non-specific low back pain and radiculopathy and were found to have an intradural lesion adjacent to the cauda equina, mimicking a nerve sheath tumour or ependymoma. Consideration of an intradural varix in the differential diagnosis of an intradural extramedullary spinal lesion is necessary to guide appropriate management. We report a case of an intradural spinal varix diagnosed with first-pass arterial and blood pool phase gadolinium-enhanced auto-triggered elliptic centric-ordered MR angiography. Digital subtraction angiography confirmed that there was no shunt but failed to demonstrate the varix. We reviewed the existing literature to look for common clinical and imaging features.

Intra-Arterial Therapy and Post-Treatment Infarct Volumes: Insights From the ESCAPE Randomized Controlled Trial.

BACKGROUND AND PURPOSE: The goal of reperfusion therapy in acute ischemic stroke is to limit brain infarction. The objective of this study was to investigate whether the beneficial effect of endovascular treatment on functional outcome could be explained by a reduction in post-treatment infarct volume. METHODS: The Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT to Recanalization Times (ESCAPE) trial was a multicenter randomized open-label trial with blinded outcome evaluation. Among 315 enrolled subjects (endovascular treatment n=165; control n=150), 314 subject's infarct volumes at 24 to 48 hours on magnetic resonance imaging (n=254) or computed tomography (n=60) were measured. Post-treatment infarct volumes were compared by treatment assignment and recanalization/reperfusion status. Appropriate statistical models were used to assess relationship between baseline clinical and imaging variables, post-treatment infarct volume, and functional status at 90 days (modified Rankin Scale). RESULTS: Median post-treatment infarct volume in all subjects was 21 mL (interquartile range =65 mL), in the intervention arm, 15.5 mL (interquartile range =41.5 mL), and in the control arm, 33.5 mL (interquartile range =84 mL; P<0.01). Baseline National Institute of Health Stroke Scale (P<0.01), site of occlusion (P<0.01), baseline noncontrast computed tomographic scan Alberta Stroke Program Early CT score (ASPECTS) (P<0.01), and recanalization (P<0.01) were independently associated with post-treatment infarct volume, whereas age, sex, treatment type, intravenous alteplase, and time from onset to randomization were not (P>0.05). Post-treatment infarct volume (P<0.01) and delta National Institute of Health Stroke Scale (P<0.01) were independently associated with 90-day modified Rankin Scale, whereas laterality (left versus right) was not. CONCLUSIONS: These results support the primary results of the ESCAPE trial and show that the biological underpinning of the success of endovascular therapy is a reduction in infarct volume. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01778335.

Clinical course of untreated cerebral cavernous malformations: a meta-analysis of individual patient data.

BACKGROUND: Cerebral cavernous malformations (CCMs) can cause symptomatic intracranial haemorrhage (ICH), but the estimated risks are imprecise and predictors remain uncertain. We aimed to obtain precise estimates and predictors of the risk of ICH during untreated follow-up in an individual patient data meta-analysis. METHODS: We invited investigators of published cohorts of people aged at least 16 years, identified by a systematic review of Ovid MEDLINE and Embase from inception to April 30, 2015, to provide individual patient data on clinical course from CCM diagnosis until first CCM treatment or last available follow-up. We used survival analysis to estimate the 5-year risk of symptomatic ICH due to CCMs (primary outcome), multivariable Cox regression to identify baseline predictors of outcome, and random-effects models to pool estimates in a meta-analysis. FINDINGS: Among 1620 people in seven cohorts from six studies, 204 experienced ICH during 5197 person-years of follow-up (Kaplan-Meier estimated 5-year risk 15·8%, 95% CI 13·7-17·9). The primary outcome of ICH within 5 years of CCM diagnosis was associated with clinical presentation with ICH or new focal neurological deficit (FND) without brain imaging evidence of recent haemorrhage versus other modes of presentation (hazard ratio 5·6, 95% CI 3·2-9·7) and with brainstem CCM location versus other locations (4·4, 2·3-8·6), but age, sex, and CCM multiplicity did not add independent prognostic information. The 5-year estimated risk of ICH during untreated follow-up was 3·8% (95% CI 2·1-5·5) for 718 people with non-brainstem CCM presenting without ICH or FND, 8·0% (0·1-15·9) for 80 people with brainstem CCM presenting without ICH or FND, 18·4% (13·3-23·5) for 327 people with non-brainstem CCM presenting with ICH or FND, and 30·8% (26·3-35·2) for 495 people with brainstem CCM presenting with ICH or FND. INTERPRETATION: Mode of clinical presentation and CCM location are independently associated with ICH within 5 years of CCM diagnosis. These findings can inform decisions about CCM treatment. FUNDING: UK Medical Research Council, Chief Scientist Office of the Scottish Government, and UK Stroke Association.

Randomized assessment of rapid endovascular treatment of ischemic stroke.

BACKGROUND: Among patients with a proximal vessel occlusion in the anterior circulation, 60 to 80% of patients die within 90 days after stroke onset or do not regain functional independence despite alteplase treatment. We evaluated rapid endovascular treatment in addition to standard care in patients with acute ischemic stroke with a small infarct core, a proximal intracranial arterial occlusion, and moderate-to-good collateral circulation. METHODS: We randomly assigned participants to receive standard care (control group) or standard care plus endovascular treatment with the use of available thrombectomy devices (intervention group). Patients with a proximal intracranial occlusion in the anterior circulation were included up to 12 hours after symptom onset. Patients with a large infarct core or poor collateral circulation on computed tomography (CT) and CT angiography were excluded. Workflow times were measured against predetermined targets. The primary outcome was the score on the modified Rankin scale (range, 0 [no symptoms] to 6 [death]) at 90 days. A proportional odds model was used to calculate the common odds ratio as a measure of the likelihood that the intervention would lead to lower scores on the modified Rankin scale than would control care (shift analysis). RESULTS: The trial was stopped early because of efficacy. At 22 centers worldwide, 316 participants were enrolled, of whom 238 received intravenous alteplase (120 in the intervention group and 118 in the control group). In the intervention group, the median time from study CT of the head to first reperfusion was 84 minutes. The rate of functional independence (90-day modified Rankin score of 0 to 2) was increased with the intervention (53.0%, vs. 29.3% in the control group; P<0.001). The primary outcome favored the intervention (common odds ratio, 2.6; 95% confidence interval, 1.7 to 3.8; P<0.001), and the intervention was associated with reduced mortality (10.4%, vs. 19.0% in the control group; P=0.04). Symptomatic intracerebral hemorrhage occurred in 3.6% of participants in intervention group and 2.7% of participants in control group (P=0.75). CONCLUSIONS: Among patients with acute ischemic stroke with a proximal vessel occlusion, a small infarct core, and moderate-to-good collateral circulation, rapid endovascular treatment improved functional outcomes and reduced mortality. (Funded by Covidien and others; ESCAPE ClinicalTrials.gov number, NCT01778335.).

Natural history and management of basilar trunk artery aneurysms.

BACKGROUND AND PURPOSE: Basilar trunk aneurysms (BTAs), defined as aneurysms distal to the basilar origin and proximal to the origin of the superior cerebellar artery, are rare and challenging to manage. We describe the natural history and management in a consecutive series of BTAs. METHODS: Between 2000 and 2013, 2522 patients with 3238 aneurysms were referred to our institution for aneurysm management. A retrospective review of this database was conducted to identify all patients with BTAs. RESULTS: In total, 52 patients had a BTA. Mean age was 56 (SD±18) years. Median clinical follow-up was 33 (interquartile range, 8-86) months, and imaging follow-up was 26 (interquartile range, 2-80.5) months. BTAs were classified into 4 causal subtypes: acute dissecting aneurysms, segmental fusiform ectasia, mural bleeding ectasia, and saccular aneurysms. Multiple aneurysms were more frequently noticed among the 13 saccular aneurysms when compared with overall population (P=0.021). There was preponderance of segmental ectasia or mural bleeding ectasia (P=0.045) in patients presenting with transit ischemic attack/stroke or mass effect. Six patients with segmental and 4 with mural bleeding ectasia demonstrated increasing size of their aneurysm, with 2 having subarachnoid hemorrhage caused by aneurysm rupture. None of the fusiform aneurysms that remained stable bled. CONCLUSIONS: BTAs natural histories may differ depending on subtype of aneurysm. Saccular aneurysms likely represent an underlying predisposition to aneurysm development because more than half of these cases were associated with multiple intracranial aneurysms. Intervention should be considered in segmental ectasia and chronic dissecting aneurysms, which demonstrate increase in size over time as there is an increased risk of subarachnoid hemorrhage.

Endovascular treatment for Small Core and Anterior circulation Proximal occlusion with Emphasis on minimizing CT to recanalization times (ESCAPE) trial: methodology.

ESCAPE is a prospective, multicenter, randomized clinical trial that will enroll subjects with the following main inclusion criteria: less than 12 h from symptom onset, age > 18, baseline NIHSS >5, ASPECTS score of >5 and CTA evidence of carotid T/L or M1 segment MCA occlusion, and at least moderate collaterals by CTA. The trial will determine if endovascular treatment will result in higher rates of favorable outcome compared with standard medical therapy alone. Patient populations that are eligible include those receiving IV tPA, tPA ineligible and unwitnessed onset or wake up strokes with 12 h of last seen normal. The primary end-point, based on intention-to-treat criteria is the distribution of modified Rankin Scale scores at 90 days assessed using a proportional odds model. The projected maximum sample size is 500 subjects. Randomization is stratified under a minimization process using age, gender, baseline NIHSS, baseline ASPECTS (8-10 vs. 6-7), IV tPA treatment and occlusion location (ICA vs. MCA) as covariates. The study will have one formal interim analysis after 300 subjects have been accrued. Secondary end-points at 90 days include the following: mRS 0-1; mRS 0-2; Barthel 95-100, EuroQOL and a cognitive battery. Safety outcomes are symptomatic ICH, major bleeding, contrast nephropathy, total radiation dose, malignant MCA infarction, hemicraniectomy and mortality at 90 days.

Clinical characteristics and preferential location of intracranial mirror aneurysms: a comparison with non-mirror multiple and single aneurysms.

INTRODUCTION: The purpose of our study was to compare the clinical characteristics and preferential localization of aneurysms in three patient groups: single aneurysm, non-mirror multiple aneurysms, and mirror aneurysms. METHODS: We retrospectively reviewed the clinical and radiological data of 2223 consecutive patients harboring 3068 aneurysms registered at the Toronto Western Hospital between May 1994 and November 2010. The patients were divided into single, non-mirror multiple, or mirror aneurysm groups. Expected incidences of mirror aneurysms at each location were calculated on the basis of the single aneurysm incidences at each location. RESULTS: Patients with mirror aneurysms (n = 197) did not differ from patients with non-mirror multiple aneurysms (n = 392) in having female predominance (81.7 vs. 76.3 %) or a family history of intracranial aneurysm (20.5 vs. 17.6 %). When compared with expected incidences at each location, mirror aneurysms were more frequently found at the cavernous internal carotid artery (30 vs. 11.5 %) (p < 0.0001). Mirror aneurysms involving the posterior circulation were less frequent (6.7 %) than aneurysms in the single (19.6 %) or non-mirror multiple aneurysm groups (18.9 %) (p < 0.05). CONCLUSION: Patients with mirror aneurysms had similar clinical characteristics to non-mirror multiple aneurysm patients. Mirror aneurysms showed a predilection for the cavernous carotid artery, whereas they were comparatively rare in the posterior circulation.

Natural history and outcome after treatment of unruptured intradural fusiform aneurysms.

BACKGROUND AND PURPOSE: Management of unruptured fusiform intracranial aneurysms is controversial because of the paucity of natural history data. We studied their natural history and outcome after treatment. METHODS: We reviewed our neurovascular database from January 2000 to October 2013. Inclusion criteria were unruptured, intradural fusiform aneurysms with a diameter of <2.5 cm. Criteria were developed to define atherosclerotic aneurysms. For outcome assessment, we used the modified Ranking Scale and aneurysm measurements on serial imaging. Mann-Whittney (continuous) and Fisher exact (categorical) tests were used for risk factor analysis. RESULTS: For nonatherosclerotic aneurysms (96 patients; 193 person-years follow-up), 1 patient died (rupture) during follow-up (mortality, 0.51% per year) and 8 patients (10%) showed aneurysm progression (risk, 1.6% per year). Risk factors for progression were maximum diameter (>7 mm; odds ratio, 12; 95% confidence interval, 1.4-104) and symptomatic clinical presentation (odds ratio, 16; 95% confidence interval, 3.1-81.4). Of the 23 treated patients, 3 had died (mortality, 12.5%) and 3 had serious disability (modified Ranking Scale, ≥3; 12.5%). For the atherosclerotic aneurysms (25 patients; 97 person-years follow-up), 5 had died (mortality, 5.2% per year) and 13 of 20 (65%) had aneurysm progression (risk, 12% per year). When compared with patients with nonatherosclerotic aneurysms, case fatality (odds ratio, 19.2; 95% confidence interval, 2.1-172) and aneurysm progression (odds ratio, 17.8; 95% confidence interval, 5.3-56) were higher. CONCLUSIONS: Nonatherosclerotic fusiform intradural aneurysms have a low risk of adverse outcome within the first few years after diagnosis and remain stable unless symptomatic on presentation or >7 mm in maximum diameter. High risks of treatment should be balanced against this benign natural history. Atherosclerotic aneurysms have a worse natural history and may represent a different disease entity.

Management of dural carotid cavernous fistulas: a single-centre experience.

OBJECTIVES: To report the epidemiological features, clinical presentation, angiographic characteristics and therapeutic options, success and complication rates in patients with dural carotid cavernous fistulas (dural CCFs). METHODS: Retrospective evaluation of patients followed in our institution between January of 2005 and September of 2013. RESULTS: There were 38 patients, 76 % females, with an average age of 63 years. Ocular symptoms and signs were the most frequent clinical findings. Dural CCFs were Barrow type B in 8%, type C in 10% and type D in 82%. Cortical venous reflux was present in 50% of cases. Medical treatment was performed in 16% of patients, external ocular compression in 8%, transarterial embolisation in 13%, transvenous embolisation in 60% and radiosurgery in 3%. Clinical and angiographic follow-up data were available in 89% and 82% of patients with a mean follow-up time of 9 and 7 months, respectively. Clinical cure was achieved in 58% of patients and improvement in 24%. Anatomical cure was demonstrated in 68%. Transient worsening or new onset of ocular symptoms was observed in 29%. There was no permanent morbidity or mortality. CONCLUSIONS: In properly selected patients, endovascular embolisation, particularly by transvenous approach, represents a safe and effective treatment for dural CCFs. KEY POINTS: Dural carotid cavernous fistulas are more common in elderly women. Dural CCFs most commonly present with ocular symptoms and signs. Endovascular treatment is effective and safe in properly selected patients.

Aneurysmal wall enhancement and perianeurysmal edema after endovascular treatment of unruptured cerebral aneurysms.

INTRODUCTION: Perianeurysmal edema and aneurysm wall enhancement are previously described phenomenon after coil embolization attributed to inflammatory reaction. We aimed to demonstrate the prevalence and natural course of these phenomena in unruptured aneurysms after endovascular treatment and to identify factors that contributed to their development. METHODS: We performed a retrospective analysis of consecutively treated unruptured aneurysms between January 2000 and December 2011. The presence and evolution of wall enhancement and perianeurysmal edema on MRI after endovascular treatment were analyzed. Variable factors were compared among aneurysms with and without edema. RESULTS: One hundred thirty-two unruptured aneurysms in 124 patients underwent endovascular treatment. Eighty-five (64.4 %) aneurysms had wall enhancement, and 9 (6.8 %) aneurysms had perianeurysmal brain edema. Wall enhancement tends to persist for years with two patterns identified. Larger aneurysms and brain-embedded aneurysms were significantly associated with wall enhancement. In all edema cases, the aneurysms were embedded within the brain and had wall enhancement. Progressive thickening of wall enhancement was significantly associated with edema. Edema can be symptomatic when in eloquent brain and stabilizes or resolves over the years. CONCLUSIONS: Our study demonstrates the prevalence and some appreciation of the natural history of aneurysmal wall enhancement and perianeurysmal brain edema following endovascular treatment of unruptured aneurysms. Aneurysmal wall enhancement is a common phenomenon while perianeurysmal edema is rare. These phenomena are likely related to the presence of inflammatory reaction near the aneurysmal wall. Both phenomena are usually asymptomatic and self-limited, and prophylactic treatment is not recommended.

Transclival pseudomeningocele secondary to ecchordosis physaliphora: case report and literature review.

We describe a 52-year-old woman who presented with meningitis secondary to a pseudomeningocele within the sphenoid sinus derived from a bony defect in the clivus. The bony defect was radiologically characteristic of an ecchordosis physaliphora (EP). She underwent surgical repair of the defect and had resolution of her symptoms. This case report will discuss the second case of transclival pseudomeningocele in the English literature and present EP as a cause.

Factors determining the success of endovascular treatments among patients with spinal dural arteriovenous fistulas.

INTRODUCTION: Despite improvements of embolization agents and techniques, endovascular treatment of spinal dural arteriovenous fistula (SDAVF) is still limited by inconsistent success. The aim of embolization is to occlude initial portion of the draining vein by liquid embolic materials. This study investigates factors that contribute to the success of embolization treatments among SDAVF patients. METHODS: We performed a retrospective analysis on consecutive SDAVF patients who received N-butyl cyanoacrylate (NBCA) glue embolization between January 1992 and June 2012. Univariable and multivariable logistic regression analyses were performed to calculate the probability of successful draining vein occlusion for variable procedure-related factors. RESULTS: We attempted endovascular approach as the first intention treatment in 66 out of 90 consecutive patients. Among them, a total of 43 NBCA glue injections were performed in 40 patients. Successful embolization was achieved in 24 patients (60 %). In multivariable analyses, antegrade flow during microcatheter test injection (OR 13.2, 95 % CI 1.7 to 105.4) and use of glue concentration ≥ 30 % (OR 0.1, 95 % CI 0.01 to 0.8) were detected as significant positive and negative predictors of successful venous penetration, respectively. With persistent antegrade flow, the success rates using a glue mixture of more than 30 % dropped significantly from 85.0 to 42.9 % (p = 0.049). If contrast stagnated during microcatheter injections, success rates were low regardless of glue concentrations. CONCLUSIONS: Presence of antegrade flow toward the draining vein and injection of NBCA glue less than 30 % are associated with higher chance of draining vein penetration and, therefore, successful endovascular SDAVF obliteration.

Challenges in the management of ruptured and unruptured brainstem arteriovenous malformations: outcome after conservative, single-modality, or multimodality treatments.

BACKGROUND: Brainstem arteriovenous malformations are challenging lesions, and benefits of treatment are uncertain. OBJECTIVE: To study the clinical course of Brainstem arteriovenous malformations and the influence of treatments on outcome. METHODS: We reviewed a prospective series of 31 brainstem arteriovenous malformations. Demographic, morphological, and clinical characteristics were recorded. Factors determining initial and final outcomes (modified Rankin Scale), results of treatments (cure rates, complications), and disease course were analyzed. RESULTS: Brainstem arteriovenous malformations were symptomatic and bled in 93% and 61% of cases, respectively. Examination was abnormal and initial modified Rankin Scale score was < 3 in 71% and 86% of patients, respectively. The average follow-up time was 6.2 years, and 26% of patients rebled (5.9 %/y). Treatment modalities included conservative, radiosurgical, endovascular, surgical, and multimodality treatment in 13%, 58%, 35%, 16%, and 26% of cases, respectively. The obliteration rate was 60% overall and 39% after radiosurgery, 40% after embolization, and 75% after microsurgery, with respective complication-free cure rates of 71%, 50%, and 0%. Overall procedural mortality and morbidity were 2.3% and 18.6%, respectively. Final modified Rankin Scale score was < 3 in 77% of cases. Neurological deterioration (35%) was related to treatment complications in 74% of cases with a negative impact of surgery (P = .04), palliative embolization (odds ratio = 16), and multimodality treatments (odds ratio = 24). Radiosurgery was inversely associated with worsening (odds ratio = 0.06). CONCLUSION: Brainstem arteriovenous malformations require individualized treatment decisions. Single-modality treatments with a reasonable chance of complete cure and low complication rate (such as radiosurgery) should be favored.

Vessel wall MRI to differentiate between reversible cerebral vasoconstriction syndrome and central nervous system vasculitis: preliminary results.

BACKGROUND AND PURPOSE: Prospective differentiation between reversible cerebral vasoconstriction syndrome and central nervous system vasculitis can be challenging. We hypothesized that high-resolution vessel wall MRI would demonstrate arterial wall enhancement in central nervous system vasculitis but not in reversible cerebral vasoconstriction syndrome. METHODS: We identified all patients with multifocal segmental narrowing of large intracranial arteries who had high-resolution vessel wall MRI and follow-up angiography at our institute over a 4-year period and performed a detailed chart review. RESULTS: Three patients lacked arterial wall enhancement, and these all had reversal of arterial narrowing within 3 months. Four patients demonstrated arterial wall enhancement, and these had persistent or progressive arterial narrowing at a median follow-up of 17 months (range, 6-36 months) with final diagnoses of central nervous system vasculitis (3) and cocaine vasculopathy (1). CONCLUSIONS: Preliminary results suggest that high-resolution contrast-enhanced vessel wall MRI may enable differentiation between reversible cerebral vasoconstriction syndrome and central nervous system vasculitis.

Impact of individual intracranial arterial aneurysm morphology on initial obliteration and recurrence rates of endovascular treatments: a multivariate analysis.

OBJECT: The goal was to investigate whether morphological features of aneurysms can be identified that determine initial success and recurrence rates of coiled aneurysms of the basilar artery tip, the posterior communicating artery (PCoA), and the anterior communicating artery. METHODS: The authors evaluated 202 aneurysms in connection with their pretreatment morphological features including size, neck-to-dome ratio, angulation of the aneurysm in relation to the parent artery, orientation of the aneurysm dome, and associated anatomical variations. The mean follow-up was 19 months (range 6-96 months) after endovascular coil occlusion. Using multivariate logistic regression, probabilities for initial complete occlusion and long-term stability of the treatment were calculated. RESULTS: Recanalization occurred in 49 of 202 cases. Favorable factors for long-term stability included small aneurysms with small necks. However, additional factors related to local hemodynamic forces could be identified for the different aneurysm locations, which may influence initial success rates and long-term stability of aneurysm treatment with endovascular coiling. These factors were a medial dome orientation and a symmetrical disposition of both A(1) segments (for the anterior communicating artery), a posteroinferior dome orientation and a small-size PCoA (for the PCoA), and a cranial symmetrical fusion (for the basilar artery tip). CONCLUSIONS: A detailed pretreatment analysis of morphological features of aneurysms may help to determine those aneurysms that are more prone to recurrence, which could add to the treatment decision and the follow-up algorithm.

Intracranial dural arteriovenous shunts: transarterial glue embolization--experience in 115 consecutive patients.

PURPOSE: To evaluate the effectiveness and safety of transarterial glue embolization of intracranial dural arteriovenous shunts (DAVS). MATERIALS AND METHODS: Institutional review board approval was obtained, with waiver of informed consent, for this retrospective study. From a single-center database of information on 371 intracranial DAVS, data in 115 consecutive patients treated with transarterial glue embolization were identified and assessed. Clinical and angiographic features, including cure rate, complications, and outcome, were evaluated. The treatment results were also compared between the patients in the first half of the consecutive series and those in the second half. The mean glue concentrations used were compared between the first and second halves of the patient series by using the Student t test. RESULTS: One hundred twenty-one lesions were treated with transarterial glue embolization. There were 31 (25.6%) Borden type I lesions, 39 (32.2%) Borden type II lesions, and 51 (42.1%) Borden type III lesions. Angiographic cure with glue embolization was achieved for 36 lesions (29.8%); 17 (14.0%) lesions were cured immediately, and 19 (15.7%) showed progressive thrombosis at follow-up. The angiographic cure rate for Borden type III lesions improved from 10% to 55% in the later group of patients as compared with the earlier group. The mean concentration of glue was significantly lower in the later group of patients. One (0.9%) of the 115 patients suffered permanent morbidity from aggravation of left extremity weakness due to venous thrombosis. Eight patients experienced nonpermanent morbidities, including transient worsening of neurologic status due to venous thrombosis (n = 4), alopecia (n = 2), scalp ulcer (n = 1), and pulmonary embolism (n = 1). Overall, improvement (n = 65) or stabilization (n = 32) of symptoms was seen in 84.3% of the patients. CONCLUSION: Transarterial glue embolization is a safe and effective method of primary treatment for intracranial DAVS, especially Borden type III lesions. Improvement of cure rates in the latter half of this study suggest that technical advances and experience may enhance outcomes.