Probabilistic tractography of the extracranial branches of the trigeminal nerve using diffusion tensor imaging.

PURPOSE: The peripheral course of the trigeminal nerves is complex and spans multiple bony foramen and tissue compartments throughout the face. Diffusion tensor imaging of these nerves is difficult due to the complex tissue interfaces and relatively low MR signal. The purpose of this work is to develop a method for reliable diffusion tensor imaging-based fiber tracking of the peripheral branches of the trigeminal nerve. METHODS: We prospectively acquired imaging data from six healthy adult participants with a 3.0-Tesla system, including T2-weighted short tau inversion recovery with variable flip angle (T2-STIR-SPACE) and readout segmented echo planar diffusion weighted imaging sequences. Probabilistic tractography of the ophthalmic, infraorbital, lingual, and inferior alveolar nerves was performed manually and assessed by two observers who determined whether the fiber tracts reached defined anatomical landmarks using the T2-STIR-SPACE volume. RESULTS: All nerves in all subjects were tracked beyond the trigeminal ganglion. Tracts in the inferior alveolar and ophthalmic nerve exhibited the strongest signal and most consistently reached the most distal landmark (58% and 67%, respectively). All tracts of the inferior alveolar and ophthalmic nerve extended beyond their respective third benchmarks. Tracts of the infraorbital nerve and lingual nerve were comparably lower-signal and did not consistently reach the furthest benchmarks (9% and 17%, respectively). CONCLUSION: This work demonstrates a method for consistently identifying and tracking the major nerve branches of the trigeminal nerve with diffusion tensor imaging.

Identifying symptomatic trigeminal nerves from MRI in a cohort of trigeminal neuralgia patients using radiomics.

INTRODUCTION: Trigeminal neuralgia (TN) is a devastating neuropathic condition. This work tests whether radiomics features derived from MRI of the trigeminal nerve can distinguish between TN-afflicted and pain-free nerves. METHODS: 3D T1- and T2-weighted 1.5-Tesla MRI volumes were retrospectively acquired for patients undergoing stereotactic radiosurgery to treat TN. A convolutional U-net deep learning network was used to segment the trigeminal nerves from the pons to the ganglion. A total of 216 radiomics features consisting of image texture, shape, and intensity were extracted from each nerve. Within a cross-validation scheme, a random forest feature selection method was used, and a shallow neural network was trained using the selected variables to differentiate between TN-affected and non-affected nerves. Average performance over the validation sets was measured to estimate generalizability. RESULTS: A total of 134 patients (i.e., 268 nerves) were included. The top 16 performing features extracted from the masks were selected for the predictive model. The average validation accuracy was 78%. The validation AUC of the model was 0.83, and sensitivity and specificity were 0.82 and 0.76, respectively. CONCLUSION: Overall, this work suggests that radiomics features from MR imaging of the trigeminal nerves correlate with the presence of pain from TN.

Microsurgical Management of the Middle Cerebral Artery Bifurcation Aneurysms: An Anatomic Feasibility Study.

BACKGROUND: The proper head positioning decreases the surgical complications by enabling a better surgical maneuverability. Middle cerebral artery (MCA) bifurcation aneurysms have been classified by Dashti et al. [Surg Neurol. 2007 May;67(5):441-56] as the intertruncal, inferior, lateral, insular, and complex types based on dome projection. Our aim was to identify the optimum head positions and to explain the anatomic variables, which may affect the surgical strategy of MCA bifurcation aneurysms. METHODS: The lateral supraorbital approach bilaterally was performed in the 4 cadaveric heads. All steps of the dissection were recorded using digital camera. RESULTS: The distal Sylvian fissure (SF) dissection may be preferred for insular type and the proximal SF dissection may be preferred for all other types. Fifteen degrees head rotation was found as the most suitable position for the intertruncal, lateral type and subtype of complex aneurysms related with superior trunk. Thirty degrees head rotation was found the most suitable position for the inferior type, insular type, and subtype of complex aneurysms related with inferior trunk. CONCLUSIONS: The head positioning in middle cerebral bifurcation aneurysms surgery is a critical step. It should be tailored according to the projection and its relationship with the parent vessels of the middle cerebral bifurcation.

A simple geometric analysis method for measuring and mitigating RF induced currents on Deep Brain Stimulation leads by multichannel transmission/reception.

The purpose of this work is to present a new method that can be used to estimate and mitigate RF induced currents on Deep Brain Stimulation (DBS) leads. Here, we demonstrate the effect of RF induced current mitigation on both RF heating and image quality for a variety of brain MRI sequences at 3 T. We acquired pre-scan images around a DBS lead (in-situ and ex-vivo) using conventional Gradient Echo Sequence (GRE) accelerated by parallel imaging (i.e GRAPPA) and quantified the magnitude and phase of RF induced current using the relative location of the B1+ null with respect to the lead position. We estimated the RF induced current on a DBS lead implanted in a gel phantom as well as in a cadaver head study for a variety of RF excitation patterns. We also measured the increase in tip temperature using fiber-optic probes for both phantom and cadaver studies. Using the magnitude and phase information of the current induced separately by two transmit channels of the body coil, we calculated an implant friendly (IF) excitation. Using the IF excitation, we acquired T1, T2 weighted Turbo Spin Echo (TSE), T2 weighted SPACE-Dark Fluid, and Ultra Short Echo Time (UTE) sequences around the lead. Our induced current estimation demonstrated linear relationship between the magnitude of the induced current and the square root SAR at the tip of the lead as measured in phantom studies. The "IF excitation pattern" calculated after the pre-scan mitigated RF artifacts and increased the image quality around the lead. In addition, it reduced the tip temperature significantly in both phantom and cadaver studies compared to a conventional quadrature excitation while keeping equivalent overall image quality. We present a relatively fast method that can be used to calculate implant friendly excitation, reducing image artifacts as well as the temperature around the DBS electrodes. When combined with a variety of MR sequences, the proposed method can improve the image quality and patient safety in clinical imaging scenarios.

The emergence of endovascular treatment-only centers for treatment of intracranial aneurysms in the United States.

BACKGROUND: Because of the availability of new technology, the spectrum of endovascular treatment for intracranial aneurysms has expanded widely. Some centers have started offering only endovascular treatment to patients with intracranial aneurysms (endovascular treatment-only centers [ETOCs]). Our objective was to identify the proportion and outcome of patients treated at ETOCs in the United States. METHODS: We determined the proportion of ETOCs in the United States using Nationwide Inpatient Survey data files from 2010. We compared short-term outcomes between ETOCs and endovascular and surgical treatment centers (ESTCs). The outcomes studied were none to minimal disability, moderate to severe disability, in-hospital mortality, postprocedure complications, length of stay, and hospital charges. RESULTS: Out of 85 hospitals performing endovascular treatment of unruptured aneurysms, 13 (15%) were categorized as ETOCs. Out of the 10,447 patients with unruptured aneurysms, 1245 (12%) were treated at ETOCs. ETOCs were more likely to be nonteaching hospitals (55% versus 45%, P=.02). The rates of in-hospital mortality (1.2% versus 1.8%) and none to minimal disability (88% versus 84%) were similar in patients treated at ETOCs and ESTC hospitals. The mean hospitalization charges were similar, but length of stay (4±7 days versus 6±10 days, P<.0001) was significantly shorter among patients treated at ETOCs. Only 2.7% patients required secondary neurosurgical procedures at the ETOCs compared with 5.8% in ESTCs (P=.09). CONCLUSION: The recent emergence of ETOCs and provision of treatment with comparable outcomes and shorter length of stay at these hospitals may change the pattern of intracranial aneurysm treatment in the United States.

Flow residence time in intracranial aneurysms evaluated by in vitro 4D flow MRI.

The process of an intracranial aneurysm development, growth, and rupture is multifaceted and complex. In addition, clinical observations have identified the potential of thrombus formation within such aneurysms. While the underlying mechanism is not fully understood, the thrombi represent a potential risk factor for ischemic stroke. Emerging studies indicate that blood residence time (RT) is a promising hemodynamic metric associated with the aneurysm rupture and formation of intra-aneurysmal thrombi. Here, we present a methodology to experimentally evaluate both trajectory-wise and local RT based on magnetic resonance imaging (MRI) velocimetry, and apply it to in vitro flow measurements in scaled-up replicas of 9 patient-specific intracranial aneurysms. Lagrangian tracks of massless tracers are integrated from the velocity fields and averaged to return the mean RT in the aneurysm sac. This is found to be closely approximated by a simple time scale based on the sac diameter and space-time average of the aneurysmal fluid velocity. The mean RT is also correlated with the inflow time scale at the parent artery. These results also provide a basis for the estimation of RT when high-resolution hemodynamic maps are not available. With the continuous increase in accuracy and resolution enabled by progress in MRI technology, the methodology described here may in the future be applicable to in vivo data.

Development of a Novel Canine Model of Ischemic Stroke: Skull Base Approach with Transient Middle Cerebral Artery Occlusion.

OBJECTIVE: Although canine stroke models have several intrinsic advantages, establishing consistent and reproducible territorial stroke in these models has been challenging because of the abundance of collateral circulation. We have described a skull-base surgical approach that yields reproducible stroke volumes. METHODS: Ten male beagles were studied. In all 10 dogs, a craniectomy was performed to expose the circle of Willis. Cerebral aneurysm clips were temporarily applied to the middle cerebral artery (MCA), anterior cerebral artery (ACA), posterior cerebral artery, and/or ophthalmic artery (OA) for 1 hour, followed by cauterization of the distal MCA pial collateral vessels. Indocyanine green angiography was performed to assess the local blood flow to the intended area of infarction. The dogs' neurologic examination was evaluated, and the stroke burden was quantified using magnetic resonance imaging. RESULTS: High mortality was observed after 1-hour clip occlusion of the posterior cerebral artery, MCA, ACA, and OA (n = 4). Without coagulation of the MCA collateral vessels, 1-hour occlusion of the MCA and/or ACA and OA yielded inconsistent stroke volumes (n = 2). In contrast, after coagulation of the distal MCA pial collateral vessels, 1-hour occlusion of the MCA, ACA, and OA yielded consistent territorial stroke volumes (n = 4; average stroke volume, 9.13 ± 0.90 cm3; no surgical mortalities), with reproducible neurologic deficits. CONCLUSION: Consistent stroke volumes can be achieved in male beagles using a skull base surgical approach with temporary occlusion of the MCA, ACA, and OA when combined with cauterization of the distal MCA pial collateral vessels.

Hemodynamics in a giant intracranial aneurysm characterized by in vitro 4D flow MRI.

Experimental and computational data suggest that hemodynamics play a critical role in the development, growth, and rupture of cerebral aneurysms. The flow structure, especially in aneurysms with a large sac, is highly complex and three-dimensional. Therefore, volumetric and time-resolved measurements of the flow properties are crucial to fully characterize the hemodynamics. In this study, phase-contrast Magnetic Resonance Imaging is used to assess the fluid dynamics inside a 3D-printed replica of a giant intracranial aneurysm, whose hemodynamics was previously simulated by multiple research groups. The physiological inflow waveform is imposed in a flow circuit with realistic cardiovascular impedance. Measurements are acquired with sub-millimeter spatial resolution for 16 time steps over a cardiac cycle, allowing for the detailed reconstruction of the flow evolution. Moreover, the three-dimensional and time-resolved pressure distribution is calculated from the velocity field by integrating the fluid dynamics equations, and is validated against differential pressure measurements using precision transducers. The flow structure is characterized by vortical motions that persist within the aneurysm sac for most of the cardiac cycle. All the main flow statistics including velocity, vorticity, pressure, and wall shear stress suggest that the flow pattern is dictated by the aneurysm morphology and is largely independent of the pulsatility of the inflow, at least for the flow regimes investigated here. Comparisons are carried out with previous computational simulations that used the same geometry and inflow conditions, both in terms of cycle-averaged and systolic quantities.

Fiber Connections of the Supplementary Motor Area Revisited: Methodology of Fiber Dissection, DTI, and Three Dimensional Documentation.

The purpose of this study is to show the methodology for the examination of the white matter connections of the supplementary motor area (SMA) complex (pre-SMA and SMA proper) using a combination of fiber dissection techniques on cadaveric specimens and magnetic resonance (MR) tractography. The protocol will also describe the procedure for a white matter dissection of a human brain, diffusion tensor tractography imaging, and three-dimensional documentation. The fiber dissections on human brains and the 3D documentation were performed at the University of Minnesota, Microsurgery and Neuroanatomy Laboratory, Department of Neurosurgery. Five postmortem human brain specimens and two whole heads were prepared in accordance with Klingler's method. Brain hemispheres were dissected step by step from lateral to medial and medial to lateral under an operating microscope, and 3D images were captured at every stage. All dissection results were supported by diffusion tensor imaging. Investigations on the connections in line with Meynert's fiber tract classification, including association fibers (short, superior longitudinal fasciculus I and frontal aslant tracts), projection fibers (corticospinal, claustrocortical, cingulum, and frontostriatal tracts), and commissural fibers (callosal fibers) were also conducted.

Stent placement for palliation of cor triatriatum dexter in a dog with suspected patent foramen ovale.

An 11 month old spayed, female dog presented with exercise intolerance and cyanosis upon exertion. Echocardiography revealed an imperforate cor triatriatum dexter with mild tricuspid valve dysplasia, an underfilled right ventricle and significant right to left shunting across a presumptive patent foramen ovale. Balloon dilation of the abnormal atrial membrane was initially successful in creating a communication between the right atrial chambers, but stenosis of the original perforation and persistent clinical signs prompted a second intervention. A balloon expandable biliary stent was placed across the abnormal partition, improving caudal venous return to the right ventricle and reducing the right to left shunt. Three months after stent placement, resting oxygen saturation had normalized. Six months after stent placement, exercise tolerance had improved and exertional cyanosis had resolved. Long term follow up will be necessary to assess for remodeling of the right ventricle with improved venous return. Stent placement can be considered as a palliative treatment option for cor triatriatum dexter, especially for stenosis post-balloon dilation.

Three-dimensional assessment of the effects of high-density embolization material on the absorbed dose in the target for Gamma Knife radiosurgery of arteriovenous malformations.

OBJECTIVE Arteriovenous malformation (AVM) is an intracranial vascular disorder. Gamma Knife radiosurgery (GKRS) is used in conjunction with intraarterial embolization to eradicate the nidus of AVMs. Clinical results indicate that patients with prior embolization tend to gain less benefit from GKRS. The authors hypothesized that this was partly caused by dosimetric deficiency. The actual dose delivered to the target may be smaller than the intended dose because of increased photon attenuation by high-density embolic materials. The authors performed a phantom-based study to quantitatively evaluate the 3D dosimetric effect of embolic material on GKRS. METHODS A 16-cm-diameter and 12-cm-long cylindrical phantom with a 16-cm-diameter hemispherical dome was printed by a 3D printer. The phantom was filled with radiologically tissue-equivalent polymer gel. To simulate AVM treatment with embolization, phantoms contained Onyx 18. The material was injected into an AVM model, which was suspended in the polymer gel. The phantom was attached to a Leksell frame by standard GK fixation method, using aluminum screws, for imaging. The phantom was scanned by a Phillips CT scanner with the standard axial-scanning protocol (120 kV and 1.5-mm slice thickness). CT-based treatment planning was performed with the GammaPlan treatment planning system (version 10.1.1). The plan was created to cover a fictitious AVM target volume near the embolization areas with eleven 8-mm shots and a prescription dose of 20 Gy to 50% isodose level. Dose distributions were computed using both tissue maximum ratio (TMR) 10 and convolution dose-calculation algorithms. These two 3D dose distributions were compared using an in-house program. Additionally, the same analysis method was applied to evaluate the dosimetric effects for 2 patients previously treated by GKRS. RESULTS The phantom-based analyses showed that the mean dose difference between TMR 10 and convolution doses of the AVM target was no larger than 6%. The difference for GKRS cases was 5%. There were small areas where a large dose difference was observed on the isodose line plots, and those differences were mostly at or in the vicinity of the embolization materials. CONCLUSIONS The results of both the phantom and patient studies showed a dose reduction no larger than 5% due to the embolization material placed near the target. Although the comparison of 3D dose distributions indicated small local effects of the embolic material, the clinical impact on the obliteration rate is expected to be small.