A quantitative and semi-automatic measurement of transverse sinus stenosis improves idiopathic intracranial hypertension diagnostic accuracy.

We propose a new reliable transverse sinus stenosis (TSS) index based on magnetic resonance venography (MRV) for the diagnosis of idiopathic intracranial hypertension (IIH). Our quantitative semi-automatic measurement analysis based on segmentation and cross-sectional TS diameter from 48 IIH patients and controls matched for age and sex, had a good inter-observer agreement (κ=0.729) compared to a visual examination (κ=0.467). A cut-off point≥2 discriminate IIH patients from controls, with a sensitivity and specificity of 100%.

[Basal ganglia calcification]. / Calcifications des noyaux gris centraux.

Calcifications of the basal ganglia are frequently seen on the cerebral CT scans and particularly in the globus pallidus. Their frequency increases physiologically with age after 50 years old. However, pathological processes can also be associated with calcium deposits in the gray nuclei, posterior fossa or white matter. Unilateral calcification is often related to an acquired origin whereas bilateral ones are mostly linked to an acquired or genetic origin that will be sought after eliminating a perturbation of phosphocalcic metabolism. In pathological contexts, these calcifications may be accompanied by neurological symptoms related to the underlying disease: Parkinson's syndrome, psychiatric and cognitive disorders, epilepsy or headache. The purpose of this article is to provide a diagnostic aid, in addition to clinical and biology, through the analysis of calcification topography and the study of different MRI sequences.

[Imaging of subarachnoid hemorrhage]. / Imagerie de l'hémorragie sous-arachnoïdienne.

Even if acute subarachnoid hemorrhage (SAH) accounts for only 5% of strokes, its diagnosis is very important because its clinical consequences can be tragic. Recent technological advances in medical imaging have improved diagnostic and therapeutic management of patients with SAH. Nonenhanced CT of the head is the initial imaging modality in suspected SAH for the detection of ruptured intracranial aneurysms. Digital subtraction angiography (DSA) remains the reference exam. Multidetector row CT angiography may potentially replace DSA in the emergency setting, as it provides image data that allows evaluating aneurysmal morphology, the neck size or the visualization of vessels in the vicinity of the aneurysm. For SAH unrelated to aneurysm rupture (15% of cases), MRI and MRA can be added to the diagnostic work-up in order to exclude other differential diagnoses such as venous thrombosis or angiitis. Finally, transcranial color-coded duplex sonography, CT, or MRI are used in clinical practice in order to detect aggravating factors of SAH like hydrocephalus or vasospasm.

Emotional facial palsy following striato-capsular infarction.

Emotional facial palsy (EFP) is a rare condition in which facial paresis is only apparent during reflex movements of the hemiface, such as smiling and laughter. We report the case of a 32-year-old man presenting with EFP as the main symptom of a small striatocapsular infarction. Our case strongly suggests that the anterior arm of the internal capsule is part of the corticonuclear tract that is involved in emotional facial motility.

Inaugural tumor-like multiple sclerosis: clinical presentation and medium-term outcome in 87 patients.

BACKGROUND: Tumefactive demyelinating lesions of the central nervous system can be the initial presentation in various pathological entities [multiple sclerosis (the most common), Balo's concentric sclerosis, Schilder's disease and acute disseminated encephalomyelitis] with overlapping clinical presentation. The aim of our study was to better characterize these patients. METHODS: Eighty-seven patients (62 women and 25 men) from different MS centers in France were studied retrospectively. Inclusion criteria were (1) a first clinical event (2) MRI showing one or more large demyelinating lesions (20 mm or more in diameter) with mass-like features. Patients with a previous demyelinating event (i.e. confirmed multiple sclerosis) were excluded. RESULTS: Mean age at onset was 26 years. The most common initial symptoms (67% of the patients) were hemiparesis or hemiplegia. Aphasia, headache and cognitive disturbances (i.e. atypical symptoms for demyelinating diseases) were observed in 15, 18 and 15% of patients, respectively. The mean largest diameter of the tumefactive lesions was 26.9 mm, with gadolinium enhancement in 66 patients (81%). Twenty-one patients (24%) had a single tumefactive lesion. During follow-up (median time 5.7 years) 4 patients died, 70 patients improved or remained stable and 12 worsened. 86% of patients received initial corticosteroid treatment, and 73% received disease-modifying therapy subsequently. EDSS at the end of the follow-up was 2.4 ± 2.6 (mean ± SD). CONCLUSION: This study provides further evidence that the clinical course of MS presenting with large focal tumor-like lesions does not differ from that of classical relapsing-remitting MS, once the noisy first relapsing occurred.

[Acute anterograde amnesia by infarction of the mamillothalamic tracts]. / Syndrome amnésique aigu par infarctus des faisceaux mamillothalamiques de Vicq d'Azir.

We report a case of persistent anterograde amnesia secondary to an anterior thalamic infarct. A 49-year-old right-handed man is referred for acute anterograde amnesia. Diffusion-weighted imaging performed at 24 hours shows an acute punctiform infarct of the left anterior thalamus, while T2-weighted imaging reveals a contralateral and symmetrical ischemic sequelae in the right anterior thalamus. The two lesions are isolated and remarkably centered with the mamillothalamic tract. We suggest the symptoms are caused by the addition of the two lesions interrupting the mamillothalamic tracts. This is the second clinico-pathological observation of a persistent amnestic syndrome secondary to a bilateral lesion of the mamillothalamic tract.

TIPIC Syndrome: Beyond the Myth of Carotidynia, a New Distinct Unclassified Entity.

BACKGROUND AND PURPOSE: The differential diagnosis of acute cervical pain includes nonvascular and vascular causes such as carotid dissection, carotid occlusion, or vasculitis. However, some patients present with unclassified vascular and perivascular changes on imaging previously reported as carotidynia. The aim of our study was to improve the description of this as yet unclassified clinico-radiologic entity. MATERIALS AND METHODS: From January 2009 through April 2016, 47 patients from 10 centers presenting with acute neck pain or tenderness and at least 1 cervical image showing unclassified carotid abnormalities were included. We conducted a systematic, retrospective study of their medical charts and diagnostic and follow-up imaging. Two neuroradiologists independently analyzed the blinded image datasets. RESULTS: The median patient age was 48 years. All patients presented with acute neck pain, and 8 presented with transient neurologic symptoms. Imaging showed an eccentric pericarotidian infiltration in all patients. An intimal soft plaque was noted in 16 patients, and a mild luminal narrowing was noted in 16 patients. Interreader reproducibility was excellent. All patients had complete pain resolution within a median of 13 days. At 3-month follow-up, imaging showed complete disappearance of vascular abnormalities in 8 patients, and a marked decrease in all others. CONCLUSIONS: Our study improved the description of an unclassified, clinico-radiologic entity, which could be described by the proposed acronym: TransIent Perivascular Inflammation of the Carotid artery (TIPIC) syndrome.

[Intracranial aneurysms presenting with ischemic stroke]. / Anévrysmes intracrâniens révélés par une ischémie cérébrale.

PURPOSE: To report four cases of patient with an acute ischemic event as a presenting symptom of a berry aneurysm. PATIENTS AND METHODS: One male and three female (aged range 38 to 65 years) patients were admitted for acute stroke. The neuroradiologic finding disclosed aneurysm thrombosis, inferior to twenty five millimetres in three cases. Lumbar puncture was done in one case and showed subarachnoid haemorrage. DISCUSSION: We will discuss the hypothesis leading to the mechanism of aneurysm thrombosis. Two theories will be presented: "hemodynamic" and "parietal" modifications. We will propose a management protocol for these patients with atypical presentation of intracranial aneurysms given the potential risk of rupture. CONCLUSION: The natural history of intracranial aneurysms is still not fully understood. Nevertheless, aneurym thrombosis may occur and lead to ischemic stroke.

[Vertebrovertebral arteriovenous fistula diagnosis and treatment: report of 8 cases and review of the literature]. / Diagnostic et traitement des fistules vertébrovertébrales. Revue de la littérature: à propos de 8 observations.

Vertebrovertebral Arteriovenous Fistula (V.V.A.V.F.) is a relatively rare entity. It may be an incidental finding or be detected in patients presenting with pulsatile tinnitus, cervical bruit, or vertebro-basilar insufficiency. It can be spontaneous but it most frequently is post-traumatic in etiology. The authors report 8 patients, 4 women and 4 men aged between 20 to 77 years, with 4 post-traumatic V.V.A.V.F. and 4 spontaneous V.V.A.V.F. that were seen over a 15 year period. Imaging work-up included Doppler US (n=4), MRI 9n=3) and angiography (n=8). Seven of 8 patients were treated successfully using an endovascular technique (5 with balloon occlusion, 1 with coil embolization and 1 using a mechanical maneuver), without complication or recurrence, except in one case. We compare our results with published reports from the literature and review the underlying pathology and management strategies of V.V.A.V.F.

[Natural history and management of mycotic intracranial aneurysm]. / Anévrysme mycotique cérébral: histoire naturelle et prise en charge thérapeutique.

INTRODUCTION: mycotic intracranial aneurysms are a rare complication of infectious endocarditis. We report four cases of patients with endocarditis, complicated by an acute stroke, revealing a mycotic intracranial aneurysm. PATIENTS AND METHODS: four men (aged range 24 to 63 year old) were admitted for endocarditis, complicated by ischemic stroke in two cases and hemorrhagic stroke in the two other cases, including one with subarachnoid hemorrhage. Neuroimaging disclosed a mycotic cerebral aneurysm in all four cases. DISCUSSION: we will discuss the natural history and the management of mycotic intracranial aneurysm based on a review of the literature and our experience. Three therapeutic options are possible: medical treatment, surgery and endovascular embolisation. CONCLUSION: management of mycotic intracranial aneurysms is still controversial, frequently requiring a multidisciplinary strategy with priority given to endovascular interventions.

[Hypertrophic olivary degeneration. MR imaging findings and temporal evolution]. / Degenerescence olivaire hypertrophique. Aspect IRM et évolution temporelle.

PURPOSE: to describe the magnetic resonance imaging features of hypertrophic olivary degeneration (HOD) subsequent to lesion in the "Guillain-Mollaret triangle". MATERIALS AND METHODS: 15 cases of HOD were diagnosed at MR imaging in 12 patients (4 women and 8 men) with posterior fossa lesion. The time interval from the beginning of the disease to the MR examination was 3 weeks to 8 (1/2) years. Evaluation of the changes in signal intensity over time of the lesions was available in 6 patients. RESULTS: Nine cases of HOD were unilateral and three were bilateral. HOD was associated to a lesion of the contralateral dentate nucleus in 8 cases, to a lesion of the ipsilateral central tegmental tract in 5 cases and to a lesion of the contralateral superior cerebellar peduncle in 2 cases. Hyperintensity and hypertrophy of the olive on proton density and T2-weighted images appeared as early as 3 weeks after the ictus. A curved central hyperintensity (CCH) could be observed 7 months after the initial presentation. Decrease in the signal intensity was observed after 3 (1/2) years and abnormal signal intensity could persist for up to 13 years. Palatal myoclonus at 5 months was associated with HOD in one case. CONCLUSION: HOD is considered a trans-synaptic degeneration subsequent to lesions in the Guillain-Mollaret triangle. Hyperintensity and hypertrophy of the olive are observed, sometimes with palatal myoclonus.

[MR-angiography of the head and neck vessels: technical considerations and clinical indications]. / ARM des vaisseaux cervico-encéphaliques: technique, principales applications cliniques.

Magnetic resonance angiography (MRA) is a very valuable tool in the routine evaluation of patients with stroke syndrome. It provides powerful noninvasive imaging of the cervical and intracranial vessels allowing the detection and the diagnosis of vascular anomalies. MRA usefully supplements, during the same examination, the analysis by MRI of the cerebral parenchyma. We will describe the indications of the various techniques (MRA with and without injection of contrast media) and show the value, artifacts and limitations of MRA in atherosclerotic stenosis or occlusive disease and in arterial dissections. This noninvasive vascular assessment will depend on the initial therapeutic orientation. Within the framework of the hemorrhagic stroke, we will discuss the role and the interest of dynamic MR angiography in the tracking and control of intracranial aneurysms and also the contribution of this newer sequences with gadolinium injection in the detection of cerebral vascular malformations.

[Endovascular carotid occlusion: a retrospective study of complications in 33 cases]. / L'occlusion carotidienne par voie endovasculaire: etude retrospective des complications á partir de 33 cas.

MATERIAL-METHODS: Thirty three patients (16 men, 17 women), mean age 45 years underwent an intravascular carotid balloon occlusion for intracavernous aneurysms, carotid-cavernous fistulas or cervical carotid injuries by Fogarty balloons (5 patients before 1982) or detachable balloons (28 patients). Transient balloon test occlusion consisted in a clinical examination, an angiographic study for 32 patients with an electroencephalogram for 16 patients. RESULTS: Early complications occurred for four patients by veineous rupture (1 patient) or ischemic injury (3 patients). Late complications occurred for two patients by ischemic injuries, one asymptomatic. DISCUSSION: These results are similar to the literature's results and the transient test occlusion consisting in clinical examination, angiographic study and EEG seems to be reliable compared to cerebral blood flow determination. CONCLUSION: Even if its indications have decreased because of technic improvements permitting carotid flow preservation, carotid endovascular balloon occlusion stays a reliable, cheap technic in carotid injuries' treatment.

[The evaluation of 3DFT time-of-flight MR-angiography versus angiography in the study of carotid atheromatous lesions with a review of the literature]. / Evaluation de l'angio-MR 3DFT temps-de-vol versus angiographie dans l'exploration de lésions athéromateuses carotidiennes avec revue de la littérature

In 37 patients suspected of having a stroke 71 carotid bifurcations were explored by MR-angiography and by digital angiography the reference technique. A 3D sequence was acquired with the time-of-flight technique, using a transmitter-receiver cranial coil, followed by a strictly receiver Helmoltz coil on a 1 Tesla magnet. Two examiners evaluated the carotid bifurcations and measured the degree of stenosis in terms of diameters, according to the north american symptomatic carotid endarterectomy trial (NASCET). Five classes were established: class 1: normal; class 2: 1 to 29%; class 3: 30 to 69%; class 4: 70 to 99% and class 5: thrombosis. The results obtained in the determination of classes were identical with both coils: the coefficient of correlation with straight angiography were 0.973 with the cranial coil and 0.966 with the Helmoltz coil. Five stenoses were overestimated and classified as Class 3 instead of Class 2. The five stenoses greater than 70% (Class 4) showed a signal-void area at their level, due to severe dephasing induced by turbulences. Finally, there was a false-negative image of occlusion: the high-intensity signal of the thrombus was mistaken for one of flow. The data of our study were in accordance with the excellent results obtained by several authors in the literature, which makes it possible for us to propose this type of examination as a novel mean of investigating bifurcations of carotid arteries. Provided a strict technique is applied, and in addition to carotid bifurcation the Willis' circle and the cerebral parenchyma are explored, MR-angiography can complete the results of Doppler-echo. Standard arteriography could then be reserved to surgical patients and to those with discordant results of MR-arteriography and Doppler echo systems.

[Symptomatic venous angioma. Report of a case]. / Angiome veineux symptomatique. A propos d'un cas.

We report a case of venous angioma revealed by seizure after a non hemorrhagic venous infarct. The initial neuroradiological work-up with CT scan, angiography and brain MRI evidenced the venous infarction with abnormal contrast uptake. The control MRI 3 months later showed clear involution of the venous infarct. Non-hemorrhagic venous infarction on venous angiomas are exceptional. Only 2 cases have been reported in the literature. Impaired venous drainage could be implicated.

[Capillary telangiectasis, angiographically occult vascular malformations. MRI symptomatology apropos of 7 cases]. / Les télangiectasies capillaires, malformations vasculaires angiographiquement occultes. Sémiologie IRM à propos de 7 observations.

OBJECTIVE: Describe the MRI findings in capillary telangiectasias. MATERIALS AND METHODS: Between 1996 and 1999, we observed 9 cases of capillary telangiectasia in 7 patients explored 5 times for posterior fossa symptoms. In two cases capillary telangiectasia was a fortuitous discovery. All patients were explored by MRI with T1 sequences with and without gadolinium injections, turbo spin echo T2 coupled in 5 cases with a double echo gradient echo T2 sequence (TR: 970 ms, TE: 15 and 35 ms). Two patients also underwent vertebral angiography. RESULTS: The telangiectasia gave a low intensity signal on T1 sequences in 2 of the 9 cases and a discretely high intensity signal on T2 sequences in all cases. After gadolinium injection, 9 telangiectasias showed homogeneous or speckled enhancement. The echo-gradient T2 images showed a very low intensity signal in 7 out of 7 cases on the second echo. At the first echo, 4 capillary telangiectasias were undetectable. The two vertebral angiographies were normal and the follow-up MRI in 5 patients showed lesion stability. CONCLUSION: Pontile lesions with no mass effect showing enhancement after gadolinium injection and with or without a discrete T2 high intensity signal but with a frank echo-gradient T2 signal strongly suggest capillary telangiectasia.

[Emergency imaging of cerebrovascular accidents]. / Imagerie des accidents vasculaires cerebraux en urgence.

Over the last 25 years, advances in neuroimaging have significantly changed the evaluation and management of acute stroke syndromes. In the seventies, computed tomography (CT) could differentiate between ischemic and hemorrhagic stroke. Magnetic resonance imaging (MRI) is nowadays the imaging modality of choice in the initial assessment of acute stroke. MRI images can better discriminate acute, subacute and chronic infarcts, differentiate venous from arterial infarcts, detect arterial dissection, stenosis or occlusion. Diffusion-weighted images are highly sensitive and specific to acute infarction and the combination with perfusion technique is suitable to define potentially reversible ischemia (area of cerebral "mismatch" which is thought to represent the so-called ischemic penumbra). This penumbra is a potential therapeutic target of valuable interest for the treating physician.

[Direct carotid-cavernous fistula. Clinical, radiologic and therapeutic studies. Apropos of 49 cases]. / Fistule carotido-caverneuse directe. Etudes clinique, radiologique et thérapeutique. A propos de 49 cas.

MATERIALS AND METHODS: From 1977 to 1996, 49 direct carotido-cavernous fistulae were studied among the sixty some cases diagnosed over these 20 years. Five were caused by spontaneous rupture of an intracavernous aneurysm and the others were caused by trauma. RESULTS: The clinical presentation in 37 patients was exophthalmia with pulsating conjunctival hyperhemia and vascular murmur. Some cases had a neurological syndrome suggesting cavernous involvement. A bilateral presentation was observed in 2 cases. One patient had no ophthalmologic syndrome but had a vascular murmur. Prior to 1982, all patients were treated and cured by occlusion of the internal carotid after direct access via the neck using a 3 F Fogarty catheter. Since 1982, patients have been treated with the detachable balloon technique. The carotid was preserved in 16 cases. In one case, secondary thrombosis occurred due to major dissection. In one case, the size of the breach was too small for the balloon so a coil was used. In one other case, insertion of the guide wire and catheter was sufficient to occlude the fistula. There was one death during treatment due to fistula rupture and one partially regressive right hemiplegia which could not be explained. This patient also developed left hemiplegia two years later, again with no explaining cause. Cure was achieved in the other patients without sequellae. DISCUSSION: Direct carotido-cavernous fistulae due to rupture of an aneurysm or trauma are uncommon. When flow through the breach is minimal, vascular treatment may not be necessary unless clinical signs appear since this type of fistula heals spontaneously. In other cases, an endovascular balloon procedure is indicated. There are few complications. Embolization with coils or other devices should only be used in selected cases when the breach is too small for the balloon.

[Current imaging of an "aberrant course" of the internal carotid artery]. / Imagerie actuelle d'un "trajet aberrant" de l'artère carotide interne.

Blood flow via an aberrant internal carotid artery within the tympanic cavity is a rare pathogenic embryonic variation causing pulsatile tintinus and a vascularized tympanum. CT-scan provides the diagnosis. MRI and 3D time-of-flight MRA appear ideal for exploring aberrant flow both for diagnostic purposes and to establish the vascular morphology.

[Dural fistula of the cavernous sinus. Clinical and angiographic aspects. Results of particulate intravascular treatment]. / Fistules durales de la loge caverneuse. Aspects cliniques et angiographiques. Résultats du traitement endovasculaire au moyen de particules.

Thirteen patients with dural fistula of the cavernous sinus were studied by angiography. Nine of them presented with ophthalmic symptoms (chemosis and oculomotor disorders caused by the fistula). In one patient the lesion was discovered by chance, and 2 other patients had consulted for a disabling tinnitus. Eight patients accepted to the treated by the endovascular route for embolization of the maxillary artery, using particles. Embolization was unilateral in 4 cases and bilateral in 4 other cases. All embolizations were followed by serial control angiography immediately performed. All subjects were seen again as out-patients at 3 month, and 5 of them accepted a control angiography. Three patients were then regarded as clinically and anatomically cured. Two patients with incomplete clinical and angiographic results had a second embolization which resulted in clinical and anatomical cure at a 4-month control examination. These 8 patients were re-examined clinically after one month of treatment and found to be symptomless. Only one complication (transient oedema of the face) was noted. Dural fistulae are lesions that are most probably acquired by alteration of the physiological dural arteriovenous shunts occurring soon after venous thrombosis. Their course is capricious, and they sometimes heal spontaneously. However, the cavernous sinus location with its repercussion on the eye usually requires treatment. This treatment is initially endovascular; surgery and multifascicular irradiation being reserved for failures. Particle embolization of maxillary arteries is a simple and efficient procedure which must be used initially. If it proves insufficient, embolization of other arterial feeders (but it is often more dangerous) or the venous route can be tried.