Emergent Large Vessel Occlusion due to Intracranial Stenosis: Identification, Management, Challenges, and Future Directions.

This comprehensive literature review focuses on acute stroke related to intracranial atherosclerotic stenosis (ICAS), with an emphasis on ICAS-large vessel occlusion. ICAS is the leading cause of stroke globally, with high recurrence risk, especially in Asian, Black, and Hispanic populations. Various risk factors, including hypertension, diabetes, hyperlipidemia, smoking, and advanced age lead to ICAS, which in turn results in stroke through different mechanisms. Recurrent stroke risk in patients with ICAS with hemodynamic failure is particularly high, even with aggressive medical management. Developments in advanced imaging have improved our understanding of ICAS and ability to identify high-risk patients who could benefit from intervention. Herein, we focus on current management strategies for ICAS-large vessel occlusion discussed, including the use of perfusion imaging, endovascular therapy, and stenting. In addition, we focus on strategies that aim at identifying subjects at higher risk for early recurrent risk who could benefit from early endovascular intervention The review underscores the need for further research to optimize ICAS-large vessel occlusion treatment strategies, a traditionally understudied topic.

Use of Impedance Planimetry in the Diagnosis of Gastric Sleeve Stenosis: The Establishment of New Benchmark Values.

INTRODUCTION: Gastric sleeve stenosis (GSS) is an increasingly common adverse event following sleeve gastrectomy for which objective diagnostic criteria are lacking. Impedance planimetry measurements show promise in characterizing GSS, though normal and abnormal benchmark values have never been established. METHODS: This was a retrospective analysis of upper endoscopies performed with impedance planimetry for suspected GSS. A bariatric endoscopist, blind to impedance planimetry measurements, assessed gastric sleeve anatomy and graded GSS severity. Impedance planimetry of diameter and distensibility index (DI) were obtained using 3 different balloon volumes (30, 40, and 50 mL). RESULTS: A total of 110 upper endoscopies were included. Distribution of GSS was graded as none, mild, moderate, and severe in 19 (17%), 27 (25%), 34 (31%), and 30 (27%) procedures, respectively. In normal gastric sleeve anatomy, mean (±SD) diameter and DI measurements using consecutive balloon volumes ranged from 19.1 (±5.5) to 23.2 (±1.7) and 16.8 (±4.9) to 23.1 (±10.9), respectively. In severe GSS, mean diameter and DI measurements ranged from 10.3 (±3.0) to 16.6 (±2.1) and 7.5 (±2.4) to 7.7 (±2.4), respectively. When stratified by severity, impedance planimetry measurements of diameter and DI were significantly lower with each subsequent increase in GSS grade regardless of balloon fill volumes ( P ≤ 0.001). DISCUSSION: Impedance planimetry measurements provide objective assessment in the diagnosis of GSS and correlate with luminal narrowing. A diameter ≥20 mm and a DI ≥15 mm 2 /mm Hg, as measured by impedance planimetry, are predictive of normal gastric sleeve anatomy. This study provides new benchmark values for the diagnosis and severity of GSS.

Differentiation Between the Low and High Trans-Stenotic Pressure Gradient in Patients With Idiopathic Intracranial Hypertension Using 4D Flow MRI-Derived Hemodynamic Parameters.

BACKGROUND: Trans-stenotic pressure gradient (TPG) measurement is essential for idiopathic intracranial hypertension (IIH) patients with transverse sinus (TS) stenosis. Four-D flow MRI may provide a noninvasive imaging method for differentiation of IIH patients with different TPG. PURPOSE: To investigate the associations between 4D flow parameters and TPG, and to evaluate the diagnostic performance of 4D flow parameters in differentiating patients with high TPG (GroupHP) from low TPG (GroupLP). STUDY TYPE: Prospective. POPULATION: 31 IIH patients with TS stenosis (age, 38 ± 12 years; 23 females) and 5 healthy volunteers (age, 25 ± 1 years; 2 females). FIELD STRENGTH/SEQUENCE: 3T, 3D phase contrast MR venography, and gradient recalled echo 4D flow sequences. ASSESSMENT: Scan-rescan reproducibility of 4D flow parameters were performed. The correlation between TPG and flow parameters was analyzed. The netflow and velocity difference between inflow plane, outflow plane, and the stenosis plane were calculated and compared between GroupHP and GroupLP. STATISTICAL TESTS: Pearson's correlation or Spearman's rank correlation coefficient, Independent samples t-test or Wilcoxon rank-sum test, Intra-class correlation coefficient (ICC), Bland-Altman analyses, Receiver operating characteristic curves. A P value <0.05 was considered significant. RESULTS: Significant correlations were found between TPG and netflow parameters including Favg,out-s, Favg,in-s, Fmax,out-s, and Fmax,in-s (r = 0.525-0.565). Significant differences were found in Favg,out-s, Fmax,out-s, Favg,in-s, and Fmax,in-s between GroupHP and GroupLP. Using the cut-off value of 2.19 mL/sec, the Favg,out-s showed good estimate performance in distinguishing GroupHP from GroupLP (AUC = 0.856). The ICC (ranged 0.905-0.948) and Bland-Altman plots indicated good scan-rescan reproducibility. DATA CONCLUSIONS: 4D flow MRI derived flow parameters showed good correlations with TPG in IIH patients with TS stenosis. Netflow difference between outflow and stenosis location at TS shows the good performance in differentiating GroupHP and GroupLP cases. LEVEL OF EVIDENCE: 2 TECHNICAL EFFICACY: Stage 2.

Predictive role of ureteral wall thickness and patient characteristics in endoscopic treatment outcomes for ureteral stricture disease following stone surgery.

PURPOSE: To evaluate the role of certain radiological parameters and patient characteristics in predicting the success of endoscopic treatment in ureteral stricture disease. METHODS: Fifty one adult patients with ureteral stricture disease (< 1 cm) after developing due to upper ureteral stones with ureteroscopic laser disintegration were included and in addition to stone and patient parameters, radiological parameters including ureteral wall thickness (UWT) at the impacted stone site were also measured on computed tomography (CT) images. Patients were divided into two groups: Group 1: Patients with endoscopic treatment success and Group 2: Patients with endoscopic treatment failure. The possible relationship between the UWT values and other radiological parameter was comparatively evaluated. RESULTS: Mean UWT value assessed at the treated stone site was significantly higher in cases unresponsive to endoscopic treatment with values of 2.77 ± 1.03 mm and 4.25 ± 1.32 mm in Group 1 and 2 respectively. A cut off value 3.55 mm for UWT was found to be highly predictive for endoscopic treatment failure. CONCLUSIONS: Our current results indicated that assessment of UWT value at the obstructing stone could be helpful enough to predict the likelihood of failure following endoscopic management of strictures with high sensitivity and specificity. Evaluation of this particular parameter could let the endourologists to look for more rational treatment alternatives with necessary measures taken on time.

Preliminary findings on diagnostic performance of computed tomography perfusion images for intracranial arterial stenosis: a retrospective study.

OBJECTIVES: Computed tomographic perfusion (CTP) can play an auxiliary role in the selection of patients with acute ischemic stroke for endovascular treatment. However, data on CTP in non-stroke patients with intracranial arterial stenosis are scarce. We aimed to investigate images in patients with asymptomatic intracranial arterial stenosis to determine the detection accuracy and interpretation time of large/medium-artery stenosis or occlusion when combining computed tomographic angiography (CTA) and CTP images. METHODS: We retrospectively reviewed 39 patients with asymptomatic intracranial arterial stenosis from our hospital database from January 2021 to August 2023 who underwent head CTP, head CTA, and digital subtraction angiography (DSA). Head CTA images were generated from the CTP data, and the diagnostic performance for each artery was assessed. Two readers independently interpreted the CTA images before and after CTP, and the results were analyzed. RESULTS: After adding CTP maps, the accuracy (area under the curve) of diagnosing internal carotid artery (R1: 0.847 vs. 0.907, R2: 0.776 vs. 0.887), middle cerebral artery (R1: 0.934 vs. 0.933, R2: 0.927 vs. 0.981), anterior cerebral artery (R1: 0.625 vs. 0.750, R2: 0.609 vs. 0.750), vertebral artery (R1: 0.743 vs. 0.764, R2: 0.748 vs. 0.846), and posterior cerebral artery (R1: 0.390 vs. 0.575, R2: 0.390 vs. 0.585) occlusions increased for both readers (p < 0.05). Mean interpretation time (R1: 72.4 ± 6.1 s vs. 67.7 ± 6.4 s, R2: 77.7 ± 3.8 s vs. 72.6 ± 4.7 s) decreased when using a combination of both images both readers (p < 0.001). CONCLUSIONS: The addition of CTP images improved the accuracy of interpreting CTA images and reduced the interpretation time in asymptomatic intracranial arterial stenosis. These findings support the use of CTP imaging in patients with asymptomatic intracranial arterial stenosis.

Management of anastomotic biliary stricture through utilizing percutaneous transhepatic cholangioscopy.

AIM: Occurrence of anastomotic biliary stricture (AS) remains an essential issue following hepatobiliary surgeries, and percutaneous transhepatic cholangioscopy (PTCS) has great therapeutic significance in handling refractory AS for patients with altered gastrointestinal anatomy after cholangio-jejunostomy. This present study aimed to investigate feasibility of PTCS procedures in AS patients for therapeutic indications. MATERIALS AND METHODS: This study was a single-center, retrospective cohort study with a total number of 124 consecutive patients who received therapeutic PTCS due to AS. Clinical success rate, required number, and adverse events of therapeutic PTCS procedures as well as patients survival state were reviewed. RESULTS: These 124 patients previously underwent choledochojejunostomy or hepatico-jejunostomy, and there was post-surgical altered gastrointestinal anatomy. Overall, 366 therapeutic PTCS procedures were performed for these patients through applying rigid choledochoscope, and the median time of PTCS procedures was 3 (1-11). Among these patients, there were 34 cases (27.32%) accompanied by biliary strictures and 100 cases (80.65%) were also combined with biliary calculi. After therapeutic PTCS, most patients presented with relieved clinical manifestations and improved liver functions. The median time of follow-up was 26 months (2-86 months), and AS was successfully managed through PTCS procedures in 104 patients (83.87%). During the follow-up period, adverse events occurred in 81 cases (65.32%), most of which were tackled through supportive treatment. CONCLUSION: PTCS was a feasible, safe and effective therapeutic modality for refractory AS, which may be a promising alternative approach in clinical cases where the gastrointestinal anatomy was changed after cholangio-jejunostomy.

Celiac trunk thrombosis in a patient with antiphospholipid syndrome induced by median arcuate ligament compression: a case presentation and literature review.

Median arcuate ligament syndrome (MALS) is a rare disorder caused by the compression of the celiac axis by the fibrous structure of the diaphragm called the median arcuate ligament. Patients with MALS are usually undiagnosed unless characteristic symptoms such as nausea and vomiting, postprandial pain, and weight loss are presented. We report a case of a 29-year-old patient diagnosed with MALS and secondary antiphospholipid syndrome (APS) that developed celiac trunk, common hepatic artery and splenic artery thrombosis. There is not enough information on MALS as a trigger of thrombosis in predisposed patients such as those with APS. However, the case gives rise to suspicion and highlights the diagnostic processes, especially for patients with APS presenting postprandial abdominal pain and weight loss. This review likewise aims at the importance of Doppler ultrasonography as a screening tool and computer tomography (CT) or magnetic resonance (MR) both in the angiography variant, especially to diagnose confirmation and underlying treatment options.

Jugular foramen stenosis in external hydrocephalus in infants.

OBJECTIVE: To measure the size of jugular foramina in infants affected by external hydrocephalus (EH) and in a control group, to support the hypothesis that a jugular foramen (JF) stenosis may determine dural venous sinus alterations and increased venous outflow resistance as main pathophysiological factor. METHODS: Minimum, maximum, and mean values of JF areas were measured in a series of phase-contrast magnetic resonance venous angiography (angio MRV PCA3D) performed on 81 infants affected by EH. Results were compared with a group of 54 controls. RESULTS: Smaller JF area was significantly smaller in patients versus controls (43.1 ± 14.6 vs. 52.7 ± 17.8; p < 0.001) resulting in a significantly smaller mean JF areas in patients vs. controls (51.6 ± 15.8 vs. 57.0 ± 18.3; p = 0.043). In patients, smaller JF areas were significantly associated with higher venous obstruction grading score (VOGS) both on the right (p = 0.018) and on the left side (p = 0.005). Positional plagiocephaly (cranial vault asymmetry index > 3.5%) was more frequent among EH patients than controls (38/17) but the difference was not significant (p = 0.07). In the 38 plagiocephalic patients, JF area was smaller on the flattened side than the contralateral in a significant number of cases both in right (21/7) and left (9/1) plagiocephaly (p < 0.0005) as well as the mean area (48.2 + 16.4 mm2 vs. 57.5 + 20.7 mm2, p = 0.002) and VOGS was significantly higher on the plagiocephalic side than on the contralateral side (1.6 ± 1.1 vs. 1.1 ± 0.9, p = 0.019). CONCLUSION: In this series of infants affected by EH, the mean size of the ostium of both JF resulted significantly smaller than controls. JF stenosis was significantly associated with higher degrees of venous obstruction on both sides, suggesting a direct extrinsic effect of JF size on dural sinus lumen and possible consequent effect on venous outflow resistance. Positional plagiocephaly, when present, was associated with a decreased JF area and increased VOGS on the flattened side.

Prevalence and Procedural Risk of Intracranial Atherosclerotic Stenosis Coexisting With Unruptured Intracranial Aneurysm.

BACKGROUND: Coexistence of intracranial atherosclerotic stenosis (ICAS) and unruptured intracranial aneurysms (UIAs) is increasingly encountered in clinical practice. This study aims to determine the prevalence of ICAS in patients with UIAs and procedural ischemic risk associated with ICAS when treating UIAs. METHODS: Based on the CAIASA study (Coexistence of Atherosclerotic Intracranial Arterial Stenosis With Intracranial Aneurysms), we prospectively included patients undergoing treatment procedures for UIAs from October 2015 to December 2020 at Beijing Tiantan Hospital, China. We used computed tomography angiography or digital subtraction angiography to diagnose ICAS (stenosis≥50%). Multivariable logistic regression and propensity-score matching were performed to evaluate the risk of procedure-related ischemic stroke and unfavorable outcome associated with ICAS. The ICAS score was used to explore the association between different burden of ICAS and procedure-related ischemic risk. RESULTS: Among 3949 patients who underwent endovascular or open surgical procedures for UIAs, 245 (6.2%) had ICAS. After exclusion, 15.7% (32/204) of patients with ICAS experienced procedure-related ischemic stroke compared with 5.0% (141/2825) of patients without ICAS. From the unmatched and matched cohort, ICAS was significantly associated with increased risk of procedure-related ischemic stroke (unmatched: adjusted odds ratio=3.11 [1.89-5.11]; and matched: adjusted odds ratio=2.99 [1.38-6.48]). This association became more evident among patients not receiving antiplatelet therapy (Pinteraction=0.022). For patients undergoing different treatment modalities, similar increased risks were observed (clipping: adjusted odds ratio=3.43 [1.73-6.79]; and coiling: adjusted odds ratio=3.59 [1.94-6.65]). Higher ICAS score was correlated with higher procedural ischemic risk (Ptrend<0.001). CONCLUSIONS: The occurrence of ICAS is not infrequent in patients with UIAs. ICAS confers an ~2-fold increased procedural ischemic risk, irrespective of clipping or coiling. Previous antiplatelet therapy may decrease the risk. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT02795078.

4Dflow-VP-Net: A deep convolutional neural network for noninvasive estimation of relative pressures in stenotic flows from 4D flow MRI.

PURPOSE: To estimate relative transvalvular pressure gradient (TVPG) noninvasively from 4D flow MRI. METHODS: A novel deep learning-based approach is proposed to estimate pressure gradient across stenosis from four-dimensional flow MRI (4D flow MRI) velocities. A deep neural network 4D flow Velocity-to-Presure Network (4Dflow-VP-Net) was trained to learn the spatiotemporal relationship between velocities and pressure in stenotic vessels. Training data were simulated by computational fluid dynamics (CFD) for different pulsatile flow conditions under an aortic flow waveform. The network was tested to predict pressure from CFD-simulated velocity data, in vitro 4D flow MRI data, and in vivo 4D flow MRI data of patients with both moderate and severe aortic stenosis. TVPG derived from 4Dflow-VP-Net was compared to catheter-based pressure measurements for available flow rates, in vitro and Doppler echocardiography-based pressure measurement, in vivo. RESULTS: Relative pressures calculated by 4Dflow-VP-Net and in vitro pressure catheterization revealed strong correlation (r2 = 0.91). Correlations analysis of TVPG from reference CFD and 4Dflow-VP-Net for 450 simulated flow conditions showed strong correlation (r2 = 0.99). TVPG from in vitro MRI had a correlation coefficient of r2 = 0.98 with reference CFD. 4Dflow-VP-Net, applied to 4D flow MRI in 16 patients, showed comparable TVPG measurement with Doppler echocardiography (r2 = 0.85). Bland-Altman analysis of TVPG measurements showed mean bias and limits of agreement of -0.20 ± 2.07 mmHg and 0.19 ± 0.45 mmHg for CFD-simulated velocities and in vitro 4D flow velocities. In patients, overestimation of Doppler echocardiography relative to TVPG from 4Dflow-VP-Net (10.99 ± 6.77 mmHg) was observed. CONCLUSION: The proposed approach can predict relative pressure in both in vitro and in vivo 4D flow MRI of aortic stenotic patients with high fidelity.

High-Resolution Vessel Wall MRI in Assessing Postoperative Restenosis of Intracranial Atherosclerotic Disease Before Drug-Coated Balloon Treatment: An Outcome Prediction Study.

BACKGROUND: Postoperative restenosis frequently occurs in intracranial atherosclerotic disease (ICAD) patients after drug-coated balloon (DCB) treatment. However, high-risk plaques associated with postoperative restenosis remain to be explored. PURPOSE: To assess whether high-resolution vessel wall MRI (HR-VWI) contributes to the identification of high-risk plaques associated with postoperative restenosis before DCB treatment. STUDY TYPE: Retrospective. SUBJECTS: A total of 70 patients with ICAD who underwent DCB treatment. FIELD STRENGTH/SEQUENCE: 3.0 T; magnetic resonance angiography, HR-VWI. ASSESSMENT: All patients underwent HR-VWI examination prior to DCB treatment. Digital subtraction angiography (DSA) measurement was assessed 6 months (±1 month) after operation to determine the vessel restenosis, classifying patients into three groups of no stenosis, mild stenosis (<50%), and restenosis (>50%). Clinical factors and HR-VWI characteristics, including vessel and lumen area at maximal lumen narrowing (MLN), plaque area and length, degree of stenosis, plaque burden, remodeling index, and enhancement amplitude, were compared among three groups. Clinical factors and HR-VWI characteristics were separately evaluated for the association with postoperative restenosis. STATISTICAL TESTS: Kolmogorov-Smirnov test, intra-class correlation coefficient, Kruskal Wallis H test, Mann-Whitney U test, receiver operating characteristic (ROC) curve, multivariable linear regression analysis. P-values <0.05 was considered statistically significant. RESULTS: During the follow-up DSA measurement, 13 lesions (18.5%) showed restenosis. With HR-VWI, significant differences among three groups were observed in plaque length, lumen area of MLN, degree of stenosis, enhancement amplitude, and plaque burden. In ROC analysis, plaque length (area under the curve [AUC] = 0.809), and enhancement amplitude (AUC = 0.880) provided higher efficacy in identification of high-risk plaques associated with postoperative restenosis than degree of stenosis (AUC = 0.746) and plaque burden (AUC = 0.759). Multivariable linear regression analysis showed that plaque length and enhancement amplitude were independent prognostic factors of postoperative restenosis. DATA CONCLUSION: HR-VWI has the potential to identify high-risk plaques in ICAD patients before DCB treatment. LEVEL OF EVIDENCE: 4 TECHNICAL EFFICACY: Stage 2.

Association of albumin levels with the risk of intracranial atherosclerosis.

OBJECTIVE: Intracranial artery stenosis from atherosclerosis is one of the etiologies of ischemic stroke. There is a correlation between serum albumin level and atherosclerosis. We aimed to investigate whether serum albumin level is related to intracranial atherosclerosis and its significance. METHODS: A retrospective analysis of 150 individuals who underwent cervical cerebral angiography after admission, including clinical data, imaging data, and laboratory data. Since atherosclerosis cannot be used as a good quantitative indicator, we choose the degree of arterial stenosis to reflect atherosclerosis. SPSS 24 software was used for data analysis, and P < .05 was considered statistically significant. RESULTS: Univariate analysis showed that age, diabetes, and serum albumin level were risk factors for intracranial atherosclerosis (P < .05). Multivariate analysis showed that diabetes and serum albumin levels were independent risk factors for intracranial atherosclerosis (P< 0.05). The average serum albumin level in the non-severe group was 39.80 g/L, and the average serum albumin level in the severe group was 37.60 g/L. The area under the ROC curve of serum albumin was 0.667 (95%CI 0.576-0.758, P = .001), the cutoff value was 0.332176, the sensitivity was 75.9%, and the specificity was 57.3%. CONCLUSION: Serum albumin level is an independent risk factor for intracranial atherosclerosis, and provides a new direction for clinical prevention and treatment.

Endovascular stenting to treat an acute stroke caused by severe stenosis of the duplicated middle cerebral artery.

BACKGROUND: The duplicated middle cerebral artery (DMCA), a rare anatomical variant of the middle cerebral artery, arises between the anterior choroidal artery and the distal end of the internal carotid artery. We present the case of a patient who had an acute progressive stroke caused by severe stenosis in the initial segment of the DMCA and was successfully treated with endovascular stenting. CASE PRESENTATION: A 57-year-old man was admitted to our hospital with sudden left extremity weakness for three days. Cranial magnetic resonance imaging revealed multiple fresh infarcts in the right basal ganglia and temporal lobe. Cerebrovascular imaging revealed severe stenosis of the right DMCA's initial segment. However, despite standard medical therapy, the patient's limb weakness worsened. Based on the clinical and imaging findings, we speculated that severely stenotic DMCA is responsible for the acute progressive stroke. On the basis of the best medical treatment, the patient successfully underwent endovascular stent implantation under general anesthesia two weeks after the onset. The patient's condition was stable after interventional therapy, and his postoperative follow-up prognosis was favorable. CONCLUSIONS: Endovascular stenting may be a feasible treatment for symptomatic severe stenosis of the DMCA in cases of poor control with standard medications.

Evaluation of symptomatic small bowel stricture in Crohn's disease by double-balloon endoscopy.

PURPOSE: To assess the efficacy of double-balloon endoscopy (DBE) for the detection of small-bowel strictures in Crohn's disease (CD). METHODS: This tertiary-referral hospital cohort study was conducted between January 2018 and May 2022. CD patients with symptoms of small-bowel stricture were enrolled sequentially. All of the patients were subjected to both computed tomography enterography (CTE) and DBE, and their symptoms of stricture were assessed using the Crohn's Disease Obstructive Score (CDOS). The diagnostic yield of DBE was compared to that of CTE, and the relationship between the DBE findings and CDOS was investigated. The factors influencing the DBE diagnosis were examined using Cox regression analysis. RESULTS: This study included 165 CD patients. The CDOS scores were higher in 95 patients and lower in 70 patients. DBE detected 92.7% (153/165) and CTE detected 85.5% (141/165) of the strictures. The DBE diagnostic yields were 94.7% (90/95) in the high CDOS patients and 91.4% (64/70) in the low CDOS patients (P = 0.13). Patients with a history of abdominal surgery and abscess had a lower diagnosis rate in the multivariate analysis. CONCLUSION: DBE has been demonstrated to be an efficient diagnostic method for detecting small bowel strictures in CD patients. Additionally, there was no difference in the diagnostic yields between patients with low and high obstructive scores.

Reversible cerebral vasoconstriction syndrome after levonorgestrel-releasing intrauterine device placement-Case report.

BACKGROUND: Reversible cerebral vasoconstriction syndrome (RCVS) is a disease characterized by reversible multifocal narrowing of the cerebral arteries with clinical manifestations that typically include thunderclap headache and occasionally brain edema, stroke, or seizure. The exact pathophysiology of RCVS is not well known. CASE: A 46-year-old female with history of episodic migraine presented with 1-month duration of worsening headaches that had become more severe over the past 2 weeks. The headaches were episodic and thunderclap in onset and aggravated by physical exertion or emotional situations. A neurological examination was unremarkable including initial head computed tomography (CT). A CT angiogram of the head showed multifocal stenosis in the right anterior cerebral artery, bilateral middle cerebral arteries, and right posterior cerebral artery. Cerebral angiogram confirmed the CT angiogram findings. A repeated CT angiogram a few days later showed improvement in the multifocal cerebral arterial stenosis. Lumbar puncture and autoimmune workup were not suggestive of neuroinflammatory etiology. She had one generalized tonic-clonic seizure during her second day of hospitalization. The patient's thunderclap onset headaches resolved in 1 week after she was managed with blood pressure control and pain medication. She denied any illicit drug use or any new medications other than the placement of a levonorgestrel-releasing intrauterine device (IUD) about 6 weeks prior to her presentation. CONCLUSIONS: Our case suggests a possible link between RCVS and levonorgestrel-releasing IUDs.

Measurement of Stricture Dimensions Using a Visual Comparative Estimation Method With Biopsy Forceps During Endoscopy.

BACKGROUND: Estimation of the dimensions of endoscopic findings such as stricture diameter is largely subjective. Accurate assessment of stricture dimensions has multiple benefits including facilitating the choice of appropriately sized endoscopic therapies for treating stricture, properly tracking response to endoscopic therapies between procedures, and potentially even predicting outcomes of endoscopic therapy. METHODS: Endoscopies performed in children with repaired esophageal atresia between August 2019 and August 2021 for which both (1) an endoscopic estimate of esophageal stricture diameter obtained by visual comparison with the known dimensions of the biopsy forceps and (2) an intraoperative esophageal fluoroscopy study were performed were included for analysis. Fluoroscopic stricture diameter measurements were manually obtained using a software ruler tool calibrated to the known dimensions of the intraluminal endoscope. Statistical concordance was calculated between the visual diameter estimates and the standard fluoroscopic stricture measurements. RESULTS: One hundred ninety-one endoscopies were included for analysis. Lin's concordance correlation coefficient was 0.92 (95% confidence interval: 0.89-0.94) between the visual diameter estimates and the fluoroscopic stricture measurements. Correlation was strongest for smaller to mid-sized stricture diameters. CONCLUSIONS: Use of the biopsy forceps as a visual reference of known dimensions enables accurate visual estimation of esophageal stricture diameter during endoscopy using commonly available tools, with high concordance with standard fluoroscopic measurement techniques.

Comparison of single coronal thick-slab minimum intensity projection with flexible bronchoscopy for airway compression in children with lymphobronchial tuberculosis.

AIM: To generate standardised coronal minimum intensity projection (MinIP) computed tomography (CT) reconstructions, and compare these with flexible bronchoscopy in children with lymphobronchial tuberculosis (LBTB). MATERIALS AND METHODS: Standardised coronal MinIP reconstructions were performed from CT images in children with LBTB and the findings of three readers were compared with the reference standard, flexible bronchoscopy (FB), regarding airway narrowing. Intraluminal lesions, the site of the stenosis, and the degree of stenosis were also evaluated. The length of stenosis was evaluated by CT MinIP only. RESULTS: Sixty-five children (38 males; 58.5% and 27 females; 41.5%), with ages ranging from 2.5 to 144 months were evaluated. Coronal CT MinIP demonstrated a sensitivity of 96% and specificity of 89% against FB. The most common site of stenosis was the bronchus intermedius (91%), followed by the left main bronchus (85%), the right upper lobe bronchus RUL (66%), and the trachea (60%). CONCLUSION: Coronal CT MinIP reconstruction is useful in demonstrating airway stenosis in children with lymphobronchial TB, with high sensitivity and specificity. CT MinIP had additional advantages over FB in that it allowed objective measurement of the diameter of stenosis, measurement of the length of stenosis, and evaluation of post-stenotic segments of the airways and lung parenchymal abnormalities.

Assessment of the degree of arterial stenosis in intracranial atherosclerosis using 3D high-resolution MRI: comparison with time-of-flight MRA, contrast-enhanced MRA, and DSA.

AIM: To compare the accuracy of three-dimensional (3D) high-resolution (HR) magnetic resonance imaging (MRI), time-of-flight magnetic resonance angiography (TOF-MRA), contrast-enhanced magnetic resonance angiography (CE-MRA), and digital subtraction angiography (DSA) in measuring the degree of stenosis in intracranial atherosclerosis. MATERIALS AND METHODS: All patients with intracranial artery ischaemic events underwent HR-MRI, TOF-MRA, and CE-MRA analysis, and some of these patients underwent DSA examination. The correlation between different methods for measuring the degree of lumen stenosis was analysed. The accuracy of HR-MRI, TOF-MRA, and CE-MRA was evaluated and compared with that of DSA. RESULTS: A total of 189 arterial stenoses were identified in 93 patients. Of these, 72 patients with 142 arterial stenoses underwent DSA examination. A very strong correlation between HR-MRI and CE-MRA measurements was shown (r=0.839, p<0.0001). The correlation between HR-MRI and TOF-MRA measurements was strong (r=0.720, p<0.0001). A very strong correlation between HR-MRI and DSA measurements was found (r=0.864, p<0.0001), and a similar correlation was observed between CE-MRA, and DSA measurements (r=0.843, p<0.0001). The correlation between TOF-MRA and DSA measurements was strong (r=0.686, p<0.0001). There was substantial agreement between HR-MRI and DSA measurements (K = 0.772) and between CE-MRA, and DSA measurements (K = 0.734) that was slightly higher than the agreement between TOF-MRA and DSA measurements (K = 0.636). CONCLUSION: HR-MRI can accurately measure stenosis (especially for moderate and severe stenosis) in intracranial atherosclerosis by direct visualisation of the vessel lumen and steno-occlusive plaque.

Effect of Truncal-Type Occlusion Based on Multiphase or Single-Phase Computed Tomographic Angiography in Predicting Intracranial Atherosclerotic Stenosis-Related Acute Middle Cerebral Artery Occlusion.

OBJECTIVE: To investigate whether truncal-type occlusion based on multiphase computed tomographic angiography (mpCTA) was more effective for predicting intracranial atherosclerotic stenosis-related occlusion (ICAS-O) than occlusion type based on single-phase computed tomographic angiography (spCTA) in patients with acute ischemic stroke with large-vessel occlusion (AIS-LVO) in the middle cerebral artery (MCA). METHODS: Data were retrospectively collected from 72 patients with AIS-LVO in the MCA between January 2018 and December 2019. The occlusion types included truncal-type and branching-site occlusions. The association between ICAS-O and occlusion type based on the 2 computed tomographic angiography patterns was analyzed, and receiver operating characteristic curves were plotted for assessment. The areas under the curve were compared to determine the difference between the predictive powers of truncal-type occlusion based on mpCTA and spCTA. RESULTS: Among the 72 patients, 16 were classified as having ICAS-O and 56 as having embolisms. In univariate analysis, truncal-type occlusion was significantly associated with ICAS-O ( P < 0.001 for mpCTA and P = 0.001 for spCTA). After multivariable analysis, truncal-type occlusion based on both mpCTA and spCTA remained independently associated with ICAS-O ( P = 0.002 for mpCTA and P = 0.029 for spCTA). The areas under the curve were 0.821 for mpCTA and 0.683 for spCTA; this difference was statistically significant ( P = 0.024). CONCLUSIONS: In patients with AIS-LVO in the MCA, truncal-type occlusion based on mpCTA enables more accurate detection of ICAS-O than that based on spCTA.

Cognitive impairment in asymptomatic cerebral arterial stenosis: a P300 study.

BACKGROUND: Cerebral arterial stenosis (CAS), in the absence of a structural lesion, can result in cognitive impairment that represents an ongoing contention among studies. Accordingly, we investigated cognitive functions in asymptomatic patients with CAS, using P300 which is a neurophysiological tool. We also compared cognition in intracranial stenosis (ICS) and extracranial stenosis (ECS). METHODS: Asymptomatic patients with CAS (≥ 70%) in the absence of structural brain lesions were categorized into ICS and ECS groups of 15 patients each, in addition to 15 normal controls. MRI, MRA, CT angiography, P300 analysis, Mini-Mental State examination (MMSE), Wisconsin Card Sorting Test (WCST), and Wechsler Memory Scale Test-Revised (WMST) were performed to all patients. RESULTS: Impairment on all cognitive scales ranged from 70 up to 100% among CAS group. Prolonged p300 latency and reaction time correlated with worse performance on WMST (p = 0.02), while lower amplitude and decreased accuracy correlated with more errors on WCST (p = 0.01). ICS scores on WCTS were lower than those of ECS group (p = 0.001), while ECS had a longer reaction time (p = 0.02) and lower scores on MMS and WMST than those of ICS group (p = 0.03). CONCLUSION: Patients with asymptomatic CAS had a high prevalence of cognitive dysfunction which places them at risk of higher morbidity. ICS group showed impairment on executive functions, while the ECS group showed predilection to memory and information processing dysfunction.