Stroke with large vessel occlusion in the posterior circulation: IV thrombolysis plus thrombectomy versus IV thrombolysis alone.

Efficacy and safety of mechanical thrombectomy (MT) for stroke with posterior circulation large vessel occlusion (LVO) is still under debate. We aimed to compare the outcomes of stroke patients with posterior circulation LVO treated with intravenous thrombolysis (IVT) (< 4.5 h after symptom onset) plus MT < 6 h after symptom onset with those treated with IVT alone (< 4.5 h after symptom onset). Patients enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke (IRETAS) and in the Italian centers included in the SITS-ISTR were analysed. We identified 409 IRETAS patients treated with IVT plus MT and 384 SITS-ISTR patients treated with IVT alone. IVT plus MT was significantly associated with higher rate of sICH (ECASS II) compared with IVT alone (3.1 vs 1.9%; OR 3.984, 95% CI 1.014-15.815), while the two treatments did not differ significantly in 3-month mRS score ≤ 3 (64.3 vs 74.1%; OR 0.829, 95% CI 0.524-1.311). In 389 patients with isolated basilar artery (BA) occlusion, IVT plus MT was significantly associated with higher rate of any ICH compared with IVT alone (9.4 vs 7.4%; OR 4.131, 95% CI 1.215-14.040), while two treatments did not differ significantly in 3-month mRS score ≤ 3 and sICH per ECASS II definition. IVT plus MT was significantly associated with higher rate mRS score ≤ 2 (69.1 vs 52.1%; OR 2.692, 95% CI 1.064-6.811) and lower rate of death (13.8 vs 27.1%; OR 0.299, 95% CI 0.095-0.942) in patients with distal-segment BA occlusion, while two treatments did not differ significantly in 3-month mRS score ≤ 3 and sICH per ECASS II definition. IVT plus MT was significantly associated with lower rate of mRS score ≤ 3 (37.1 vs 53.3%; OR 0.137, 0.009-0.987), mRS score ≤ 1 (22.9 vs 53.3%; OR 0.066, 95% CI 0.006-0.764), mRS score ≤ 2 (34.3 vs 53.3%; OR 0.102, 95% CI 0.011-0.935), and higher rate of death (51.4 vs 40%; OR 16.244, 1.395-89.209) in patients with proximal-segment BA occlusion. Compared with IVT alone, IVT plus MT was significantly associated with higher rate of sICH per ECASS II definition in patients with stroke and posterior circulation LVO, while two treatment groups did not differ significantly in 3-month mRS score ≤ 3. IVT plus MT was associated with lower rate of mRS score ≤ 3 compared with IVT alone in patients with proximal-segment BA occlusion, whereas no significant difference was found between the two treatments in primary endpoints in patients isolated BA occlusion and in the other subgroups based on site occlusion.

IV thrombolysis plus thrombectomy versus IV thrombolysis alone for minor stroke with anterior circulation large vessel occlusion from the IRETAS and Italian SITS-ISTR cohorts.

INTRODUCTION: The aim of this study was to compare the outcomes of patients treated with intravenous thrombolysis (IVT) <4.5 h after symptom onset plus mechanical thrombectomy (MT) <6 h with those treated with IVT alone <4.5 h for minor stroke (NIHSS ≤5) with large vessel occlusion (LVO) in the anterior circulation. PATIENTS AND METHODS: Patients enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke (IRETAS) and in the Italian centers included in the SITS-ISTR were analyzed. RESULTS: Among the patients with complete data on 24-h ICH type, 236 received IVT plus MT and 382 received IVT alone. IVT plus MT was significantly associated with unfavorable shift on 24-h ICH types (from no ICH to PH-2) (OR, 2.130; 95% CI, 1.173-3.868; p=0.013) and higher rate of PH (OR, 4.363; 95% CI, 1.579-12.055; p=0.005), sICH per ECASS II definition (OR, 5.527; 95% CI, 1.378-22.167; p=0.016), and sICH per NINDS definition (OR, 3.805; 95% CI, 1.310-11.046; p=0.014). Among the patients with complete data on 3-month mRS score, 226 received IVT plus MT and 262 received IVT alone. No significant difference was reported between IVT plus MT and IVT alone on mRS score 0-1 (72.1% versus 69.1%), mRS score 0-2 (79.6% versus 79%), and death (6.2% versus 6.1%). CONCLUSIONS: Compared with IVT alone, IVT plus MT was associated with unfavorable shift on 24-h ICH types and higher rate of 24-h PH and sICH in patients with minor stroke and LVO in the anterior circulation. However, no difference was reported between the groups on 3-month functional outcome measures.

MR-guided focused ultrasound-induced blood-brain barrier opening for brain metastasis: a review.

Although the therapeutic armamentarium for brain metastases (BMs) has been expanded from innovative surgical techniques and radiotherapy to include targeted therapies and immunotherapy, the prognosis of BMs remains poor. Despite the proven efficacy of numerous compounds in preclinical studies, the limited penetration of promising therapeutic agents across the blood-brain barrier (BBB) remains an unaddressed issue. Recently, low-intensity magnetic resonance-guided focused ultrasound (MRgFUS) in combination with microbubbles has been shown to overcome vascular and cellular transport barriers in the brain and tumor microenvironment, resulting in increased drug diffusion and preliminary effective results. Preclinical studies have investigated the increased penetration of many therapeutic agents including doxorubicin, trastuzumab, and ipilimumab into the CNS with promising results. Furthermore, anticancer drugs combined with MRgFUS-induced BBB opening have been demonstrated to improve animal survival and slow tumor progression. Accordingly, the first clinical trial has recently been launched and hopefully the results will provide evidence for the safety and efficacy of drug delivery enhanced by MRgFUS-induced BBB opening in BMs. This review aims to provide an overview of transcranial low-intensity MRgFUS application for BBB disruption and a comprehensive overview of the most relevant evidence in the treatment of BMs.

Structural and functional brain networks of individual differences in trait anger and anger control: An unsupervised machine learning study.

The ability to experience, use and eventually control anger is crucial to maintain well-being and build healthy relationships. Despite its relevance, the neural mechanisms behind individual differences in experiencing and controlling anger are poorly understood. To elucidate these points, we employed an unsupervised machine learning approach based on independent component analysis to test the hypothesis that specific functional and structural networks are associated with individual differences in trait anger and anger control. Structural and functional resting state images of 71 subjects as well as their scores from the State-Trait Anger Expression Inventory entered the analyses. At a structural level, the concentration of grey matter in a network including ventromedial temporal areas, posterior cingulate, fusiform gyrus and cerebellum was associated with trait anger. The higher the concentration, the higher the proneness to experience anger in daily life due to the greater tendency to orient attention towards aversive events and interpret them with higher hostility. At a functional level, the activity of the default mode network (DMN) was associated with anger control. The higher the DMN temporal frequency, the stronger the exerted control over anger, thus extending previous evidence on the role of the DMN in regulating cognitive and emotional functions in the domain of anger. Taken together, these results show, for the first time, two specialized brain networks for encoding individual differences in trait anger and anger control.

Imaging of inner ear malformations: a primer for radiologists.

In the multidisciplinary management of patients with inner ear malformations (IEMs), the correct diagnosis makes the differences in terms of clinical and surgical treatment. The complex anatomical landscape of the inner ear, comprising several small structures, makes imaging of this region particularly challenging for general radiologists. Imaging techniques are important for identifying the presence and defining the type of IEM and the cochlear nerve condition. High-resolution magnetic resonance imaging (MRI) sequences and high-resolution computed tomography (HRCT) are the mainstay imaging techniques in this area. Dedicated MRI and HRCT protocols play an important role in the diagnosis and treatment of patients with inner ear disease. The most suitable technique should be selected depending on the clinical setting. However, in cases of congenital malformation of the inner ear, these techniques should be considered complementary. Since prompt intervention has a positive impact on the treatment outcomes, early diagnosis of IEMs is very important in the management of deaf patients. This article reviews the key concepts of IEMs for clinical radiologists by focusing on recent literature updates, discusses the principal imaging findings and clinical implications for every IEM subgroup, thus providing a practical diagnostic approach.

Mild Encephalitis/Encephalopathy with Reversible Splenial Lesion (MERS) due to Cytomegalovirus: Case Report and Review of the Literature.

Mild encephalopathy with a reversible splenial lesion (MERS) is a clinico-radiological syndrome characterized by a transient mild encephalopathy and MRI findings of a reversible lesion in the splenium of corpus callosum (SCC). It is classified in MERS type I and MERS type II, depending on the involvement of SCC alone or also other white matter areas. The syndrome mainly affects children and young adults; the prognosis is favorable with complete or nearly complete neurological and radiological resolution within days or weeks. The vast majority of the cases described in the literature involve Asian and Australian children. The exact pathophysiology is unknown; however, infectious-related MERS (in particular virus associated MERS) remains the most common cause of reversible splenial lesions in childhood. To the best of our knowledge, there is only one published case of MERS associated with cytomegalovirus (CMV) infection involving an Australian child. We present here the first case of a CMV-related MERS in a European Caucasian child.

Cingulum bundle alterations underlie subjective fatigue in multiple sclerosis.

OBJECTIVE: To evaluate the neural basis of subjective fatigue in subjects with multiple sclerosis (MS) using a connectionist framework. METHODS: Seventy seven subjects with relapsing-remitting MS were recruited in the study and underwent subjective fatigue evaluations and a diffusion MRI scan. Firstly, local white matter Fractional Anisotropy values were correlated with subjective fatigue scores using a voxel-wise approach. The long-range loss of connectivity due to structural damage in the white matter voxels thus associated with subjective fatigue was then assessed using the Network Modification (NeMo) package. RESULTS: A voxel-wise regression analysis with fatigue scores revealed a significant association between structural damage and fatigue levels in two discrete white matter clusters, both included in the left cingulate bundle. The connectivity analysis revealed that damage in these clusters was associated with loss of structural connectivity in the anterior and medial cingulate cortices, dorsolateral prefrontal areas and in the left caudate. DISCUSSION: Our data point to the cingulum bundle and its projections as the key network involved in subjective fatigue perception in MS. More generally, these results suggest the potential of the connectionist framework to generate coherent models of the neural basis of complex symptomatology in MS.

Upper limb motor rehabilitation impacts white matter microstructure in multiple sclerosis.

Upper limb impairments can occur in patients with multiple sclerosis, affecting daily living activities; however there is at present no definite agreement on the best rehabilitation treatment strategy to pursue. Moreover, motor training has been shown to induce changes in white matter architecture in healthy subjects. This study aimed at evaluating the motor behavioral and white matter microstructural changes following a 2-month upper limb motor rehabilitation treatment based on task-oriented exercises in patients with multiple sclerosis. Thirty patients (18 females and 12 males; age=43.3 ± 8.7 years) in a stable phase of the disease presenting with mild or moderate upper limb sensorimotor deficits were randomized into two groups of 15 patients each. Both groups underwent twenty 1-hour treatment sessions, three times a week. The "treatment group" received an active motor rehabilitation treatment, based on voluntary exercises including task-oriented exercises, while the "control group" underwent passive mobilization of the shoulder, elbow, wrist and fingers. Before and after the rehabilitation protocols, motor performance was evaluated in all patients with standard tests. Additionally, finger motor performance accuracy was assessed by an engineered glove. In the same sessions, every patient underwent diffusion tensor imaging to obtain parametric maps of fractional anisotropy, mean diffusivity, axial diffusivity, and radial diffusivity. The mean value of each parameter was separately calculated within regions of interest including the fiber bundles connecting brain areas involved in voluntary movement control: the corpus callosum, the corticospinal tracts and the superior longitudinal fasciculi. The two rehabilitation protocols induced similar effects on unimanual motor performance, but the bimanual coordination task revealed that the residual coordination abilities were maintained in the treated patients while they significantly worsened in the control group (p=0.002). Further, in the treatment group white matter integrity in the corpus callosum and corticospinal tracts was preserved while a microstructural integrity worsening was found in the control group (fractional anisotropy of the corpus callosum and corticospinal tracts: p=0.033 and p=0.022; radial diffusivity of the corpus callosum and corticospinal tracts: p=0.004 and p=0.008). Conversely, a significant increase of radial diffusivity was observed in the superior longitudinal fasciculi in both groups (p=0.02), indicating lack of treatment effects on this structure, showing damage progression likely due to a demyelination process. All these findings indicate the importance of administering, when possible, a rehabilitation treatment consisting of voluntary movements. We also demonstrated that the beneficial effects of a rehabilitation treatment are task-dependent and selective in their target; this becomes crucial towards the implementation of tailored rehabilitative approaches.

Ophthalmoplegic migraine: from questions to answers.

INTRODUCTION: The International Classification of Headache Disorders classifies ophthalmoplegic migraine (OM) under "cranial neuralgias and central causes of facial pain." OM is diagnosed when all the following criteria are satisfied: A. At least two attacks fulfilling criterion B. B. Migraine-like headache accompanied or followed within four days of its onset by paresis of one or more of the III, IV and/or VI cranial nerves. C. Parasellar orbital fissure and posterior fossa lesions ruled out by appropriate investigations. In children the syndrome is rare and magnetic resonance (MR) shows strongly enhancing thickened nerve at the root entry zone (REZ). METHOD: The authors review the literature focusing on pathogenesis theories. RESULTS: The authors suggest that ischemic reversible breakdown of the blood-nerve barrier is the most probable cause of OM and to include MR findings in the hallmarks of the disease. CONCLUSION: OM is the same disease in adulthood and childhood, even if in adults the MR imaging findings are negative. In the authors' opinion, OM should be classified as migraine.

Conventional MRI-Derived Biomarkers of Adult-Type Diffuse Glioma Molecular Subtypes: A Comprehensive Review.

The introduction of molecular criteria into the classification of diffuse gliomas has added interesting practical implications to glioma management. This has created a new clinical need for correlating imaging characteristics with glioma genotypes, also known as radiogenomics or imaging genomics. Although many studies have primarily focused on the use of advanced magnetic resonance imaging (MRI) techniques for radiogenomics purposes, conventional MRI sequences remain the reference point in the study and characterization of brain tumors. A summary of the conventional imaging features of glioma molecular subtypes should be useful as a tool for daily diagnostic brain tumor management. Hence, this article aims to summarize the conventional MRI features of glioma molecular subtypes in light of the recent literature.

Occipital horn syndrome in a woman: skeletal radiological findings.

Ehlers-Danlos type IX syndrome, also called occipital horn syndrome (OHS), is a milder and rare form of Menkes disease where the patient reaches adulthood. As an X-linked disease, it typically occurs in male subjects, while female subjects are usually healthy carriers. OHS is mainly characterized by connective tissue disorders and slightly subnormal intelligence or signs of autonomic dysfunction are the only apparent neurological abnormalities, in connection with molecular defects in copper metabolism. Our purpose is to report on radiological skeletal findings that may be incidental or investigated when OHS is suspected and to underline the possible involvement and expression in the female. Moreover, the impact of skeletal findings is also highlighted in the prevention of serious complications of the disease.

Clinical and Brain Imaging Findings in a Child with Vitamin B12 Deficiency.

Vitamin B12 (Vit-B12) deficiency is a rare and treatable cause of failure to thrive and delayed development in infants who are exclusively breastfed. Apart from genetic causes, it can be related to a malabsorption syndrome or when the mother follows a strict vegetarian or vegan diet, causing a low hepatic storage of Vit-B12 in the infant at birth. As the neurological symptoms are nonspecific, a brain magnetic resonance imaging (MRI) exam is usually performed to rule out primary causes of neurodevelopmental delay. Findings related to brain atrophy are usually observed. A favorable response is achieved with Vit-B12 therapy, and neurological symptoms dramatically improve within a few days after the treatment. We present the case of an infant with severe Vit-B12 deficiency, exclusively breastfed by his young vegan mother, and whose clinical symptoms together with MRI findings improved after treatment. Brain atrophy recovery after Vit-B12 therapy has been seldom documented.

Predict Treatment Response by Magnetic Resonance Diffusion Weighted Imaging: A Preliminary Study on 46 Meningiomas Treated with Proton-Therapy.

OBJECTIVE: a considerable subgroup of meningiomas (MN) exhibit indolent and insidious growth. Strategies to detect earlier treatment responses based on tumour biology rather than on size can be useful. We aimed to characterize therapy-induced changes in the apparent diffusion coefficient (ADC) of MN treated with proton-therapy (PT), determining whether the pre- and early post-treatment ADC values may predict tumour response. METHODS: Forty-four subjects with MN treated with PT were retrospectively enrolled. All patients underwent conventional magnetic resonance imaging (MRI) including diffusion-weighted imaging (DWI) at baseline and each 3 months for a follow-up period up to 36 months after the beginning of PT. Mean relative ADC (rADCm) values of 46 MN were measured at each exam. The volume variation percentage (VV) for each MN was calculated. The Wilcoxon test was used to assess the differences in rADCm values between pre-treatment and post-treatment exams. Patients were grouped in terms of VV (threshold -20%). A p < 0.05 was considered statistically significant for all the tests. RESULTS: A significant progressive increase of rADCm values was detected at each time point when compared to baseline rADCm (p < 0.05). Subjects that showed higher pre-treatment rADCm values had no significant volume changes or showed volume increase, while subjects that showed a VV < -20% had significantly lower pre-treatment rADCm values. Higher and earlier rADCm increases (3 months) are related to greater volume reduction. CONCLUSION: In MN treated with PT, pre-treatment rADCm values and longitudinal rADCm changes may predict treatment response.

Transcranial Magnetic Resonance Imaging-Guided Focused Ultrasound with a 1.5 Tesla Scanner: A Prospective Intraindividual Comparison Study of Intraoperative Imaging.

BACKGROUND: High-quality intraoperative imaging is needed for optimal monitoring of patients undergoing transcranial MR-guided Focused Ultrasound (tcMRgFUS) thalamotomy. In this paper, we compare the intraoperative imaging obtained with dedicated FUS-Head coil and standard body radiofrequency coil in tcMRgFUS thalamotomy using 1.5-T MR scanner. METHODS: This prospective study included adult patients undergoing tcMRgFUS for treatment of essential tremor. Intraoperative T2-weighted FRFSE sequences were acquired after the last high-energy sonication using a dedicated two-channel FUS-Head (2ch-FUS) coil and body radiofrequency (body-RF) coil. Postoperative follow-ups were performed at 48 h using an eight-channel phased-array (8ch-HEAD) coil. Two readers independently assessed the signal-to-noise ratio (SNR) and evaluated the presence of concentric lesional zones (zone I, II and III). Intraindividual differences in SNR and lesional findings were compared using the Wilcoxon signed rank sum test and McNemar test. RESULTS: Eight patients underwent tcMRgFUS thalamotomy. Intraoperative T2-weighted FRFSE images acquired using the 2ch-FUS coil demonstrated significantly higher SNR (R1 median SNR: 10.54; R2: 9.52) compared to the body-RF coil (R1: 2.96, p < 0.001; R2: 2.99, p < 0.001). The SNR was lower compared to the 48-h follow-up (p < 0.001 for both readers). Intraoperative zone I and zone II were more commonly visualized using the 2ch-FUS coil (R1, p = 0.031 and p = 0.008, R2, p = 0.016, p = 0.008), without significant differences with 48-h follow-up (p ≥ 0.063). The inter-reader agreement was almost perfect for both SNR (ICC: 0.85) and lesional findings (k: 0.82-0.91). CONCLUSIONS: In the study population, the dedicated 2ch-FUS coil significantly improved the SNR and visualization of lesional zones on intraoperative imaging during tcMRgFUS performed with a 1.5-T MR scanner.

Imaging of Substantia Nigra in Parkinson's Disease: A Narrative Review.

Parkinson's disease (PD) is a progressive neurodegenerative disorder, characterized by motor and non-motor symptoms due to the degeneration of the pars compacta of the substantia nigra (SNc) with dopaminergic denervation of the striatum. Although the diagnosis of PD is principally based on a clinical assessment, great efforts have been expended over the past two decades to evaluate reliable biomarkers for PD. Among these biomarkers, magnetic resonance imaging (MRI)-based biomarkers may play a key role. Conventional MRI sequences are considered by many in the field to have low sensitivity, while advanced pulse sequences and ultra-high-field MRI techniques have brought many advantages, particularly regarding the study of brainstem and subcortical structures. Nowadays, nigrosome imaging, neuromelanine-sensitive sequences, iron-sensitive sequences, and advanced diffusion weighted imaging techniques afford new insights to the non-invasive study of the SNc. The use of these imaging methods, alone or in combination, may also help to discriminate PD patients from control patients, in addition to discriminating atypical parkinsonian syndromes (PS). A total of 92 articles were identified from an extensive review of the literature on PubMed in order to ascertain the-state-of-the-art of MRI techniques, as applied to the study of SNc in PD patients, as well as their potential future applications as imaging biomarkers of disease. Whilst none of these MRI-imaging biomarkers could be successfully validated for routine clinical practice, in achieving high levels of accuracy and reproducibility in the diagnosis of PD, a multimodal MRI-PD protocol may assist neuroradiologists and clinicians in the early and differential diagnosis of a wide spectrum of neurodegenerative disorders.

Brain Mapping-Aided SupraTotal Resection (SpTR) of Brain Tumors: The Role of Brain Connectivity.

Brain gliomas require a deep knowledge of their effects on brain connectivity. Understanding the complex relationship between tumor and functional brain is the preliminary and fundamental step for the subsequent surgery. The extent of resection (EOR) is an independent variable of surgical effectiveness and it correlates with the overall survival. Until now, great efforts have been made to achieve gross total resection (GTR) as the standard of care of brain tumor patients. However, high and low-grade gliomas have an infiltrative behavior and peritumoral white matter is often infiltrated by tumoral cells. According to these evidences, many efforts have been made to push the boundary of the resection beyond the contrast-enhanced lesion core on T1w MRI, in the so called supratotal resection (SpTR). SpTR is aimed to maximize the extent of resection and thus the overall survival. SpTR of primary brain tumors is a feasible technique and its safety is improved by intraoperative neuromonitoring and advanced neuroimaging. Only transient cognitive impairments have been reported in SpTR patients compared to GTR patients. Moreover, SpTR is related to a longer overall and progression-free survival along with preserving neuro-cognitive functions and quality of life.

Unusual diagnostic findings in temporal lobe epilepsy: A combined MRI and 18F-dopa case study.

Temporal lobe epilepsy is the most common focal epilepsy in adults and often causes pharmacoresistant seizures. Magnetic resonance imaging (MRI) and PET studies have widely demonstrated a number of morphological and molecular abnormalities in epilepsy. However, considering the dopaminergic system, only a bilateral 18F-DOPA uptake reduction within the basal ganglia has been described. We report the unusual finding of increased 18F-DOPA uptake in a patient with focal recurrent seizures and "deja vu" experiences in the setting of cortical swelling detected at MRI exam. The final diagnosis was in in keeping with hippocampal sclerosis, confirmed during follow-up MR exams. In this case 18F-DOPA uptake may represent increased dopamine transport induced by seizures. Nuclear medicine physicians and radiologists should be aware of clinical and electroencephalographic findings when interpreting brain areas of tracer uptake, which are not always related to malignancy.

Oropharyngeal Hairy Polyp: A Case of Respiratory Failure in a Newborn.

Hairy polyps, also known as dermoid polyps (DPs), are rare benign cystic lesions of bigerminal origin that may occur in several head and neck regions, including the oropharynx. Despite their benign histopathological nature, DPs may be life threatening, due to their upper airway location, and DPs represent one of the most unusual causes of respiratory distress during the neonatal period. In this paper, we describe a case of respiratory failure in a newborn with an oropharyngeal mass that was accidentally found during difficult intubation. Magnetic resonance imaging (MRI) detected a well-defined soft tissue pedunculated mass, arising from the left oropharynx wall, consistent with an oropharyngeal DP. The newborn had a prompt recovery after trans-oral mass removal. Our case underlines the importance of imaging in differential diagnosis of children's respiratory distress, secondary to a variety of lesions within the region of the skull base or oropharynx. It allowed us to assess the origin of the lesion, as well as its relationship with the adjacent soft tissues, and to exclude intracranial extension, thus providing essential information for the surgical planning.