Limitation of updated MR images on the vestibular hydrops in Meniere's disease.

PURPOSE: This study adopted the cervical and ocular vestibular-evoked myogenic potential (cVEMP and oVEMP) tests in Meniere's disease (MD) patients to correlate them with vestibular endolymphatic hydrops (EH) on MR images. METHODS: A total of 25 patients with unilateral definite MD identified by positive cochlear hydrops on MR images were enrolled. All patients underwent audiometry, cVEMP test and oVEMP test, followed by MR imaging for confirmation. RESULTS: A significantly declining sequence of abnormality rates in MD patients was identified from the audiometry (92%), cVEMP test (52%) to the oVEMP test (40%), which was consistent with a significantly decreasing order of prevalence of EH on MR images running from the cochlea (100%), saccule (56%) to the utricle (52%). The cVEMP test for detecting the saccular hydrops revealed a sensitivity of 62%, while the oVEMP test for assessing the utricular hydrops showed a sensitivity of 70%. However, correlating VEMP results with vestibular hydrops did not show any significant relationship. In addition, mean hearing level (MHL) at four frequencies (500, 1000, 2000, and 3000 Hz) of Grade I cochlear hydrops (51 ± 19 dB) did not significantly differ from Grade II cochlear hydrops (53 ± 19 dB). CONCLUSION: Limitations of the updated MR imaging for visualizing the hydrops comprised: (1) failure to correlate vestibular hydrops with VEMP results, and (2) failure to correlate grade of cochlear hydrops with MHL. The reason is probably because updated MR imaging fails to identify distorted contour of the cochlea/utricle/saccule. Further advanced technique using ultrahigh resolution of fine structures in the inner ear compartments is essential to promote a wider use of MR imaging.

Magnetic resonance imaging: Role on diagnosing all types of endolymphatic hydrops.

BACKGROUND/PURPOSE: This study utilized the recently advanced technique in MR imaging to establish its role on diagnosing all types of endolymphatic hydrops (EH). METHODS: Twenty-two patients (26 ears) with clinical EH were admitted due to acute hearing loss and/or vertiginous attack. Each patient underwent an inner ear test battery comprising audiometry, cervical and ocular vestibular-evoked myogenic potential tests, and caloric test, followed by MR imaging for confirmation. RESULTS: Of the 22 clinical EH patients, 12 patients were referred to primary EH (Meniere's disease), 8 patients were secondary EH (including delayed EH in 5), and 2 patients were EH of embryopathic origin. MR imaging of 26 affected ears demonstrated EH in the cochlea only for 14 ears, in the utricle and saccule only for 1 ear, and in all three endorgans for 3 ears, accounting for a sensitivity of 69% (18/26). The 8 affected ears showing negative MR images were EH patients with hearing recovery 1, just after vertiginous attack 3, and chronic low-tone hearing loss 4. In contrast, 3 out of 18 unaffected ears demonstrated asymptomatic EH in the cochlea, representing a specificity of 83% (15/18). CONCLUSION: The sensitivity and specificity of MR imaging for confirming all types of EH were 69% and 83%, respectively. Although diagnostic criteria can identify primary and delayed EH, MR imaging may provide a supplementary tool for diagnosing secondary, embryopathic, or asymptomatic EH, if patients are not with hearing recovery, chronic low-tone hearing loss, or just after vertiginous attack.

Angiographic early hyperemia in the middle cerebral artery territory after thrombectomy is associated with favorable clinical outcome in anterior circulation stroke.

OBJECTIVES: Angiographic cortical early hyperemia (EH) is frequently observed after endovascular thrombectomy (EVT) for large vessel occlusion (LVO) stroke. The aim of the study is to investigate the relationship between EH and clinical outcomes. METHODS: Between January 2015 and September 2018, consecutive patients who underwent EVT for anterior circulation LVO stroke with optimal recanalization (modified thrombolysis in cerebral infarction 2b or 3) were included. Angiographic studies after immediate reperfusion were used for analysis for cortical EH sign. Clinical functional outcomes were evaluated with the modified Rankin Scale (mRS) at 90 days. Safety outcomes, including mortality and intracerebral hemorrhage, were assessed. The association of EH between clinical functional and safety outcomes was analyzed. RESULTS: A total of 143 patients were analyzed (mean age: 71 years; median National Institutes of Health Stroke Scale score: 18). A positive EH sign was observed in 88 (62%) patients. Good functional outcome at 90 days was significantly different between the EH+ and EH- groups (p = .0157). Intracerebral hemorrhage and mortality did not differ between groups. In multivariate logistic regression analysis, EH was an independent predictor for good clinical outcome (mRS ≤ 2, odds ratio: 3.49, p = .0034) in addition to young age. CONCLUSION: Results revealed that the presence of EH is associated with better clinical outcome at 90 days, but not associated with increased hemorrhagic complication. These findings with clinically relevant implications require further validation. KEY POINTS: • Angiographic cortical hyperemia is a common finding immediately after endovascular thrombectomy. • Presence of cortical hyperemia is an independent prognostic factor for good clinical outcome. • Hemorrhagic complication is not associated with cortical hyperemia.

Safety and efficacy of the transbrachial approach for endovascular thrombectomy in patients with acute large vessel occlusion stroke.

BACKGROUND: The transbrachial approach (TBA) is an alternative method to the transfemoral approach (TFA). We herein aimed to evaluate the safety and efficacy of the TBA for endovascular thrombectomy (EVT) in patients with acute large vessel occlusion stroke. METHODS: We reviewed the records of 297 patients who had undergone EVT from January 2015 to July 2019. Eighteen patients who had undergone 19 procedures were included. Indications for arterial access, devices, recanalization rates, complication rates, and clinical outcomes were evaluated. RESULTS: There were 15 and 4 cases of anterior and posterior circulation stroke, respectively. The mean patient age was 80.1 years. Eight patients were male. The median National Institutes of Health Stroke Scale score was 18. The total procedure duration tended to be longer when the TBA was used after failure of the TFA (n = 6, 32%, median: 60.5 min) than when the TBA was used as the first treatment approach (n = 13, 68%, median: 22 min). Optimal recanalization (a modified Thrombolysis in Cerebral Infarction score of 2b or 3) was achieved for 15 procedures. Local complications were observed in two cases: one with brachial artery pseudoaneurysm and another with brachial artery occlusion. Three patients with anterior circulation stroke exhibited good clinical outcomes (modified Rankin score ≤ 2) at 90 days. Symptomatic intracranial hemorrhage occurred in one patient. Mortality was noted in four patients. CONCLUSION: The TBA for EVT is a suitable alternative when adoption of the TFA is difficult or impossible.

Predicting positive cochlear endolymphatic hydrops on magnetic resonance images.

Objective/hypothesis: This study correlated audiological results with magnetic resonance (MR) images to predict positive cochlear endolymphatic hydrops (EH) on MR images in patients with Meniere's disease (MD). Study design: Retrospective study. Methods: Twenty definite MD patients with positive cochlear EH on MR images were assigned to Group A. Another 20 definite MD patients with negative cochlear EH on MR images were assigned to Group B. All patients underwent an inner ear test battery followed by MR imaging using HRDROPS-Mi2 technique. Results: The mean hearing levels (MHLs) at frequencies of 125, 250, 500 and 1000 Hz revealed significantly worse in Group A than Group B. Significantly deteriorated MHLs were noted from Grades 0 to II at low frequency (125, 250, and 500 Hz), but not at mid-frequency and high frequency. The respective cutoff hearing thresholds at frequencies of 125, 250, and 500 Hz were 27.5, 32.5, and 40 dBHL, which help predict positive cochlear EH on MR images. By using the sum (27.5 + 32.5 + 40 = 100 dBHL) of cutoff thresholds from three low frequencies as a cutoff value, Group A (80%) showed significantly more ears with sum of low-frequency hearing threshold >100 dBHL than Group B (30%). Conclusion: When sum of three low-frequency (125, 250, and 500 Hz) hearing levels is >100 dBHL, positive cochlear EH may be shown on MR images in definite MD patients. In contrast, those MD patients with sum of three low-frequency hearing levels <100 dBHL, MR imaging should be postponed because resolution of EH may cause negative MR images. Level of evidence: 4.

Incidence and prognostic significance of extranodal extension in isolated nodal recurrence of oral squamous cell carcinoma.

BACKGROUND: Extranodal extension (ENE) is a crucial prognostic factor of oral squamous cell carcinoma (OSCC). However, the role of ENE in regional recurrence (rENE) remains unclear. The purpose of our study is to assess the salvage outcome according to the presence of rENE in oral cancer patients with isolated nodal recurrence. METHODS: Oral cancer patients diagnosed with isolated nodal recurrence at the National Taiwan University Hospital between January 2010 and December 2015 were reviewed. All patients were classified into two groups: with and without rENE. The treatment included salvage neck dissection (ND) ± metronomic chemotherapy, salvage ND and radiation (RT)/concurrent chemoradiation (CCRT), Salvage RT/CCRT alone, metronomic chemotherapy, or supportive care. RESULTS: We analyzed 198 patients, 156 with rENE and 42 without rENE. rENE presented more frequently in patients with initial ENE+ (OR = 3.17, p = 0.04), prior RT+ (OR = 2.96, p = 0.02), initial N2/N3 (OR = 2.76, p = 0.01), and recurrent LN size >1.5 cm (OR = 2.33, p = 0.03). The extent of rENE were also significantly different in these patients. The 2-year disease-free survival for patients with and without rENE were 15.7% and 31.7%, respectively (p = 0.002). The 2-year overall survival for patients with and without rENE were 19.6% and 43.9%, respectively (p = 0.004). For patients without rENE, those received salvage ND had better survival outcome (p < 0.001). By contrast, for patients with rENE, those received salvage RT/CCRT had better survival outcome (p < 0.001). CONCLUSION: The rENE is frequently present (78.79%) in OSCC patients with isolated nodal recurrence. Individualized treatment modalities based on the presence of rENE should be recommended to achieve better salvage outcomes.

Transcarotid Mechanical Thrombectomy for Embolic Intracranial Large Vessel Occlusion after Endovascular Deconstructice Embolization for Carotid Blowout Syndrome.

Carotid blowout syndrome (CBS) is a fatal complication of head and neck cancer. Endovascular treatment, particularly deconstructive embolization, is effective for CBS, but it might result in thromboembolic events. We report the case of a 57-year-old man with underlying recurrent head and neck cancer who had CBS. The patient received endovascular embolization of the right internal, external, and common carotid arteries. Right internal carotid artery to middle cerebral artery embolic occlusion was noted immediately after the procedure, and left-sided weakness and facial palsy were found. Ipsilateral suprabulbar cervical internal carotid artery puncture was performed under fluoroscopic guidance, and rescue suction thrombectomy was successful. The patient had no significant neurological sequela. Transcarotid intraarterial thrombectomy is a reasonable method for managing postembolization large vessel occlusion, even in the neck, after irradiation.

Engorged medullary vein on CT angiography in patients with dural arteriovenous fistula: prevalence, types, and comparison between regional and extensive types.

BACKGROUND AND PURPOSE: Engorged medullary vein (EMV) in patients with intracranial dural arteriovenous fistula (DAVF) suggests venous congestion. The aim of this study is to investigate its prevalence, pattern, and correlation with clinical findings. MATERIALS AND METHODS: CT angiography (CTA) raw data of DAVF were used for multiplanar reconstruction and then analyzed for the presence and pattern of EMV, which is defined as a dilated vein in the cerebral white matter. Patients with EMV were divided into two groups: regional and extensive. Regional type is defined as EMV limited to one cerebral hemisphere or cerebellum without evidence of subcortical calcification. Extensive type is defined as EMV involvement of more than one cerebral hemisphere or both the cerebrum and cerebellum. Descriptive analysis of clinical information, DAVF characteristics, and other imaging findings was conducted. Clinical information, including demographic data, clinical presentation, and hemorrhage, were correlated with both types of EMV. RESULTS: Among 192 eligible patients with DAVF, 71 (37%) had EMV. Patients with EMV were older (63 years vs 56 years, P=0.02), with DAVF more often at the transverse and sigmoid sinus (P<0.001), and more often presented with aggressive symptoms (59% vs 34%, P=0.02) than non-EMV patients, but there was no difference in the presentation of hemorrhage (15% vs 16%, P=0.99). Patients with regional EMV had a higher proportion of hemorrhage than those with the extensive type (24% vs 0%, P=0.006). CONCLUSIONS: EMV in patients with DAVF is associated with an aggressive manifestation. Regional type EMV is associated with a higher risk of a hemorrhagic presentation.