Direct aspiration for thrombectomy in ischemic stroke: Impact of dwell time.

OBJECTIVE: To evaluate the impact of dwell time on the efficacy of the direct aspiration thrombectomy in ischemic stroke. METHODS: The study is a review of our prospective cerebral thrombectomy database of subjects admitted from January to December 2017. We performed direct aspiration with 2 min dwell time as recommended by the manufacturer (group 1) and 5 min dwell time (group 2) between January-June and July-December, respectively. The primary outcome was successful reperfusion after the first pass defined as modified Thrombolysis in Cerebral Infarction scores 2 b/3. RESULTS: Eighty-five patients had a cerebral thrombectomy by direct aspiration, 45 in group 1 and 40 in group 2. There was no statistically significant difference between the two groups but a trend toward a better modified Thrombolysis in Cerebral Infarction first pass 2 b/3 rate in group 2 (70% versus 48.8%, p = 0.06). Although not statistically significant (p = 0.07), the ratio of rescue therapy with stent retriever was higher in group 1 (40%) than in group 2 (22.5%). After all passes, modified Thrombolysis in Cerebral Infarction 2 b-3 was obtained in 82.2% (37/45) of cases in group 1 and in 90% (36/40) of cases in group 2. Among 76 patients (89.5%) with modified Rankin Scale assessment at three months, no significant difference (p = 0.3) was found in the proportion of functionally independent individuals between groups 1 and 2 (51.8% versus 55.6%, respectively). CONCLUSION: Although statistical significance was not reached, our retrospective analysis exhibited a strong trend toward modified Thrombolysis in Cerebral Infarction first pass improvement when dwell time was increased from 2 to 5 min.

Safety and Efficacy of Femoral Artery Closure with the FemoSeal Device After Cerebral Thrombectomy Using an 8 French Sheath.

PURPOSE: To evaluate the feasibility and safety of using the FemoSeal vascular closure device (VCD) to seal 8F access sites during mechanical thrombectomy for stroke. METHODS: A retrospective review of a prospective database was undertaken to evaluate the safety and efficacy of femoral arterial closure using FemoSeal device in all patients who underwent mechanical thrombectomy using an 8F sheath between January 2015 and July 2017. Efficacy endpoints were the successful deployment of the system and haemostasis success. Safety endpoints included the incidence of in hospital access site haematoma >5 cm, bleeding complications, pseudoaneurysms, arteriovenous fistula, infection, or other complications requiring surgery. RESULTS: 197 patients (96 men; mean age 68 years, range 25-99) were included. Successful haemostasis with FemoSeal was obtained in 98.9% of the patients. Only one haematoma >5 cm (0.5%) was observed, which reabsorbed spontaneously without issue. Nine haematomas <5 cm (4.5%) were also found. No major complications requiring surgical repair or transfusion were observed. There were no pseudoaneurysms, arteriovenous fistulae, or infections. CONCLUSION: The use of the FemoSeal device to close an 8F access sheath puncture site is feasible and safe, with a low complication rate.

Intra-Arterial Delivery of Idarubicin in Two Patients with Glioblastoma.

There is no effective treatment for recurrent glioblastoma (GB) when temozolomide-based radiochemotherapy fails. In theory, intra-arterial (IA) delivery of cytotoxic agents could achieve higher drug concentrations in tumors compared to intravenous injection. Moreover, choosing a highly lipid-soluble drug could make the most of the first-pass effect. Here, we evaluated idarubicin (IDA), a lipophilic anthracycline, in an in vitro assay using four human GB cell lines and compared it with 11 other drugs previously used for the IA treatment of brain tumors. Despite impressive in vitro cytotoxicity, IA IDA did not produce a beneficial effect in 2 patients with recurrent GB.

An unusual, duplicate origin of the anterior choroidal artery with aneurysm: a case report.

BACKGROUND AND IMPORTANCE: Aneurysms of the anterior choroidal artery (AChoA) are rare and often difficult to treat. Variations may be present and must be identified prior to treatment. We report a unique case of a ruptured aneurysm located at the origin of a duplicate branch of the AChoA. CLINICAL PRESENTATION: A 56-year-old male was admitted to our university hospital for coma. A brain CT scan showed a subarachnoid hemorrhage, and CT angiography revealed a duplication of the right AChoA, with an aneurysm located at the branch's origin. We decided to embolize this aneurysm. Four weeks later, our patient was able to transfer to the rehabilitation unit. CONCLUSION: To the best of our knowledge, this is one of the first descriptions of an aneurysm located at the origin of a duplicate branch of the AChoA.

A relapsing macrodactyly.

Lipofibromatous hamartoma is an uncommon benign tumor, usually unknown or misdiagnosed. We report the case of a 61-year-old patient presenting an acquired painful macrodactyly of the left thumb with paresthesia in the median nerve territory. Clinical examination reveals a tumefaction of the volar side of the wrist. She had a medical history of amputation of the forefinger for macrodactyly without any diagnosis. Paraclinical exploration guided us to the correct diagnosis; hypertrophic bone structures of the affected finger were detected on radiographs. The left median nerve appeared hypertrophic, with a fatty infiltration on the ultrasound exploration. These pathological findings revealed a late discovered lipofibromatous hamartoma of the median nerve, a rare entity often associated with macrodactyly and diagnosed in childhood. Therefore, we retrospectively made the same diagnosis for the amputated index finger with the analysis of her ancient paraclinical exams. Lipofibromatous hamartoma remains an obscure pathology and its treatment stays controversial.

Cognitive impairment and dementia after intracerebral hemorrhage: a cross-sectional study of a hospital-based series.

BACKGROUND: Frequencies of cognitive impairment and dementia have not been assessed in spontaneous intracerebral hemorrhage (ICH). The objective of this study was to determine the frequencies and patterns of cognitive impairment and dementia in a cross-sectional study of consecutive patients hospitalized in a single university medical center. METHODS: Of 183 consecutive patients hospitalized between 2002 and 2006, 80 survivors were contacted and 78 were included (mean time since stroke 40 months). Thirty patients were scored with the Informant Questionnaire on Cognitive Decline in the Elderly and Instrumental Activities of Daily Living in a telephone interview, and 48 underwent a comprehensive clinical and neuropsychological assessment. RESULTS: Dementia was observed in 18 of 78 patients (23%; 95% confidence interval [CI] 13-32%) and cognitive impairment without dementia was seen in 37 of 48 patients (77%; 95% CI 65-89%). The cognitive disorders mainly concerned episodic memory (52%), psychomotor speed (44%), and executive function (37%), followed by language and visuoconstructive abilities. In a logistic regression analysis, Rankin score >1 at discharge and hemorrhage volume were the initial factors to be selected as a predictor of long-term dementia. CONCLUSIONS: This single-center, cross-sectional study revealed that the prevalence of dementia and cognitive impairment without dementia after ICH are high and are similar to those observed in cerebral infarct. Further longitudinal, prospective studies are required to assess accurately the prevalence, mechanisms and predictors of post-ICH dementia.

Cerebral Blood and CSF Flow Patterns in Patients Diagnosed for Cerebral Venous Thrombosis - An Observational Study.

BACKGROUND AND PURPOSE: Recent studies of the organization of the cerebral venous system in healthy subjects using phase contrast magnetic resonance imaging (PC-MRI) show its structural complexity and inter-individual variations. Our objective was to study the venous blood and CSF flows in cerebral venous thrombosis (CVT). MATERIALS AND METHODS: PC-MRI sequences were added to brain MRI conventional protocol in 19 patients suspected of CVT, among whom 6 patients had CVT diagnosis confirmed by MR venography. Results were compared with 18 healthy age-matched volunteers (HV). RESULTS: In patients without CVT (NoCVT) confirmed by venography, we found heterogeneous individual venous flows, and variable side dominance in paired veins and sinuses, comparable to those in healthy volunteers. In CVT patients, PC-MRI detected no venous flow in the veins and/or sinuses with thrombosis. Arterial flows were preserved. CSF aqueductal and cervical stroke volumes were increased in a patient with secondary cerebral infarction, and decreased in 4 patients with extended thrombosis in the superior sagittal and transverse sinuses. These results suggest the main role of the venous system in the regulation of the dynamic intracranial equilibrium. CONCLUSIONS: CVT produces highly individualized pattern of disturbance in venous blood drainage. Complementary to MRI venography, PC-MRI provides non-invasive data about venous blockage consequences on CSF flow disturbances.

Functional consequences of a section of the anterior part of the body of the corpus callosum: evidence from an interhemispheric transcallosal approach.

The aim of this study was to determine the neuropsychological consequences of a middle interhemispheric approach for the removal of tumors of the third or lateral ventricles. A retrospective analysis of eight callosotomized patients for ventricular tumors (three males/five females; mean age: 48.7 ± 11.2 years; education level: 11.9 ± 2.9 years) and eight healthy subjects was performed. An extensive neuropsychological test battery was used to evaluate global intellectual efficiency, memory capacities, executive functions, and interhemispheric transfer of a procedural learning task (serial reaction time task/SRTT). Neuropsychological results showed that: (1) five of eight patients operated through a middle transcallosal approach had disturbances of verbal or visual memory; (2) three of eight patients displayed a dysexecutive cognitive syndrome(two of eight of whom presenting with a deficit of verbal fluency); (3) two of eight patients presented a dysexecutive behavior syndrome; and (4) with regard to the SRTT, although all participants learned the task, in contrast to controls, the callosotomized patients showed an increase in reaction times and an absence of interhemispheric transfer of learning from one hand to the other. The transcallosal approach transects a large number of callosal fibers. This damage accounts for the deficits of memory, the dysexecutive cognitive and behavioral syndrome, and disturbances in interhemispheric transfer of learning.

A phase-contrast MRI study of acute and chronic hydrodynamic alterations after hydrocephalus induced by subarachnoid hemorrhage.

OBJECTIVE: To determine acute intracranial hydrodynamic changes after subarachnoid hemorrhage (SAH) via phase-contrast MRI (PC-MRI) analysis of the CSF stroke volume in the aqueduct (SVaq) and the foramen magnum (SVfm). METHODS: A prospective PC-MRI study was performed on 34 SAH patients in the acute and late phase. Data on CSF flow and hemorrhage site were analyzed according to acute or chronic hydrocephalus (HC). RESULTS: In the acute phase, CSF analysis was performed for 31 patients, 12 of whom presented HC. All 12 had an abnormal SVaq; those with communicating HC (n = 7) had an elevated SV and those with noncommunicating HC (n = 5) had a nil SV. None of the patients with a normal SVaq (n = 11) developed acute HC. Intraventricular bleeding led to more cases of acute HC (P = .005), which was communicating in 58% of cases. In the chronic phase, CSF analysis was performed for 27 patients, 7 of whom presented HC. None of these 7 patients displayed a depressed SVaq. CONCLUSION: SAH led to changes in cerebrospinal fluid hydrodynamics in the majority of patients. Acute HC was communicating in most cases, even when there was intraventricular bleeding. In the late phase, all chronic HC were communicating and did not display aqueductal stenosis.

Presence of intracranial artery calcification is associated with mortality and vascular events in patients with ischemic stroke after hospital discharge: a cohort study.

BACKGROUND AND PURPOSE: Although intracranial artery calcification (IAC) has been reported to be a risk factor for ischemic stroke, the prognostic implications of IAC in stroke outcome are unknown. The purpose of this study was to determine the association between IAC and risk of vascular events and death in patients with stroke after hospital discharge. METHODS: All patients with ischemic stroke over a 1-year period were included (n=302). IAC, assessed by multidetector CT, was defined as hyperdense foci (peak density>130 Hounsfield units) and assessed in the 7 major cerebral arteries. The IAC scores ranged from 0 (no calcification) to 7. Follow-up information on major clinical events (including fatal or nonfatal ischemic stroke, cardiac and peripheral artery events, and all-cause death) was obtained by means of a structured phone interview. RESULTS: IAC was present in 260 patients (83%). With a mean follow-up of 773±223 days, 88 major clinical events occurred in 67 patients (22%): 45 new ischemic vascular events (ischemic stroke: n=22; cardiac event: n=15; peripheral artery event: n=8) and 43 deaths from any cause. Patients with the highest IAC scores had significantly higher rates of death and vascular events than those with the lowest IAC scores (log rank test, P=0.029). In the Cox proportional hazards regression model, the IAC score was significantly associated with major clinical events (hazard ratio, 1.34; 95% CI, 1.11-1.61; P=0.002). CONCLUSIONS: In patients with ischemic stroke, IAC detection may constitute a simple marker of a high risk of future major clinical events.

Cerebrospinal fluid and blood flow in mild cognitive impairment and Alzheimer's disease: a differential diagnosis from idiopathic normal pressure hydrocephalus.

BACKGROUND: Phase-contrast magnetic resonance imaging (PC-MRI) enables quantification of cerebrospinal fluid (CSF) flow and total cerebral blood (tCBF) flow and may be of value for the etiological diagnosis of neurodegenerative diseases. This investigation aimed to study CSF flow and intracerebral vascular flow in patients with Alzheimer's disease (AD) and patients with amnesic mild cognitive impairment (a-MCI) and to compare the results with patients with idiopathic normal pressure hydrocephalus (NPH) and with healthy elderly volunteers (HEV). METHODS: Ten a-MCI and 9 mild AD patients were identified in a comprehensive neurological and neuropsychological assessment. They underwent brain MRI; PC-MRI pulse sequence was performed with the following parameters: two views per segment; flip angle: 25° for vascular flow and 20° for CSF flow; field-of-view (FOV): 14 × 14 mm²; matrix: 256 × 128; slice thickness: 5 mm; with one excitation for exams on the 3 T machine, and 2 excitations for the 1.5 T machine exams. Velocity (encoding) sensitization was set to 80 cm/s for the vessels at the cervical level, 10 or 20 cm/s for the aqueduct and 5 cm/s for the cervical subarachnoid space (SAS). Dynamic flow images were analyzed with in-house processing software. The patients' results were compared with those obtained for HEVs (n = 12), and for NPH patients (n = 13), using multivariate analysis. RESULTS: Arterial tCBF and the calculated pulsatility index were significantly greater in a-MCI patients than in HEVs. In contrast, vascular parameters were lower in NPH patients. Cervical CSF flow analysis yielded similar values for all four populations. Aqueductal CSF stroke volumes (in µl per cardiac cycle) were similar in HEVs (34 ± 17) and AD patients (39 ± 18). In contrast, the aqueductal CSF was hyperdynamic in a-MCI patients (73 ± 33) and even more so in NPH patients (167 ± 89). CONCLUSION: Our preliminary data show that a-MCI patients present with high systolic arterial peak flows, which are associated with higher mean total cerebral arterial flows. Aqueductal CSF oscillations are within normal range in AD and higher than normal in NPH. This study provides an original dynamic vision of cerebral neurodegenerative diseases, consistent with the vascular theory for AD, and supporting primary flow disturbances different from those observed in NPH.

Percutaneous vertebroplasty for pain management in malignant fractures of the spine with epidural involvement.

PURPOSE: To evaluate the feasibility, efficacy, and safety of percutaneous vertebroplasty (PV) in the treatment of pathologic fractures owing to malignancy with epidural involvement, with or without neurologic symptoms of spinal cord or cauda equina compression. MATERIALS AND METHODS: This study was approved by the local ethics committee; informed consent was obtained from all patients. This retrospective review was performed for 51 consecutive patients with metastatic disease or multiple myeloma treated by means of vertebroplasty, who presented with at least one vertebral lesion with epidural involvement, with or without clinical symptoms of spinal cord or cauda equina compression. All patients with neurologic deficit were terminally ill. A neurologic examination was performed before and after treatment in all patients. All imaging examinations and treatments were reviewed, and chi(2), Mann Whitney, or Fisher exact testing was performed for univariate analysis of variables. RESULTS: A total of 74 vertebrae were treated in 51 patients, 22 women and 29 men with a mean age of 62.5 years (range, 28-85 years). Fifteen (29%) patients presented symptoms of complete or incomplete spinal cord or cauda equina compression before vertebroplasty and no further clinical deterioration was observed after treatment. The analgesic efficacy of vertebroplasty was satisfactory for 94% (48 of 51) of patients after 1 day, 86% (31 of 36) patients after 1 month, and 92% (11 of 12) patients after 1 year. One patient with no clinical neurologic deficit before treatment experienced symptoms of cauda equina compression 2 days after vertebroplasty. No other major complication was observed. CONCLUSION: The feasibility, efficacy, and safety of PV were confirmed in patients experiencing pain related to malignant spinal tumors with epidural extension, with a low complication rate. PV should become part of the palliative analgesic treatment for such patients. (c) RSNA, 2010.

First case of human spondylodiscitis due to Shewanella algae.

We present the first case of human spondylodiscitis due to Shewanella algae. Our patient did not have any predisposing factors. The portal of entry was probably a cutaneous lesion on the leg, exposed to seawater. Bacteria were isolated in pure culture from a needle biopsy specimen of the vertebral disk. Automated identification systems identified the organism as Shewanella putrefaciens. However, molecular biology identified it as S. algae. Treatment with ceftriaxone and amikacin, then ciprofloxacin successfully addressed the infection. We also review four published cases of human osteoarticular infections caused by Shewanella spp: two cases of arthritis and two cases of osteomyelitis. Two patients had predisposing factors, and contact with water was found in two cases. The clinical, radiological and biological characteristics of S. algae spondylodiscitis are indistinguishable from those of spondylodiscitis of other causes. A cutaneous lesion with exposure to water is a potential portal of entry. Molecular typing is necessary to obtain a precise bacteriological identification.

Hepatic vascular flow measurements by phase contrast MRI and doppler echography: a comparative and reproducibility study.

PURPOSE: To directly compare and study the variability of parameters related to hepatic blood flow measurements using 3 T phase-contrast magnetic resonance imaging (PC-MRI) and Doppler ultrasound (US). MATERIALS AND METHODS: Nine healthy subjects were studied. Blood velocities and flow rate measurements were performed in the portal vein and the proper hepatic artery. MR studies were performed using a 3 T imager. Gradient-echo fast phase contrast sequences were used with both cardiac and respiratory gating. MR and Doppler flow parameters were extracted and compared. Two methods of calculation were used for Doppler flow rate analysis. RESULTS: Compared to Doppler US, PC-MRI largely underestimated hepatic flow data with lower variability and higher reproducibility. This reproducibility was more pronounced in the portal vein than in the proper hepatic artery associated with poorer velocity correlations. Total hepatic flow values were 1239 +/- 223 mL/min and 1595 +/- 521 mL/min for PC-MRI and Doppler US, respectively. CONCLUSION: Free-breathing PC-MRI can provide reliable noninvasive measurement of hepatic flow parameters compared to Doppler US. The MR technique could help to improve Doppler flow calculations, thereby allowing standardization of protocols, particularly for applications in disease.

Microsurgical anatomy of the ventral callosal radiations: new destination, correlations with diffusion tensor imaging fiber-tracking, and clinical relevance.

OBJECT: In the current literature, there is a lack of a detailed map of the origin, course, and connections of the ventral callosal radiations of the human brain. METHODS: The authors used an older dissection technique based on a freezing process as well as diffusion tensor imaging to investigate this area of the human brain. RESULTS: The authors demonstrated interconnections between areas 11, 12, and 25 for the callosal radiations of the trunk and rostrum of the corpus callosum; between areas 9, 10, and 32 for the genu; and between areas 6, 8, and 9 for the ventral third of the body. The authors identified new ventral callosal connections crossing the rostrum between both temporal poles and coursing within the temporal stem, and they named these connections the "callosal radiations of Peltier." They found that the breadth of the callosal radiations slightly increases along their course from the rostrum to the first third of the body of the corpus callosum. CONCLUSIONS: The fiber dissection and diffusion tensor imaging techniques are complementary not only in their application to the study of the commissural system in the human brain, but also in their practical use for diagnosis and surgical planning. Further investigations, neurocognitive tests, and other contributions will permit elucidation of the functional relevance of the newly identified callosal radiations in patients with disease involving the ventral corpus callosum.

Hematogenous Staphylococcus aureus discitis in adults can start outside the vertebral body.

BACKGROUND: Textbooks describe hematogenous discitis in adults as starting in the anterior vertebral body near the endplates. CASE REPORT: Hematogenous Staphylococcus aureus discitis developed at L1-L2 in an 81-year-old woman. On the first magnetic resonance imaging (MRI) scan performed 4 days after symptom onset, the only abnormalities were high signal from the disk on T2-weighted images, gadolinium enhancement of the soft tissues anterior to L1-L2, and epidural involvement. The endplates and vertebral bodies were normal. A subsequent MRI scan showed features typical of infectious discitis. DISCUSSION: We found a single similar case report in the medical literature, indicating that discitis starting outside the anterior vertebral body is rare. Nevertheless, an increasing number of similar cases may be diagnosed in the future, as MRI is being performed increasingly early in patients with a clinical suspicion of infectious discitis. CONCLUSION: Hematogenous infectious discitis in adults may start in some patients within the disk, soft tissues anterior to the disk, or epidural space. To avoid diagnostic and therapeutic delays, physicians should be aware of this unusual presentation of infectious discitis on very early MRI scans. When the clinical picture suggests discitis and findings from the early MRI scan are atypical, a repeat MRI scan should be obtained 1 week later to confirm the diagnosis.

A phase-contrast MRI study of physiologic cerebral venous flow.

Although crucial in regulating intracranial hydrodynamics, the cerebral venous system has been rarely studied because of its structural complexity and individual variations. The purpose of our study was to evaluate the organization of cerebral venous system in healthy adults. Phase-contrast magnetic resonance imaging (PC-MRI) was performed in 18 healthy volunteers, in the supine position. Venous, arterial, and cerebrospinal fluid (CSF) flows were calculated. We found heterogeneous individual venous flows and variable side dominance in paired veins and sinuses. In some participants, the accessory epidural drainage preponderated over the habitually dominant jugular outflow. The PC-MRI enabled measurements of venous flows in superior sagittal (SSS), SRS (straight), and TS (transverse) sinuses with excellent detection rates. Pulsatility index for both intracranial (SSS) and cervical (mainly jugular) levels showed a significant increase in pulsatile blood flow in jugular veins as compared with that in SSS. Mean cervical and cerebral arterial blood flows were 714+/-124 and 649+/-178 mL/min, respectively. Cerebrospinal fluid aqueductal and cervical stroke volumes were 41+/-22 and 460+/-149 microL, respectively. Our results emphasize the variability of venous drainage for side dominance and jugular/epidural organization. The pulsatility of venous outflow and the role it plays in the regulation of intracranial pressure require further investigation.