Recent Administration of Iodinated Contrast Renders Core Infarct Estimation Inaccurate Using RAPID Software.

BACKGROUND AND PURPOSE: Automated CTP software is increasingly used for extended window emergent large-vessel occlusion to quantify core infarct. We aimed to assess whether RAPID software underestimates core infarct in patients with an extended window recently receiving IV iodinated contrast. MATERIALS AND METHODS: We reviewed a prospective, single-center data base of 271 consecutive patients who underwent CTA ± CTP for acute ischemic stroke from May 2018 through January 2019. Patients with emergent large-vessel occlusion confirmed by CTA in the extended window (>6 hours since last known well) and CTP with RAPID postprocessing were included. Two blinded raters independently assessed CT ASPECTS on NCCT performed at the time of CTP. RAPID software used relative cerebral blood flow of <30% as a surrogate for irreversible core infarct. Patients were dichotomized on the basis of receiving recent IV iodinated contrast (<8 hours before CTP) for a separate imaging study. RESULTS: The recent IV contrast and contrast-naïve cohorts comprised 23 and 15 patients, respectively. Multivariate linear regression analysis demonstrated that recent IV contrast administration was independently associated with a decrease in the RAPID core infarct estimate (proportional increase = 0.34; 95% CI, 0.12-0.96; P = .04). CONCLUSIONS: Patients who received IV iodinated contrast in proximity (<8 hours) to CTA/CTP as part of a separate imaging study had a much higher likelihood of core infarct underestimation with RAPID compared with contrast-naïve patients. Over-reliance on RAPID postprocessing for treatment disposition of patients with extended window emergent large-vessel occlusion should be avoided, particularly with recent IV contrast administration.

Interrater Reliability in the Measurement of Flow Characteristics on Color-Coded Quantitative DSA of Brain AVMs.

BACKGROUND AND PURPOSE: Hemodynamic features of brain AVMs may portend increased hemorrhage risk. Previous studies have suggested that MTT is shorter in ruptured AVMs as assessed on quantitative color-coded parametric DSA. This study assesses the interrater reliability of MTT measurements obtained using quantitative color-coded DSA. MATERIALS AND METHODS: Thirty-five color-coded parametric DSA images of 34 brain AVMs were analyzed by 4 neuroradiologists with experience in interventional neuroradiology. Hemodynamic features assessed included MTT of the AVM and TTP of the dominant feeding artery and draining vein. Agreement among the 4 raters was assessed using the intraclass correlation coefficient. RESULTS: The interrater reliability among the 4 raters was poor (intraclass correlation coefficient = 0.218; 95% CI, 0.062-0.414; P value = .002) as it related to MTT assessment. When the analysis was limited to cases in which the raters selected the same image to analyze and selected the same primary feeding artery and the same primary draining vein, interrater reliability improved to fair (intraclass correlation coefficient = 0.564; 95% CI, 0.367-0.717; P < .001). CONCLUSIONS: Interrater reliability in deriving color-coded parametric DSA measurements such as MTT is poor so minor differences among raters may result in a large variance in MTT and TTP results, partly due to the sensitivity and 2D nature of the technique. Reliability can be improved by defining a standard projection, feeding artery, and draining vein for analysis.

Multicenter Postmarket Analysis of the Neuroform Atlas Stent for Stent-Assisted Coil Embolization of Intracranial Aneurysms.

BACKGROUND AND PURPOSE: The Neuroform Atlas is a new microstent to assist coil embolization of intracranial aneurysms that recently gained FDA approval. We present a postmarket multicenter analysis of the Neuroform Atlas stent. MATERIALS AND METHODS: On the basis of retrospective chart review from 11 academic centers, we analyzed patients treated with the Neuroform Atlas after FDA exemption from January 2018 to June 2019. Clinical and radiologic parameters included patient demographics, aneurysm characteristics, stent parameters, complications, and outcomes at discharge and last follow-up. RESULTS: Overall, 128 aneurysms in 128 patients (median age, 62 years) were treated with 138 stents. Risk factors included smoking (59.4%), multiple aneurysms (27.3%), and family history of aneurysms (16.4%). Most patients were treated electively (93.7%), and 8 (6.3%) underwent treatment within 2 weeks of subarachnoid hemorrhage. Previous aneurysm treatment failure was present in 21% of cases. Wide-neck aneurysms (80.5%), small aneurysm size (<7 mm, 76.6%), and bifurcation aneurysm location (basilar apex, 28.9%; anterior communicating artery, 27.3%; and middle cerebral artery bifurcation, 12.5%) were common. A single stent was used in 92.2% of cases, and a single catheter for both stent placement and coiling was used in 59.4% of cases. Technical complications during stent deployment occurred in 4.7% of cases; symptomatic thromboembolic stroke, in 2.3%; and symptomatic hemorrhage, in 0.8%. Favorable Raymond grades (Raymond-Roy occlusion classification) I and II were achieved in 82.9% at discharge and 89.5% at last follow-up. mRS ≤2 was determined in 96.9% of patients at last follow-up. The immediate Raymond-Roy occlusion classification grade correlated with aneurysm location (P < .0001) and rupture status during treatment (P = .03). CONCLUSIONS: This multicenter analysis provides a real-world safety and efficacy profile for the treatment of intracranial aneurysms with the Neuroform Atlas stent.

Endovascular management of distal ACA aneurysms: single-institution clinical experience in 22 consecutive patients and literature review.

BACKGROUND AND PURPOSE: Distal ACA aneurysms remain difficult to treat with endovascular therapy, but improved technology and experience allows for the treatment of some of these aneurysms with excellent results. The purpose of this study was to assess the status of endovascular treatment of distal ACA aneurysms by comparing our results with recent endovascular and microsurgical series of distal ACA aneurysms. MATERIALS AND METHODS: Between 2000 and 2008, a total of 22 consecutive patients (14 women; mean age, 58.4 years) with distal ACA aneurysms underwent coil placement at Barrow Neurological Institute. Clinical presentations, radiographic findings, endovascular management, and outcomes were reviewed retrospectively. RESULTS: Of the 22 patients, 13 (59%) presented with subarachnoid hemorrhage. Six patients were HH grade I or II, 1 was grade III, 5 were grade IV, and 1 was grade V. Frontal lobe hematomas occurred in 5 patients with ruptured aneurysms. The mean aneurysm size was 7.5 mm (range, 2.8-25 mm); 55% were smaller than 7 mm. Twelve aneurysms (55%) arose from the origin of the callosomarginal artery (55%). Complete occlusion was achieved in 50% of the cases and near-complete occlusion in 45%. The few periprocedural complications included 1 retroperitoneal hematoma and 1 intraoperative rupture. Four patients had thromboembolic events adequately treated intraprocedurally with abciximab. No deaths occurred in the patients treated. CONCLUSIONS: The characteristics of the patients and aneurysms treated in our series were comparable to previous reports of endovascular treatment of ACA aneurysms with respect to rupture status. Periprocedural morbidity and mortality rates in our series fared well compared with previous reports, as did our combined rate of complete or near-complete occlusions. Recent advances in endovascular devices and techniques have improved outcomes of distal ACA aneurysms.

Spinal chronic subdural hematoma.

Although chronic subdural hematomas are rare, they are likely to be more frequently reported as the clinical and magnetic resonance imaging characteristics become defined. Chronic spinal subdural hematomas (CSSDH) are extremely rare; these hematomas are frequently spontaneous and related to minor trauma. Although generally said to carry a poor prognosis, CSSDH can be a reversible cause of paraplegia. This article reviews the history, classification, clinical presentation, and treatment of CSSDH.

Major cerebral vessels injury caused by a seatbelt shoulder strap: case report.

Major cerebral arterial injury may result from penetrating or blunt trauma. In blunt trauma, clinical suspicion of such injury may not be raised, especially if the cranial CT scan is negative. We report a case of a seatbelt shoulder strap to the neck resulting in injury to three major cerebral vessels as demonstrated by cerebral angiography. Although the initial cranial CT scans were negative, a cerebral infarction ultimately developed. The patient was managed conservatively and recovered most of her functions. The importance of clinical suspicion and cerebral angiography is stressed.

MR imaging in the diagnosis of spontaneous spinal epidural hematomas.

Three patients with spontaneous (idiopathic) spinal epidural hematomas were diagnosed with magnetic resonance (MR) imaging. Magnetic resonance is an accurate, rapid method of localizing and characterizing the hematomas. We believe that MR (where available) should be the primary method of diagnosis in cases in which spinal epidural hematoma is suspected.

Classification of acute spinal cord injury, neurological evaluation, and neurosurgical considerations.

This article provides an overview of the classification of acute spinal cord injuries as well as the description of the pathophysiology and neuroanatomy of the most commonly traumatized areas of the spinal cord. The essentials of the neurological examination relative to spinal cord injuries is discussed and the specific abnormalities found in patients with spinal cord syndromes. Management principles are briefly summarized.

Surgical management of orbital lymphangioma with the carbon dioxide laser.

Lymphangiomas of the ocular adnexa, especially those in the orbit, are difficult to treat because the unencapsulated tumor freely interdigitates with normal orbital tissue, obliterating any potential surgical plane. Because of the hemorrhagic and friable nature of the tumor, conventional surgical techniques are frequently complicated by bleeding. We used the CO2 laser to remove these lesions subtotally by controlled vaporization in six patients (four girls and two boys, 5 to 17 years old). Three pupils remained dilated postoperatively because of damage to the ciliary nerves and symblepharon formation occurred in one case. None of these has produced any symptoms. In one case, however, laser treatment may have produced corneal anesthesia.

Brain abscess due to Haemophilus aphrophilus: possible canine transmission.

A 58-year-old patient developed progressive right hemiparesis and a hemisensory loss. Computed tomography demonstrated a lesion in the left frontoparietal region with ring enhancement. A craniotomy was performed and an abscess was removed, which on culture grew Haemophilus aphrophilus. The same organism was isolated from the patient's poodle dog but not from three other poodles of family members. This, along with previous reports, suggests that the poodle may be a vector in the transmission of this organism, which rarely may cause a brain abscess.

Intrasellar mucocele simulating pituitary adenoma: case report.

Mucoceles occupying the sella turcica with suprasellar extension are quite rare. A case of intrasellar mucocele is reported. The preoperative clinical and computed tomographic appearance could not be differentiated from that of pituitary adenoma.

Fibrosis surrounding a silicone implant simulating recurrent orbital meningioma. Case report.

A patient with the preoperative diagnosis of recurrent orbital apical meningioma was found to have a fibrotic capsule surrounding a silicone plate implanted 3 years previously to reconstruct the orbital roof. Caution is urged in using alloplastic orbital implants for reconstructive purposes in patients undergoing orbital surgery, because associated fibrous capsule formation may mimic tumor recurrence.