Diagnostic Accuracy of Posterior/Anterior Periventricular WMH Ratio to Differentiate CAA From Hypertensive Arteriopathy.

BACKGROUND: Periventricular white matter hyperintensities (PVWMHs) in cerebral amyloid angiopathy (CAA) have been reported posterior predominant using semiautomated segmentation method and logarithmic transformation. We aimed to compare PVWMH extent and posterior/anterior distribution between patients with CAA and patients with hypertensive arteriopathy with radiological tools available in daily practice. METHODS: We retrospectively analyzed confluent PVWMH directly adjacent to lateral ventricles on axial FLAIR (fluid-attenuated inversion recovery) from 108 patients with CAA and 99 patients with hypertensive arteriopathy presenting with hemorrhage-related symptoms consecutively recruited in our stroke database (Nîmes University Hospital, France) between January 2015 and March 2022. For each of the left (L), right (R), anterior (A), and posterior (P) horns of lateral ventricles, the maximal distance between the outer PVWMH border and ventricle border was measured. The sum of anterior left PVWMH and anterior right PVWMH, and posterior left PVWMH and posterior right PVWMH resulted in anterior and posterior extent, respectively. RESULTS: Compared with hypertensive arteriopathy, patients with CAA were older (median, 77 versus 71; P=0.0010) and less frequently male (46% versus 64%; P=0.012) and had less frequent hypertension (45% versus 63%; P=0.013) and more chronic hemorrhages (P<0.0001). CAA showed slightly more extensive anterior right PVWMH (median, 6.50 versus 5.90 mm; P=0.034), far more extensive (all P<0.0001) posterior left PVWMH (median, 13.95 versus 6.95 mm), posterior right PVWMH (median, 14.15 versus 5.45 mm), posterior (median, 27.95 versus 13.00 mm), and total (median, 39.60 versus 24.65 mm) PVWMH, and higher posterior/anterior ratios (median, 1.82 versus 1.01). Age-/sex-adjusted model predicting CAA incorporating total PVWMH extent and posterior/anterior ratios for the given score (-4.3683+0.0268×PVWMH-T+0.3749×posterior/anterior PVWMH ratio+0.0394×age+0.3046 when female) showed highest area under the curve (0.76 [0.70-0.83]), with a 72% [62.50-80.99] sensitivity and 76% [67.18-84.12] specificity. Values above the optimal threshold of 0.22 for the score showed a crude relative risk of 2.75 (2.26-2.37; P<0.0001). CONCLUSIONS: Severe posterior PVWMH and high posterior/anterior PVWMH ratio assessed by radiological tools used in daily practice are associated with probable CAA versus hypertensive arteriopathy. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT05486897.

Acute phase supra-aortic intraluminal thrombus signal changes on magnetic resonance angiography: A case series: Intraluminal thrombus signal changes on MRA.

BACKGROUND AND OBJECTIVES: Intraluminal thrombus (ILT) is a relatively rare cause of stroke. MRI/MRA is increasingly used for stroke patients eligible for acute treatment. Radiological ILT characteristics have never been studied systematically on MRA. We aimed to analyse signal changes and other radiological characteristics of ILT in the acute phase on MRA in a case series of ILT patients. MATERIALS AND METHODS: Consecutive stroke patients registered in our stroke database between January 2013 and September 2022 were screened for supra-aortic ILT on MRA, in whom MRA was the first supra-aortic vessel imaging performed. Twelve patients were included for analysis. Radiological analysis on MRA included ILT localisation, diameter of the free-floating ILT component, total ITL length, degree of stenosis caused by ILT, and ILT signal intensity. RESULTS: Median age was 65 years and 92% were men. Median time interval between stroke onset and MRA was 0.5 days. Atherosclerosis was the underlying ILT aetiology in half of the patients. The most frequent ILT localisation was the internal carotid artery, always involving the C1 segment. Median ILT diameter was 4.35 mm, median length 20.9 mm, median stenosis 65%, and with a homogeneous hypointensity of the ILT in 67% and a mixed hypo-hyperintensity in 33% (with ILT showing central hyperintensity surrounded by peripheral hypointensity). DISCUSSION: When observed on MRA, ILT showed a homogeneous hypointensity in two-thirds and a mixed hypo-hyperintensity in one third of patients. In future studies, follow-up MRA scans should be performed to analyse whether these signal changes are time-related or influenced by antithrombotic treatment for ILT.

Cerebellar Superficial Siderosis in Cerebral Amyloid Angiopathy on 1.5T T2*-Weighted Imaging.

BACKGROUND: Cerebellar superficial siderosis (SS) has been recently reported to be present in about 10% of both hereditary and sporadic cerebral amyloid angiopathy (CAA) on 3T MRI using primarily susceptibility-weighted imaging. OBJECTIVES: Our aim was to assess cerebellar SS in sporadic CAA patients using 1.5T T2*-weighted MRI and to evaluate possible underlying mechanisms. METHOD: We retrospectively screened MRI scans of sporadic probable CAA patients initially presenting with intracerebral hemorrhage-, acute subarachnoid hemorrhage- or cortical SS-related symptoms between September 2009 and January 2022 registered in our stroke database. Patients with familial CAA were excluded. On 1.5T T2*-weighted MRI, cerebellar SS (including kappa statistics for interobserver agreement) was assessed together with typical CAA hemorrhagic features and with the presence of supratentorial macrobleed and cortical SS adjacent to the tentorium cerebelli (TC) and TC hemosiderosis. RESULTS: We screened 151 patients and finally included 111 CAA patients (median age 77) with cerebellar SS observed in 6 (5%) patients. Cerebellar SS presence was associated with a higher number of supratentorial macrobleeds (median n = 3 vs. n = 1, p = 0.0012), presence of supratentorial macrobleed adjacent to the TC (p = 0.002), and TC hemosiderosis (p = 0.005). CONCLUSIONS: Cerebellar SS in CAA patients can be identified on 1.5T T2*-weighted imaging. Associated MRI characteristics suggest contamination from supratentorial macrobleeds.

Brain hemorrhage on 24h-CT and functional outcome in stroke patients with cerebral amyloid angiopathy features on pre-thrombolysis MRI treated with intravenous thrombolysis: A case series.

BACKGROUND AND OBJECTIVES: In stroke patients treated with intravenous thrombolysis (IVT), presence and high number of strictly lobar cerebral microbleeds (compatible with cerebral amyloid angiopathy, CAA) seems to be associated with increased risk of hemorrhagic transformation, symptomatic hemorrhagic transformation, remote hemorrhage, and poor functional outcome. Some of these CAA patients with cerebral microbleeds also have chronic lobar intracerebral hemorrhage. Few data are available on IVT-treated CAA patients showing cortical superficial siderosis. There are no reports studying factors associated with brain hemorrhagic complication or functional outcome in IVT-treated CAA patients. We present a case series study of IVT-treated stroke patients with CAA features on pre-IVT MRI in whom we have evaluated brain hemorrhagic complications on 24 h-CT and functional outcome after IVT. MATERIAL AND METHODS: In our stroke center, IVT decision in patients with CAA MRI features is at the physician's discretion. We retrospectively screened our stroke database between January 2015 and July 2022 for pre-IVT imaging of 959 consecutive IVT-treated stroke patients without ongoing anticoagulation therapy for probable CAA MRI features defined by modified Boston criteria. After exclusion of 119 patients with missing MRI (n = 47), MRI showing motion artefacts (n = 49) or with alternative chronic brain hemorrhage cause on MRI (n = 23), 15 IVT-treated patients with probable CAA on pre-IVT MRI were identified. In these 15 patients, clinical, biological and MRI characteristics were compared between patients with vs. without post-IVT hemorrhage and between patients with poor (MRS 3-6) vs. good (MRS 0-2) functional outcome at discharge. RESULTS: Two patients showed brain hemorrhage on 24 h-CT and both died after 40 and 31 days respectively. The remaining patients had no brain hemorrhage and showed very good outcome except one. Atrial fibrillation (p = 0.029) and Fazekas scale (p = 0.029) were associated with brain hemorrhage whereas atrial fibrillation (p = 0.0022), NIHSS (p = 0.027), blood glucose level (p = 0.024), CRP (p = 0.022) and DWI ASPECT (p = 0.016) were associated with poor outcome. DISCUSSION: Consequences of IVT in CAA patients can be dramatic. Larger studies are needed to compare IVT risks and outcome between CAA and non-CAA patients, also including CAA patients with chronic intracerebral hemorrhage or cortical superficial siderosis. In addition, future studies should try to identify clinical, biological and radiological features at high risk for brain hemorrhage and poor outcome in order to assess the risk-benefit ratio for IVT in CAA. CLINICAL TRIAL REGISTRATION-URL: http://www. CLINICALTRIALS: gov. Unique identifier: NCT05565144.

Subarachnoid extension of lobar hemorrhage on acute/subacute MRI is associated with cerebral amyloid angiopathy criteria.

Subarachnoid hemorrhage extension (SAHE) in the acute phase of cerebral amyloid angiopathy (CAA)-related lobar hemorrhage (LH) assessed by CT is very frequent. Recently, SAHE, together with finger-like projections on CT and ApoE4, has been used in a prediction model for histopathologically proven CAA showing excellent discrimination. Our aim was to analyze SAHE on MRI in the acute and subacute phase of LH in patients with and without associated hemorrhagic features supportive of CAA (i.e. chronic LH, cortical superficial siderosis [CSS], and strictly lobar cerebral microbleeds [CMB]). We retrospectively studied SAHE on MRI performed in the acute and subacute phase (within 21 days) in a cohort of consecutive patients with acute LH recruited between January 2012 and April 2018. Sixty-eight acute LH patients (35 men and 33 women, mean age 74 [range 50-89]) were analyzed. Mean delay between symptom onset and MRI was 3.8 days, and 32 patients underwent MRI within 24 h. Based on MRI, 51 patients were classified as probable CAA and 17 patients without probable CAA. Both groups were comparable regarding age, sex, time of MRI performance, MRI field strength, and acute LH volume. Overall, SAHE was observed in 46 (68%) patients, including 39 (76%) patients with probable CAA and 7 (41%) patients without probable CAA (p = 0.015). SAHE presence was also associated with larger LH volumes. During the work-up in the acute/subacute phase of patients with acute LH, in addition to T2*-weighted imaging in search for other hemorrhagic features (chronic LH, CSS, or lobar CMB) evoking probable underlying CAA etiology, search for SAHE on adapted MRI sequences (FLAIR and T2*-weighted imaging) seems to be interesting because of the association with the presence of probable CAA criteria.

Finger-Like Projections in Lobar Haemorrhage on Early Magnetic Resonance Imaging Is Associated with Probable Cerebral Amyloid Angiopathy.

BACKGROUND: Recently, finger-like projections (FLP) and subarachnoid haemorrhage extension (SAHE) of lobar intracerebral haemorrhage (LH) on acute CT together with ApoE4 genotype have been used in a prediction model for histopathologically proven cerebral amyloid angiopathy (CAA). Our aim was to analyse FLP and SAHE on acute/early subacute magnetic resonance imaging (MRI) and to assess the association with probable CAA diagnosis according to modified Boston criteria. METHODS: We retrospectively studied MRI scans (and CT if available) performed <7 days in a cohort of consecutive acute LH patients >55 years. RESULTS: Forty-six patients (24 men and 22 women; mean age 73; 28 probable and 18 possible CAA patients) were analysed. Mean symptom onset-MRI delay was 1.3 days (including 26 patients with MRI <24 h). Both probable and possible CAA groups were comparable regarding age, sex, time MRI and CT performance, MRI field strength, and LH volume. On MRI, both FLP and SAHE were observed more frequently in probable than in possible CAA (FLP 43 vs. 6%, p = 0.0073; SAHE 79 vs. 44%, p = 0.027), and associated with larger LH volumes (FLP, p = 0.011; SAHE, p = 0.047). FLP was associated with earlier performed MRI (mean 0.3 vs. 1.75 days, p = 0.025). In the subgroup of 35 patients with available CT (performed a mean of 2.2 days before or after MRI), FLP presence on CT was observed more frequently in probable than in possible CAA (57 vs. 7%, p = 0.0039). Concordance of MRI and CT for FLP presence/absence was 89%. CONCLUSIONS: In acute LH patients, FLP and SAHE on acute/early subacute phase MRI are associated with probable CAA diagnosis. Larger LH volumes are associated with FLP and SAHE on MRI, and early performed MRI with FLP.

An Uncommon Cause of Longitudinally Extensive Transverse Myelitis.

Considering that currently Romania has the highest tuberculosis incidence in Europe, the recognition of the infection is an acknowledged health issue. Central nervous system tuberculosis accounts for approximately 1% of all cases of tuberculosis. Longitudinally extensive transverse myelitis is a contiguous infl ammatory lesion of the spinal cord which involves three or more spinal segments. In tuberculosis, spinal cord involvement is rare and is usually rather due to radiculomyelitis or spinal tuberculoma, and only very rare due to longitudinally extensive transverse myelitis. We present the case of a 52-year-old man referred to our department for progressive neurological deficits due to a longitudinally extensive transverse myelitis. After a thorough work-up we diagnosed the patient with longitudinally extensive transverse myelitis secondary to infection with Mycobacterium tuberculosis.