Surgical Treatment of Arteriovenous Malformations: Role of Preoperative Staged Embolization.

Preoperative embolization is complementary to surgery for large brain arteriovenous malformations (AVMs). From January 2005 to December 2015, 69 patients harboring an AVM were managed in our department by the same surgeon (RG). Forty one were ruptured and 65 were supratentorial. Thirty nine smaller AVMs were treated with surgery stand-alone, whereas, for 30 larger malformations, surgery was combined with adjuvant treatment involving preoperative staged embolization and/or, less frequently, radiosurgery. In all patients treated with surgery alone, complete resection of AVM was achieved. A successful preoperative partial endovascular obliteration of AVM was obtained in 24 out of 27 more complex cases, with a zero mortality rate and a very low morbidity. Here, embolization was of a certain utility in the handling of deeper feeders and nidus excision, also facilitating intraoperative hemostasis. In three cases of residuals, radiosurgery was performed. In those patient treated with a combined approach, a good overall outcome, 0-2 modified Rankin Scale (mRS), was achieved in 25 cases. Preoperative embolization proved to be a reasonable option complementary to high-grade AVMs surgery, reducing the frequency of breakthrough hemorrhages, aiding the elimination of deep feeders, and making the nidus dissection easier.

Thoracic spine trauma: advanced imaging modality.

Technological advances in diagnostic imaging make the diagnosis of spinal trauma more accurate both in the acute and in the chronic settings. Improvements in medical care and in diagnostic imaging lead to an increasing prevalence of patients' surviving injuries. The management of these patients depends on early and appropriate radiological evaluation in the acute phase. The aim of this work was to review advanced imaging modalities employed to study thoracic spine and spinal cord in injured patients.

Indications and efficacy of O2-O3 intradiscal versus steroid intraforaminal injection in different types of disco vertebral pathologies: a prospective randomized double-blind trial with 517 patients.

OBJECTIVE: The aim of this study was to prospectively evaluate the clinical efficacy of perigangliar steroid and local anesthetic with intradiscal O2-O3 injection versus steroid and local anesthetic intraforaminal injection in different types of herniation and grade of disc degeneration. MATERIALS AND METHODS: A total of 517 patients were randomly assigned to two groups. Control Group (159 men, 101 women; age range 25-89 years) underwent steroid and local anesthetic intraforaminal injection. Study Group (163 men, 94 women; age range 22-92 years) underwent the same treatment with addiction of O2-O3 intradiscal injection. Procedures were performed under computed tomographic guidance. Visual Analog Scale Questionnaire was administered before treatment and at intervals, the last at 6-month follow-up. Results were compared with Kruskal-Wallis and t test. RESULTS: After 6 months, O2-O3 discolysis was successful in 106 (41.24 %) Study Group patients with extrusions compared with 9 Control Group patients (3.5 %) (P < 0.001). In 89 (34.6 %) Study Group patients with protrusions, success rate was statistically significant compared with 5 Control Group patients (1.9 %). Significant difference was detected in the presence of Grade I, II, III of Degenerated Disc in 185 of Study Group patients (68.4 %) compared with 4 Control Group patients (1.5 %). CONCLUSIONS: The addition of O2-O3 discolysis is more effective at 6 months than perigangliar steroid and local anesthetic injection, especially in cases of herniated or protruded discs and with a Grade of Disc Degeneration from mild to moderate range.

Magnetic resonance imaging (MRI) of the lumbar spine with dedicated G-scan machine in the upright position: a retrospective study and our experience in 10 years with 4305 patients.

PURPOSE: To evaluate the pathological changes of the lumbar spine and the instability of the lumbar intervertebral joints observed in patients with low back pain, with the study of the transition from supine to orthostatic position through the use of dedicated MRI-G-scan machine. MATERIALS AND METHODS: Within 10 years, 4305 patients, aged between 21 and 80 years old, with history of low back pain with or without sciatica, underwent MRI examinations in upright and in supine position. The open MRI-scanner used is Esaote G-scan, which enables the acquisition of images in supine and standing positions. The used sequences were sagittal T2-weighted FSE, T1-weighted SE and axial 3D HYCE. Patients were divided into two groups: "negatives", with no changes in the two positions (supine and upright), and "positives", with MRI modifications of imaging in upright position. RESULTS: Orthostatic examination showed MRI changes in 2870 out of 4305 (66.6%) patients, including 1252 males and 1618 females. CONCLUSIONS: The G-scan is useful to assess instability of the lumbar spine detecting hidden modifications of protrusions and/or herniated discs already present in the supine position. It is also helpful in assessing the presence or modification of spondylolisthesis and lumbar canal stenosis.

Vascular malformation mimicking multiple sclerosis active plaque: Usefulness of susceptibility weighted imaging (SWI) to perform correct diagnosis.

Brain focal hyperdensity areas are common findings in computed tomography examinations, often further evaluated in magnetic resonance imaging exams. These are usually haemosiderin and calcified perivascular clusters known as cerebral microbleeds and may be secondary signs of brain disorders. Cerebral microbleeds are paramagnetic and ferromagnetic substances determining magnetic field inhomogeneity. Susceptibility weighted imaging (SWI) performed at 3T with phase post-processing is very useful in evaluating this field variation. In fact in the past decade SWI has been increasingly reported for its clinical value in adults with neurologic disorders, traumas, arterial venous malformations, occult venous diseases, tumours and functional brain imaging. The occasional computed tomography findings of single or multiple focal hyperdense areas can mimic many of these brain disorders and lead to misinterpretations. For these reason it is useful to have a more detailed diagnosis with MRI brain examination. The authors highlight the role of SWI sequence in the differential diagnosis among active plaque, vascular malformation and haemorrhagic lesion in a case report of a 41-year-old woman suffering from multiple sclerosis with a focal hyperdense area reported in a computed tomography brain examination.

Recurrence of Cerebral Amyloid Angiopathy-Related Inflammation: A Report of Two Cases from the iCAß International Network.

BACKGROUND: Cerebral amyloid angiopathy-related inflammation (CAA-ri) represents the most readily responsive form of CAA, if diagnosed and treated early. Although CAA-ri typically presents with a monophasic pattern, recurrences have been occasionally reported. OBJECTIVES: To describe the evolution of the clinical and neuroradiological features of CAA-ri recurrence. METHODS: From the 60 CAA-ri cases recruited through the iCAß International Network, we identified those patients who experienced a CAA-ri recurrence at more than 12 months after the first inflammatory event. Neuroradiological evidence of cerebral inflammation (vasogenic edema) and sulcal superficial siderosis or multiple areas of cortical/subcortical microhemorrhages (MHs) were evaluated based upon fluid-attenuated inversion recovery and T2 *-weighted gradient echo or susceptibility weighted imaging, respectively. In one patient, the deposition of amyloid-ß was evaluated using 11C-Pittsburgh Compound B-positron emission tomography (PiB-PET). RESULTS: Of the 60 cases, two were identified as having experienced a late CAA-ri recurrence, at two and seven years after the first presentation, respectively. At recurrence, the inflammatory lesions colocalized with the appearance of new MHs and were observed in brain areas different from those where the first onset occurred. PiB-PET four months after remission showed particularly low amyloid-ß deposition in the left frontal lobe, while no change was observed in the area of the inflammatory relapse. CONCLUSIONS: Our observations highlight the importance of not underestimating any new neurological symptoms in patients who have already experienced an episode of CAA-ri. Although the frequency of CAA-ri recurrences is rare, in cases of suspected relapse, a prompt clinical and radiological follow-up should be considered in order to obtain a timely diagnosis and treatment, having a potential strong impact on patients' clinical outcome.

Does evaluator experience have an impact on the diagnosis of lumbar spine instability in dynamic MRI? Interobserver agreement study.

OBJECTIVES: We aimed to evaluate interobserver agreement in the definition of spine instability among spine neuroradiologists with or without experience in dynamic magnetic resonance imaging (MRI). MATERIAL AND METHODS: Two expert neuroradiologists and two residents retrospectively evaluated the pre-operative dynamic MRI examinations of patients with vertebral instability. Segmental motion, defined as excessive (more than 3 mm) translational motion from supine to upright, was investigated in 103 subjects (309 segments) using kinetic MRI. Radiographic parameters which can help indicate segmental instability include disc degeneration, facet joint osteoarthritis, and ligament flavum hypertrophy. These three radiographic parameters were simultaneously evaluated, and the combinations corresponding to significant segmental instability at each level were determined. The agreement among the neuroradiologists was calculated using the kappa coefficient. All patients had neurosurgical intervention to stabilize the spine. RESULTS: Agreement was high among experienced and non-experienced neuroradiologists. Agreement was nearly perfect for spinal location of spinal instability. CONCLUSIONS: This study demonstrates that the experience of the evaluator has a low impact on the assessment of spinal instability if correct classification is used. The interobserver agreement confirms the usefulness and safety of kinetic MRI in the correct diagnosis of spinal instability even by less experienced evaluators.

MRI DWI/ADC signal predicts shrinkage of lumbar disc herniation after O2-O3 discolysis.

PURPOSE: Evaluate the discal morpho-structural changes as a predictive sign in the clinical outcome after ozone therapy in lumbar disc herniation using the T2-shine through effect in diffusion-weighted imaging (DWI). METHOD: One hundred and fifty-four patients suffering from lumbosciatica (89 men and 65 women; age range, 23-62 years) were included, previous MR study performed with FSE-T2 and T2-fat, SE-T1 and DWI sequences, and were randomly assigned to two groups. Seventy-seven patients (control group) underwent conservative treatment with intraforaminal injection of steroid and anaesthetic. The remaining 77 patients (study group) underwent the same treatment with the addition of oxygen-ozone (O2-O3). During the following six months, a MRI follow-up with the same sequences was performed. An intervertebral disc volumetric analysis (IDVA), DWI signal score and post treatment clinical outcome evaluation were performed for an assessment of hernia reduction. χ² test, Student's t test and analysis of covariance were used for comparison of variables. RESULTS: In the study group, 58 of 77 patients had a successful outcome (responders). In the responders group, DWI T2-shine through effect was present during MRI follow-up and in particular in 53 of 77 patients in six months of follow-up (p < 0.05). Moreover, in the same group a statistically significant disc shrinkage was shown by IDVA in sixth months of follow-up (p < 0.05). CONCLUSIONS: T2-shine through effect in DWI is present before morphological disc reduction and moreover could be considered as a predictive sign of response to oxygen-ozone treatment.

Neuromyelitis optica: atypical clinical and neuroradiological presentation.

The extreme variability of clinical and MRI findings in the suspicion of Devic's disease always requires the detection of specific antibodies (AQP4). MRI scans were performed with a high-field MRI scanner (1.5T General Electric Signa Horizon): the MRI protocol of the brain employed axial DP, T2, T1, FLAIR and DWI weighted images (wi) and coronal T2-wi. After intravenous administration of contrast medium axial and sagittal T1-weighted images of the brain were repeated. The spine protocol employed after contrast medium included sagittal T2-wi, T2-wi with fat suppression and T1-wi. In May 2004, a 64-year-old healthy Caucasian woman began to suffer loss of motor and thermal sensitivity in the left lower limb. MRI showed non-specific areas of abnormal signal intensity on the deep left frontal and right frontoparietal white matter with no pathological enhancement after contrast medium and a small intramedullary area of altered signal at metameric level C2-C4 with a diagnosis of post-viral transverse myelitis. The patient had two similar episodes years later so the neurologist decided to search for circulating IgG AQP4 with the definitive diagnosis of neuromyelitis optica. In this case, compared to a clinical presentation of atypical deficit neurological involvement, the neuroradiological results of a progressive diffuse involvement of the white matter were atypical.

T2 shine-through phenomena in diffusion-weighted MR imaging of lumbar discs after oxygen-ozone discolysis: a randomized, double-blind trial with steroid and O2-O3 discolysis versus steroid only.

PURPOSE: To evaluate the discal morpho-structural changes as predictive sign in the clinical outcome after Ozone Therapy in lumbar disc herniation using the T2 shine-through effect in DWI. METHODS: One hundred and fifty-four patients suffering from lumbosciatica (89 men and 65 women; range 23-62 years) were included in previous MR study performed with FSE-T2 and T2-fat, SE-T1 and DWI sequences and were randomly assigned to two groups. Seventy-seven patients (Control Group) underwent conservative treatment with intraforaminal injection of steroid and anesthetic. The remaining 77 patients (Study Group) underwent the same treatment with the addiction of oxygen-ozone (O2-O3). During the coming 6 months, an MRI follow-up with the same sequences was performed. An intervertebral disc volumetric analysis (IDVA), DWI signal score and post treatment clinical outcome evaluation were performed for an assessment of hernia reduction. χ (2) test, Student's t test and analysis of covariance were used for comparison of variables. RESULTS: In the Study Group, 58 over 77 patients had a successful outcome (Responders). In the Responders group, DWI T2 shine-through effect was present during MRI follow-up and in particular in 53 of 77 patients in the 6 months of follow-up (P < 0.05). Moreover, in the same group was present a statistically significant discs' shrinkage in the sixth month of follow-up (P < 0.05) as showed by IDVA. CONCLUSIONS: T2 shine-through effect in DWI is present before morphological disc reduction and moreover could be considered as a predictive sign of response to oxygen-ozone treatment.

The Italian Registry of Endovascular Treatment in Acute Stroke: rationale, design and baseline features of patients.

Endovascular treatment (ET) showed to be safe in acute stroke, but its superiority over intravenous thrombolysis is debated. As ET is rapidly evolving, it is not clear which role it may deserve in the future of stoke treatments. Based on an observational design, a treatment registry allows to study a broad range of patients, turning into a powerful tool for patients' selection. We report the methodology and a descriptive analysis of patients from a national registry of ET for stroke. The Italian Registry of Endovascular Treatment in Acute Stroke is a multicenter, observational registry running in Italy from 2010. All patients treated with ET in the participating centers were consecutively recorded. Safety measures were symptomatic intracranial hemorrhage, procedural adverse events and death rate. Efficacy measures were arterial recanalization and 3-month good functional outcome. From 2008 to 2012, 960 patients were treated in 25 centers. Median age was 67 years, male gender 57 %. Median baseline NIHSS was 17. The most frequent occlusion site was Middle cerebral artery (46.9 %). Intra-arterial thrombolytics were used in 165 (17.9 %) patients, in 531 (57.5 %) thrombectomy was employed, and 228 (24.7 %) patients received both treatments. Baseline features of this cohort are in line with data from large clinical series and recent trials. This registry allows to collect data from a real practice scenario and to highlight time trends in treatment modalities. It can address unsolved safety and efficacy issues on ET of stroke, providing a useful tool for the planning of new trials.

Neural activity related to cognitive and emotional empathy in post-traumatic stress disorder.

The aim of this study is to evaluate the empathic ability and its functional brain correlates in post-traumatic stress disorder subjects (PTSD). Seven PTSD subjects and ten healthy controls, all present in the L'Aquila area during the earthquake of the April 2009, underwent fMRI during which they performed a modified version of the Multifaceted Empathy Test. PTSD patients showed impairments in implicit and explicit emotional empathy, but not in cognitive empathy. Brain responses during cognitive empathy showed an increased activation in patients compared to controls in the right medial frontal gyrus and the left inferior frontal gyrus. During implicit emotional empathy responses patients with PTSD, compared to controls, exhibited greater neural activity in the left pallidum and right insula; instead the control group showed an increased activation in right inferior frontal gyrus. Finally, in the explicit emotional empathy responses the PTSD group showed a reduced neural activity in the left insula and the left inferior frontal gyrus. The behavioral deficit limited to the emotional empathy dimension, accompanied by different patterns of activation in empathy related brain structures, represent a first piece of evidence of a dissociation between emotional and cognitive empathy in PTSD patients. The present findings support the idea that empathy is a multidimensional process, with different facets depending on distinct anatomical substrates.

MRI anatomical variants of mammillary bodies.

The mammillary bodies (MBs) are classically defined as a pair of small round structures located on the undersurface of the diencephalon. The systematic observation of MR brain images of patients with neurological diseases, but also of healthy subjects enrolled in research protocols, reveals, however, a greater anatomical variability. The aim of the present study was to define the spectrum of such variability using spatial normalized 3D TFE T1-weighted MR images in a group of 151 healthy right-handed young subjects (78 females, age range 16-39 years). The MBs were identified on reformatted coronal and axial images and classified according to morphological, positional and numerical criteria. On the basis of coronal images, MBs were first divided into symmetrical (86.1 %) and asymmetrical (13.9 %), depending on their respective height. Symmetrical MBs were further subdivided into three variants [type A (2.7 %), B (76.2 %), C (7.3 %)] according to the depth of the intermammillary sulcus. Two morphological variants were defined on axial images, depending on whether the MBs were circular (63.6 %) or elliptic (36.4 %). This latter group was further divided in two subgroups, depending on whether the MBs were parallel (21.9 %) or convergent (14.6 %). Finally, two subjects (1.3 %) presented a supernumeral MB. The transverse size of the third ventricle was greater in the type A compared to the type B and C groups. Gender did not significantly affect the frequency of MBs variants, except for the three symmetrical subgroups in which the variants A and C were more frequent in males than in females. These findings suggest the presence of an anatomical variability of the MBs, in contrast to their classical definition. Therefore, atypical presentation of MBs can be the expression of this variability rather than a marker of neurological disorders (i.e. cerebral malformation, mesial temporal sclerosis, Wernicke-Korsakoff syndrome).

Spine epidural and sacroiliac joints injections--when and how to perform.

OBJECTIVES: To review the state-of-the-art of image-guided techniques used to treat painful syndromes of the lower back, their indications, how they should be performed, their related risks and the expected results. METHODS: We describe the actual standards about image-guided infiltrative therapies both on spine and on sacroiliac joints. RESULTS: Both spinal epidural and sacroiliac injections appear useful in a large percentage of treated patients to get control of the perceived pain. Performing these therapies under CT or fluoroscopic guidance is the best and safest way to obtain satisfactory results because it is possible to target the use of drugs directly to the involved painful structures. CONCLUSIONS: Image-guided injections of the epidural space and of the sacroiliac joints are effective techniques for the treatment of pain; their effectiveness is sometimes not lasting for long periods of time but considering the low associated risk when performed by trained personnel, they can be easily repeated.

Progressive Multifocal Leukoencephalopathy Following Treatment with Rituximab in an HIV-Negative Patient with Non-Hodgkin Lymphoma. A Case Report and Literature Review.

Progressive multifocal leukoencephalopathy (PML) is a rare rapidly progressive demyelinating disease of the central nervous system caused by reactivation of latent John Cunningham (JC) polyomavirus (JCV) infection. We describe an unusual case of PML in a 54-year-old patient with follicular non-Hodgkin lymphoma who received rituximab plus cyclophosphamide, hydroxydaunorubicin, oncovicin and prednisolone (R-CHOP) therapy. She started to notice gradual progressive neurological symptoms about two months after completion of rituximab treatment and was therefore admitted to hospital. On admission, brain CT and MRI showed widespread lesions consistent with a demyelinating process involving the subcortical and deep white matter of the cerebral and cerebellar hemispheres. CT and MRI findings were suggestive of PML, and JC virus DNA was detected by polymerase chain reaction assay of the cerebrospinal fluid and serum. The patient was treated supportively but reported a progressive worsening of the clinical and radiological findings. Our report emphasizes the role of CT and MRI findings in the diagnosis of PML and suggests that PML should be considered in patients with progressive neurological disorders involving the entire nervous system and mainly the white matter, especially in the presence of previous immunomodulatory treatment or immunosuppression.

320-Row Detector Dynamic 4D-CTA for the Assessment of Brain and Spinal Cord Vascular Shunting Malformations. A Technical Note.

Shunting vascular malformations of the brain and spinal cord are traditionally studied using digital subtraction angiography (DSA), the current gold standard imaging method routinely used because of its favourable combination in terms of spatial and temporal resolution. Because DSA is relatively expensive, time-consuming and carries a risk of silent embolic events and a small risk of transient or permanent neurologic deterioration, a non-invasive alternative angiographic method is of interest. New 320 row-detector CT scanners allow volumetric imaging of the whole brain with temporal resolution up to ≌ 3 Hz. Those characteristics make computed tomography angiography (CTA) an affordable imaging method to study the haemodynamics of the whole brain and can also be applied to the study of limited portions of the spinal cord. The aim of this paper is to make a brief summary of our experience in studying shunting vascular malformation of the brain and spinal cord using dynamic 4D-CTA, explaining the technical details of the studies performed at our institution, and the state-of-the-art major advantages and drawbacks of this new technique. We found that dynamic 4D-CTA is able to depict the main architectural characteristics of previously untreated vascular shunting malformations both in brain and spinal cord (i.e. their main arterial feeders and draining veins) allowing their correct diagnosis and exhaustive classification, limiting the use of DSA for therapeutic purposes.

Occult neural foraminal stenosis caused by association between disc degeneration and facet joint osteoarthritis: demonstration with dedicated upright MRI system.

PURPOSE: The aim of our study was to evaluate the presence of dynamic foraminal stenosis using a new low-field dedicated magnetic resonance (MR) unit with a balancing system that allows images to be acquired both in the recumbent and upright position. Imaging of lumbar spine with the patient in a supine, nonweight-bearing position is likely to misrepresent the degree and potential risk of spinal stenosis. MATERIALS AND METHODS: In the period between September 2008 and May 2011, we selected 630 symptomatic patients aged 40-65 years (mean age 56) who underwent conventional MR in clinostatic position. The study only included selected patients (total 160) who underwent clinostatic and orthostatic evaluation using a dedicated MR system (G-scan). The biomechanical parameters were also considered. Changes in the dimension of the neural foramina were compared using the presence of disc and facet degeneration by statistical analysis. RESULTS: Stenosis of the intervertebral foramen was never found in the presence of normal intervertebral discs either in the presence or in the absence of facet disease, in either clinostatic or orthostatic position. Sixty-one stenotic levels were detected which were visualised exclusively in scans obtained under weight-bearing conditions. We named this dynamic condition "occult stenosis". In all of these cases, disc disease was associated with facet pathology. CONCLUSION: Our data show that the association between disc pathology and facet osteoarthrosis can cause occult foraminal stenosis. Strategies to image the spine under physiological load conditions may improve the clinical diagnosis of radicular pain.

Guidelines from The Italian Neurological and Neuroradiological Societies for the use of magnetic resonance imaging in daily life clinical practice of multiple sclerosis patients.

MRI is highly sensitive in detecting focal white matter lesions in multiple sclerosis (MS). For this reason, it has been formally included in the diagnostic workup of patients with clinically isolated syndromes suggestive of MS, through the definition of ad hoc sets of criteria to show disease dissemination in space and time. MRI is used in virtually all clinical trials of the disease as a surrogate measure of treatment response. Several guidelines have been published to help characterizing the imaging features on conventional MR sequences of "typical" MS lesions and work has also been performed to identify "red flags" which should alert the clinicians to exclude possible alternative conditions. Despite this, the application of the available guidelines and criteria in daily life clinical practice is still limited and varies among and within countries (including Italy) due to regulatory issues and heterogeneity of MRI facilities. It is crucial for neurologists and neuroradiologists to become familiar with these criteria to improve the quality of their diagnostic assessment. In patients with established MS, the main problem is to define standard procedures for monitoring the course of the disease and treatment response. This review aims at providing daily life guidelines to clinicians for a correct application of MRI in the workup of patients suspected of having MS as well as in the monitoring of disease evolution in those with established MS. It also offers clues for the standardization of MRI studies and relative reporting to be applied at a national level.