Diffusion tensor imaging assessment of the epileptogenic zone in children with localization-related epilepsy.

BACKGROUND AND PURPOSE: Patients with MR imaging-negative epilepsy could have subtle FCD. Our aim was to determine if structural changes could be identified by using DTI in children with intractable epilepsy, from MR imaging-visible FCD and MR imaging-negative localization-related epilepsy, that were concordant with the epileptogenic zone as defined by using the MEG dipole cluster. MATERIALS AND METHODS: Eight children with MR imaging-visible FCD and 16 with MR imaging-negative epilepsy underwent DTI and MEG. Twenty-six age-matched healthy children underwent DTI. Analysis was performed on controls across individual patients. Agreement between the location of DTI abnormalities and FCD and MEG dipole clusters was assessed. RESULTS: In patients with MR imaging-visible FCD, abnormal FA, MD, λ(1), λ(2), and λ(3) were lobar concordant with the MEG dipole cluster in 4/8 (50.0%), 5/8 (62.5%), 3/8 (37.5%), 6/8 (75.0%), and 5/8 (62.5%), respectively. In patients with MR imaging-visible FCD, abnormal FA, MD, λ(1), λ(2), and λ(3) overlapped the x-, y-, and z-axes of the MEG dipole cluster in 1/8 (12.5%), 4/8 (50%), 4/8 (50%), 6/8 (75%), and 4/8 (50%), respectively, and with FCD in 1/8 (12.5%), 3/8 (37.5%), 0/8 (0%), 3/8 (37.5%), and 1/8 (12.5%), respectively. In patients with MR imaging-negative epilepsy, abnormal FA, MD, λ(1), λ(2), and λ(3) were lobar-concordant with the MEG dipole cluster in 11/16 (68.8%), 11/16 (68.8%), 8/16 (50.0%), 10/16 (62.5%), and 10/16 (62.5%), respectively, and overlapped the x-, y-, and z-axes of the MEG dipole cluster in 9/16 (56.3%), 10/16 (62.5%), 8/16 (50%), 8/16 (50%), and 8/16 (50%), respectively. There was no significant difference between abnormal DTI lobar concordance with the MEG dipole cluster in patients with MR imaging-visible FCD and MR imaging-negative epilepsy. CONCLUSIONS: White matter changes can be detected with DTI in children with MR imaging-visible FCD and MR imaging-negative epilepsy, which were concordant with the epileptogenic zone in more than half of the patients.

Transvenous embolization of intracranial dural arteriovenous shunts through occluded venous segments: experience in 51 Patients.

BACKGROUND AND PURPOSE: DAVFs with cortical venous reflux carry a high risk of morbidity and mortality. Endovascular treatment options include transarterial embolization with a liquid embolic agent or transvenous access with occlusion of the involved venous segment, which may prove difficult if the venous access route is thrombosed. The aim of this article is to describe the technique and results of the transvenous approach via thrombosed venous segments for occlusion of DAVFs. MATERIALS AND METHODS: Our study was a retrospective analysis of 51 patients treated with a transvenous approach through an occluded sinus that was reopened by gentle rotational advancement of a 0.035-inch guidewire, which opened a path for a subsequently inserted microcatheter. RESULTS: Of 607 patients with DAVFs, the transvenous reopening technique was attempted in 62 patients in 65 sessions and was successful in 51 patients and 53 sessions. Immediate occlusion was seen in 42 patients; on follow-up, occlusion was seen in 49 patients, whereas 2 patients had reduced flow without cortical venous reflux. No permanent procedure-related morbidity was noted. CONCLUSIONS: The reopening technique to gain access to isolated venous pouches or the cavernous sinus for the treatment of DAVFs is a safe and effective treatment, which should be considered if transarterial approaches fail or are anticipated to result only in an incomplete anatomic cure.

Impact of anatomical variations of the circle of Willis on the incidence of aneurysms and their recurrence rate following endovascular treatment.

AIM: To analyse the impact of anatomical variations of the parent arteries on the incidence and recurrence rate following coil embolization of aneurysms of the anterior (AcoA), posterior communicating artery (PcoA) and basilar artery (BA) tip. METHODS: Two hundred and two (96 AcoA, 67 PcoA, and 29 BA) aneurysms in 200 patients were treated with coil embolization between January 2000 and April 2008. Parent artery variations at each location were classified as: AcoA: A1 aplasia versus hypoplasia versus symmetrical size; PcoA: foetal origin versus medium versus small size, BA: cranial versus caudal versus asymmetrical fusion. The incidence of aneurysms and difference between recurrence rates for each group were recorded on follow-up. RESULTS: AcoA, PcoA, and BA aneurysms were more often associated with embryonically earlier vessel wall dispositions (A1 aplasia, foetal PcoA, asymmetrical fusion). Two of these variations were also associated with aneurysm recurrence following coil embolization: asymmetrical A1 segment (p=0.01), and asymmetrical BA tip (p=0.02). CONCLUSIONS: AcoA, PcoA, and BA tip aneurysms tend to occur more often in anatomically variant parent artery dispositions, some of which are related to aneurysm recurrence following coil embolization. This may relate to a more fragile vessel disposition as it is not fully matured or to altered haemodynamics secondary to the anatomical variations.

Functional MR imaging in patients with carotid artery stenosis before and after revascularization.

BACKGROUND AND PURPOSE: Significant extracranial stenosis of the ICA is a known risk factor for future stroke and it has been shown that revascularization reduces the risk of future stroke. We applied BOLD fMRI in patients with carotid artery stenosis before and after CEA. Our purpose was to determine whether fMRI is able to demonstrate impaired CVR and to identify patient parameters that are associated with postoperative changes of cerebral hemodynamics. MATERIALS AND METHODS: Nineteen consecutive patients with symptomatic (n = 13) and asymptomatic (n = 6) stenosis of the ICA were prospectively recruited (male/female ratio = 16:3; age, 69 ± 8,1 years). fMRI using a simple bilateral motor task was performed immediately before and after CEA. RESULTS: Mean BOLD MSC was significantly increased postoperatively (MSC, 0.13 ± 0.66; P = 0.0002). Patients with a stenosis of <80% demonstrated an increase in MSC (MSC, 0.32 ± 0.59; P ≤ .0001). Patients with previous ischemic stroke showed a larger MSC than patients with TIAs (stroke: MSC, 0.55 ± 0.65; P ≤ .0001; TIA: MSC, 0.05 ± 0.26; P = 0.054). Patients older than 70 years had a significantly larger MSC following surgery (≤70 years: MSC, -0.01 ± 0.39; P = .429; >70 years: MSC, 0.29 ± 0.48; P ≤ .0001). CONCLUSIONS: BOLD fMRI can demonstrate changes in cerebral hemodynamics before and after CEA, indicative of an ameliorated CVR. This response is dependent on the age of the patient, the degree of preoperative stenosis, and the patient's symptoms.

Bare, bio-active and hydrogel-coated coils for endovascular treatment of experimentally induced aneurysms. Long-term histological and scanning electron microscopy results.

Endovascular treatments of cerebral aneurysms with bare platinum coils have a higher rate of recurrence compared to surgical clipping. This may be related to failed vessel wall reconstruction since histological and scanning electron microscopy results following embolization failed to demonstrate neoendothelialization over the aneurysm neck. The present study tried to elucidate whether the use of modified coils resulted in a better rate of reconstructing the vessel wall over the aneurysm neck in experimental aneurysms. Aneurysms were created in 20 rabbits by intraluminal elastase incubation of the common carotid artery. Five animals each were assigned to the following groups: untreated, bare platinum coils, bioactive coils with polyglycolic/polylactic acid coating, and hydrogel-coated platinum coils. After 12 months, angiography, histology and scanning electron microscopy was performed. No neoendothelial layer was visualized in the bioactive and bare coil groups with a tendency to an increased layering of fibroblasts along the bioactive coils at the aneurysm fundus. However, at the aneurysm neck perfused clefts were present and although a thin fibrinous layer was present over some coils, no bridging neointimal or neoendothial layer was noted over different coils. Following loose Hydrogel coiling, a complete obliteration of the aneurysm was present with neoendothelialization present over different coil loops. The study demonstrates that with surface coil modifications complete and stable aneurysm obliteration may become possible. A smooth and dense surface over the aneurysm neck may be necessary for endothelial cells to bridge the aneurysm neck and to lead to vessel wall reconstruction.

Subarachnoid hemorrhage following posterior spinal artery aneurysm. A case report and review of the literature.

Isolated posterior spinal artery aneurysms are rare vascular lesions. We describe the case of a 43-year-old man presenting with spinal subarachnoid hemorrhage after a minor trauma who was found to have a dissecting aneurysm of a posterior spinal artery originating from the right T4 level. Endovascular treatment was not contemplated because of the small size of the feeding artery, whereas surgical resection was deemed more appropriate because of the posterolateral perimedullary location that was well appreciated on CT angiography. After surgical resection of the aneurysm the patient had a complete neurological recovery. In comparison to anterior spinal artery aneurysms whose pathogenesis is diverse, posterior spinal aneurysms are most often secondary to a dissection and represent false or spurious aneurysms. Although the definite diagnosis still requires spinal angiography, MRI and CT may better delineate the relationship of the aneurysm to the spinal cord in order to determine the best treatment method. Prompt treatment is recommended as they have high rebleeding and mortality rates.

Corroboration of normal and abnormal fetal cerebral lamination on postmortem MR imaging with postmortem examination.

BACKGROUND AND PURPOSE: The presence of normal fetal cerebral lamination of the germinal matrix, intermediate zone, subplate layer, and cortex can be used as a marker of normal fetal cerebral development. Our aim was to compare postmortem MR imaging assessment of normal and abnormal fetal cerebral lamination on T1- and T2-weighted images with histopathology. MATERIALS AND METHODS: Fifty-five formalin-fixed brains from postmortem fetuses, ranging from 16 to 30 weeks' gestational age, mean of 23 weeks, underwent T1- and T2- weighted MR imaging and subsequent sectioning and histologic examination. The cerebral lamination was graded as normal or abnormal on T1- and T2-weighted imaging and compared with postmortem findings. The sensitivity, specificity, and positive and negative predictive values of T1 and T2 assessment of cerebral lamination were calculated. RESULTS: Twenty-six fetuses had abnormal and 29 had normal cerebral lamination on histology. On T1, the overall sensitivity, specificity, and positive and negative predictive values of evaluating cerebral lamination were 96.15%(CI, 78.42%-99.80%), 89.66%(CI, 71.50%-97.29%), 89.29%(CI, 70.63%-97.19%), and 96.29%(CI, 79.11%-99.80%), respectively. On T2, the overall sensitivity, specificity, and positive and negative predictive values of evaluating cerebral lamination were 73.08%(CI, 51.95%-87.65%), 96.55%(CI, 80.37%-99.82%), 95.00%(CI, 73.06%-99.74%), and 80.00%(CI, 62.54%-90.94%), respectively. CONCLUSIONS: Postmortem MR imaging has high sensitivity, specificity, and positive and negative predictive values in assessing fetal cerebral lamination compared with histology. T1-weighted imaging has a higher sensitivity and negative predictive value, while T2-weighted imaging has a higher specificity and positive predictive value.

Angiographic characteristics and treatment of cervical spinal dural arteriovenous shunts.

Spinal DAVSs of the cervical level are rare lesions. The purpose of this study is to describe the clinical and angiographic characteristics of cervical spinal DAVSs. From a prospectively collected database including 449 cases of brain and spinal DAVSs, lesions located at the cervical level were selected. The clinical presentation, angiographic characteristics, and treatment outcome were assessed. Twelve cases of spinal DAVSs were identified at the level of the cervical spinal canal (male to female ratio = 8:4; mean age = 56.5 years). Five patients (41.7%) presented with hemorrhage including SAH (n = 4) and cerebellar hemorrhage (n = 1). Coincidental spinal DAVSs with cranial DAVSs or brain AVMs were noted in 5 cases (41.7%). The spinal DAVS was the symptomatic lesion in 10 cases and was incidentally discovered during evaluation for SAH from a coincidental lesion in 2 cases. Combined endovascular and surgical resection resulted in symptomatic improvement in 10 patients. In conclusion, DAVSs of the cervical spine are rare lesions which often present with hemorrhage and are frequently associated with complex coincidental vascular lesions. Combined endovascular and surgical treatment will result in good outcome.

Alteration of human fetal subplate layer and intermediate zone during normal development on MR and diffusion tensor imaging.

BACKGROUND AND PURPOSE: The subplate layer and intermediate zone are the precursors for neonatal white matter. The aims of this study were to evaluate 1) T1 and T2 signal intensity, and 2) FA of subplate and intermediate zone in postmortem fetuses and correlate with histology, and 3) T2 signal intensity of subplate and intermediate zone on antenatal MR imaging. MATERIALS AND METHODS: Fourteen immersion-fixed normal brains from 18 to 25 gestational weeks underwent 1.5T MR imaging, including DTI and histologic examination. The subplate and intermediate zone were graded on a scale of 1-5 on T1 and T2, and FAs were evaluated and then correlated with age. Seventeen antenatal MR images from 20 to 26 gestational weeks with normal brain were evaluated by using the same grading. RESULTS: On T1 postmortem MR imaging, subplate has lower signal intensity compared with intermediate zone; subplate signal intensity correlated positively (r = 0.66, P = .012) with age, and intermediate zone signal intensity correlated negatively (r = -0.78, P = .001) with age. On T2 postmortem MR imaging, subplate has higher signal intensity compared with intermediate zone and remained persistently high in signal intensity; intermediate zone signal intensity showed moderate correlation (r = 0.48, P = .086) with age. FA of subplate correlated positively (r = 0.55, P < .001) with age; FA of intermediate zone correlated negatively (r = -0.64, P < .0001) with age. On histology, extracellular matrix decreased and cellularity increased in subplate layer, tangentially organized cellularity decreased, and projecting fibers became thicker in intermediate zone with increasing gestation. The findings on T2-weighted antenatal MR imaging were similar to T2-weighted postmortem MR imaging. CONCLUSIONS: The changes in signal intensity and FA of subplate and intermediate zone in the second trimester reflect microstructural changes on histology.

Imaging characteristics of arteriovenous malformations simulating vascular tumors of the temporalis muscle: a report of two cases.

Arteriovenous malformations (AVMs) of the temporalis muscle are an extremely rare subgroup of head and neck AVMs. The authors report two cases presenting with temporal fossa tumor-like lesions. MRI demonstrated enlargement of the temporalis muscle with hypointensity on T1, hyperintensity on T2 and moderate contrast enhancement. Angiography shows slow arteriovenous shunting with a dense capillary blush of the entire muscle before draining into facial veins. The arterial supply is characteristic of being restricted to the temporalis muscle.

Addictive illegal drugs: structural neuroimaging.

Illegal addictive drugs can lead to functional or structural impairment of the central nervous system. This review provides an overview of the structural imaging findings on CT, MR imaging, and conventional angiography related to chronic and acute abuse of the most commonly abused illegal drugs, including cannabis, organic solvents, and amphetamines and opioids and their respective derivatives. Pathomechanisms include excitotoxicity, which may lead to an acute or subacute leukoencephalopathy, and vascular complications, including vasoconstriction, vasculitis, or hypertension, which may lead to intracranial hemorrhage or ischemia. Because clinical findings alone are often nonspecific, and afflicted patients are unlikely to admit to the substance abuse, the neuroradiologist may play an important role in establishing the diagnosis and, thereby, initiating treatment.

Pulsatility of an intracavernous aneurysm demonstrated by dynamic 320-detector row CTA at high temporal resolution.

Studying the flow dynamics of intracranial aneurysms and the associated pulsatility of the aneurysm wall may help to risk-stratify unruptured aneurysms. Currently, in-vivo methods that visualize aneurysm wall movement at high temporal resolution are not yet fully established. We describe a patient with an intracavernous aneurysm in whom the area of increased aneurysm pulsatility as demonstrated by high-temporal resolution CTA was identical to the area of aneurysm growth on follow-up. A 35-year-old man presented with headaches and a sixth nerve palsy. CT including dynamic CTA demonstrated a pulsating intracavernous aneurysm. On follow-up one week later, the patient had developed hypesthesia in his V1 and V2 distribution and repeat imaging demonstrated aneurysm growth in the aneurysm part that demonstrated pulsatile movements on dynamic CTA. Stent-assisted coiling of the aneurysm was performed and led to clinical improvement. Dynamic CTA was performed using a 320-detector row CT following continuous rotational scanning during the administration of contrast with subsequent image reconstructions at 100 msec intervals. Dynamic CTA can demonstrate aneurysm pulsations that, as in the present case of a patient with a giant intracavernous aneurysm, were associated with aneurysm growth in the area of maximum pulsation. We hypothesize that this technique may predict aneurysm growth and may therefore be helpful in the non-invasive in vivo assessment of individual aneurysm features such as dome and bleb pulsations in both unruptured and ruptured aneurysms.

Dangerous extracranial-intracranial anastomoses and supply to the cranial nerves: vessels the neurointerventionalist needs to know.

Transarterial embolization in the external carotid artery (ECA) territory has a major role in the endovascular management of epistaxis, skull base tumors, and dural arteriovenous fistulas. Knowledge of the potential anastomotic routes, identification of the cranial nerve supply from the ECA, and the proper choice of embolic material are crucial to help the interventionalist avoid neurologic complications during the procedure. Three regions along the skull base constitute potential anastomotic routes between the extracranial and intracranial arteries: the orbital, the petrocavernous, and the upper cervical regions. Branches of the internal maxillary artery have anastomoses with the ophthalmic artery and petrocavernous internal carotid artery (ICA), whereas the branches of the ascending pharyngeal artery are connected to the petrocavernous ICA. Branches of both the ascending pharyngeal artery and the occipital artery have anastomoses with the vertebral artery. To avoid cranial nerve palsy, one must have knowledge of the supply to the lower cranial nerves: The petrous branch of the middle meningeal artery and the stylomastoid branch of the posterior auricular artery form the facial arcade as the major supply to the facial nerve, and the neuromeningeal trunk of the ascending pharyngeal artery supplies the lower cranial nerves (CN IX-XII).

Spinal dural arteriovenous fistulas.

Spinal dural arteriovenous (AV) fistulas are the most commonly encountered vascular malformation of the spinal cord and a treatable cause for progressive para- or tetraplegia. They most commonly affect elderly men and are classically found in the thoracolumbar region. The AV shunt is located inside the dura mater close to the spinal nerve root where the arterial blood from a radiculomeningeal artery enters a radicular vein. The increase in spinal venous pressure leads to decreased drainage of normal spinal veins, venous congestion, and the clinical findings of progressive myelopathy. On MR imaging, the combination of cord edema, perimedullary dilated vessels, and cord enhancement is characteristic. Therapy has to be aimed at occluding the shunting zone, either by superselective embolization with a liquid embolic agent or by a neurosurgical approach. Following occlusion of the fistula, the progression of the disease can be stopped and improvement of symptoms is typically observed.

Clinical characteristics of dural arteriovenous shunts in 446 patients of three different ethnicities.

SUMMARY: Dural arteriovenous shunts (DAVSs) developing in either the ventral, dorsal or lateral epidural spaces (VE, DE and LE-shunts) predictably drain in either cranio/spino-fugal or -petal directions. Associated conditions like venous outflow restrictions (VOR) may be responsible for changes in this drainage pattern. The goal of this study was to compare demographic, angiographic and clinical characteristics of different types of DAVS in Europe, South America, and Asia to find out whether the same clinical profile is present in different ethnicities. Charts and angiographic films of 446 patients with DAVS from three hospitals in Europe, Asia and South America were retrospectively evaluated. Clinical symptoms were separated into benign and aggressive and the presence or absence of cortical venous reflux (CVR) and VOR was noted. LE-shunts were present in elderly men and were always associated with CVR resulting in aggressive symptoms. VE-shunts were present in females and almost always had benign symptoms. There were no differences among the three populations for these shunts. DE-shunts in the Asian population were more aggressive secondary to a higher rate of VOR with associated CVR. VE-shunts rarely lead to CVR even in the presence of VOR, whereas LE-shunts invariably lead to CVR, irrespective of the population investigated. CVR in DE-shunts is not related to the primary disease (i.e. the shunt itself) but to associated factors that led to VOR. Since the occurrence of these varied between different ethnicities, DE-shunts were aggressive in the Asian population and benign in the European and South American populations.

Trigeminal fistula treated by combined transvenous and transarterial embolisation.

Trigeminal cavernous fistulae are rare, compared to other types of carotid-cavernous fistulae with only about 17 examples previously reported in English literature. The aetiology can be either post-traumatic or spontaneous, and in the latter group either due to a ruptured trigeminal aneurysm or postulated intrinsic weakness of the artery itself. The treatment goal is to close the fistula while preserving the parent artery and this can be done either by surgical or endovascular methods. We present a 35-year-old woman with a spontaneous trigeminal fistula treated by combined trans-venous and trans-arterial embolisation.

The aneurysmal wall. The key to a subclassification of intracranial arterial aneurysm vasculopathies?

SUMMARY: The pathogenesis of intracranial arterial aneurysms (AA) has been debated for many years and still remains unclear, although these entities might pose life-threatening risks to the patient and understanding the disease is of utmost importance for choosing treatment concepts. Apart from the "classical" berry-type aneurysm, there are different other types of intracranial AA such as infectious, dissecting or giant, partially thrombosed aneurysms. From the clinician's perspective, the hypothesis that some of these intracranial aneurysms might be due to abluminal factors has been put forward for many years. Alterations of the vessel wall, either due to luminal or abluminal factors may be employed for an etiological classification of aneurysmal vasculopathies as will be discussed in this article. Moreover, regarding certain aneurysmal vasculopathies as an abluminal disease might alter current therapeutic strategies since therapy should not only aim at the intraluminal repair of the artery but may also target the vessel wall.

Segmental neurovascular syndromes in children.

The concept of segmental vascular syndromes with different, seemingly unrelated, diseases is based on the embryology of the neural crest and the mesoderm migration of cells that share the same metameric origin. Migrating patterns of these cells link the brain, the cranial bones, and the face on the same side. A somatic mutation developing in the region of the neural crest or the adjacent cephalic mesoderm before migration can, therefore, be postulated to produce arterial or venous metameric syndromes, including PHACES, CAMS, Cobb syndrome, and Sturge-Weber syndrome. Although these diseases may be rare, their relationships among each other and their postulated linkage with the development of the neural crest and the cephalic mesoderm may shed light on the complex pathology and etiology of various cerebral vascular disorders.

Infantile dural arteriovenous shunt draining into a developmental venous anomaly.

SUMMARY: A three-year-old girl with an incidentally discovered infantile type of dural arteriovenous shunts (DAVs) along the superior sagittal sinus during investigation of a minor head trauma is presented. The DAVs drained into a developmental venous anomaly of the right cerebral hemisphere. In addition, there was a small cavernoma within the territory drained by the DVA. The patient underwent multiple transarterial embolizations to decrease the shunt flow and thus the constrained venous drainage of the DVA and right cerebral hemisphere. Pediatric dural arteriovenous shunts are a different entity from the adult type DAVs and should be managed according to the growth and development of the child. DVAs are extreme variations of the venous system with reduced flexibility to increased venous drainage. Regardless of the type of treatment employed, the DVA and its drainage pathway must be preserved.