Item response theory analysis to evaluate reliability and minimal clinically important change of the Roland-Morris Disability Questionnaire in patients with severe disability due to back pain from vertebral compression fractures

BACKGROUND CONTEXT

The majority of validation done on the Roland-Morris Disability Questionnaire (RMDQ) has been in patients with mild or moderate disability. There is paucity of research focusing on the psychometric quality of the RMDQ in patients with severe disability.

PURPOSE

To evaluate the psychometric quality of the RMDQ in patients with severe disability.

STUDY DESIGN/SETTING

Observational clinical study.

SAMPLE

The sample consisted of 214 patients with painful vertebral compression fractures who underwent vertebroplasty or kyphoplasty.

OUTCOME MEASURES

The 23-item version of the RMDQ was completed at two time points: baseline and 30-day postintervention follow-up.

METHODS

With the two-parameter logistic unidimensional item response theory (IRT) analyses, we derived the range of scores that produced reliable measurement and investigated the minimal clinically important difference (MCID).

RESULTS

Scores for 214 (100%) patients at baseline and 108 (50%) patients at follow-up did not meet the reliability criterion of 0.90 or higher, with the majority of patients having disability due to back pain that was too severe to be reliably measured by the RMDQ. Depending on methodology, MCID estimates ranged from 2 to 8 points and the proportion of patients classified as having experienced meaningful improvement ranged from 26% to 68%. A greater change in score was needed at the extreme ends of the score scale to be classified as having achieved MCID using IRT methods.

CONCLUSIONS

Replacing items measuring moderate disability with items measuring severe disability could yield a version of the RMDQ that better targets patients with severe disability due to back pain. Improved precision in measuring disability would be valuable to clinicians who treat patients with greater functional impairments. Caution is needed when choosing criteria for interpreting meaningful change using the RMDQ.

Clinical and Imaging Characteristics of Diffuse Intracranial Dolichoectasia

BACKGROUND AND PURPOSE

Among patients with vertebrobasilar dolichoectasia is a subset of patients with disease affecting the anterior circulation as well. We hypothesized that multivessel intracranial dolichoectasia may represent a distinct phenotype from single-territory vertebrobasilar dolichoectasia. The purpose of this study was to characterize clinical characteristics and angiographic features of this proposed distinct phenotype termed "diffuse intracranial dolichoectasia" and compare them with those in patients with isolated vertebrobasilar dolichoectasia.

MATERIALS AND METHODS

We retrospectively reviewed a consecutive series of patients with diffuse intracranial dolichoectasia and compared their demographics, vascular risk factors, additional aneurysm prevalence, and clinical outcomes with a group of patients with vertebrobasilar dolichoectasia. "Diffuse intracranial dolichoectasia" was defined as aneurysmal dilation of entire vascular segments involving ≥2 intracranial vascular beds. Categoric and continuous variables were compared by using χ² and Student t tests, respectively.

RESULTS

Twenty-five patients had diffuse intracranial dolichoectasia, and 139 had vertebrobasilar dolichoectasia. Patients with diffuse intracranial dolichoectasia were older than those with vertebrobasilar dolichoectasia (70.9 ± 14.2 years versus 60.4 ± 12.5 years, P = .0002) and had a higher prevalence of abdominal aortic aneurysms (62.5% versus 14.3%, P = .01), other visceral aneurysms (25.0% versus 0%, P < .0001), and smoking (68.0% versus 15.9%, P < .0001). Patients with diffuse intracranial dolichoectasia were more likely to have aneurysm growth (46.2% versus 21.5%, P = .09) and rupture (20% versus 3.5%, P = .007) at follow-up. Patients with diffuse intracranial dolichoectasia were less likely to have good neurologic function at follow-up (24.0% versus 57.6%, P = .004) and were more likely to have aneurysm-related death (24.0% versus 7.2%, P = .02).

CONCLUSIONS

The natural history of patients with diffuse intracranial dolichoectasia is significantly worse than that in those with isolated vertebrobasilar dolichoectasia. Many patients with diffuse intracranial dolichoectasia had additional saccular and abdominal aortic aneurysms. These findings suggest that diffuse intracranial dolichoectasia may be a distinct vascular phenotype secondary to a systemic arteriopathy affecting multiple vascular beds.

Lack of Association between Statin Use and Angiographic and Clinical Outcomes after Pipeline Embolization for Intracranial Aneurysms

BACKGROUND AND PURPOSE

Use of statin medications has been demonstrated to improve clinical and angiographic outcomes in patients receiving endovascular stent placement for coronary, peripheral, carotid, and intracranial stenoses. We studied the impact of statin use on long-term angiographic and clinical outcomes after flow-diverter treatment of intracranial aneurysms.

MATERIALS AND METHODS

We performed a post hoc analysis from pooled patient-level datasets from 3 Pipeline Embolization Device studies: the International Retrospective Study of the Pipeline Embolization Device, the Pipeline for Uncoilable or Failed Aneurysms Study, and the Aneurysm Study of Pipeline in an Observational Registry. We analyzed data comparing 2 subgroups: 1) patients on statin medication, and 2) patients not on statin medication at the time of the procedure and follow-up. Angiographic and clinical outcomes were compared by using the χ² test, Fisher exact test, or Wilcoxon rank sum test.

RESULTS

We studied 1092 patients with 1221 aneurysms. At baseline, 226 patients were on statin medications and 866 patients were not on statin medications. The mean length of clinical and angiographic follow-up was 22.1 ± 15.1 months and 28.3 ± 23.7 months, respectively. There were no differences observed in angiographic outcomes at any time point between groups. Rates of complete occlusion were 82.8% (24/29) versus 86.4% (70/81) at 1-year (P = .759) and 93.3% (14/15) versus 95.7% (45/47) at 5-year (P = 1.000) follow-up for statin-versus-nonstatin-use groups, respectively. There were no differences in any complication rates between groups, including major morbidity and neurologic mortality (7.5% versus 7.1%, P = .77).

CONCLUSIONS

Our study found no association between statin use and angiographic or clinical outcomes among patients treated with the Pipeline Embolization Device.

Accelerated Singular Value-Based Ultrasound Blood Flow Clutter Filtering With Randomized Singular Value Decomposition and Randomized Spatial Downsampling

Singular value decomposition (SVD)-based ultrasound blood flow clutter filters have recently demonstrated substantial improvement in clutter rejection for ultrafast plane wave microvessel imaging, and have become the commonly used clutter filtering method for many novel ultrafast imaging applications such as functional ultrasound and super-resolution imaging. At present, however, the computational burden of SVD remains as a major hurdle for practical implementation and clinical translation of this method. To address this challenge, in the study we present two blood flow clutter filtering methods based on randomized SVD (rSVD) and randomized spatial downsampling to accelerate SVD clutter filtering with minimal compromise to the clutter filter performance. rSVD accelerates SVD computation by approximating the k largest singular values, while random downsampling accelerates both full SVD and rSVD by decomposing the original large data matrix into small matrices that can be processed in parallel. An in vitro blood flow phantom study with the presence of heavy tissue clutter showed significantly improved computational performance using the proposed methods with minimal deterioration to the clutter filter performance (less than 3-dB reduction in blood to clutter ratio, less than 0.2-cm²/s² increase in flow mean squared error, less than 0.1-cm/s increase in the standard deviation of the vessel blood flow signal, and less than 0.3-cm/s increase in tissue clutter velocity for both full SVD and rSVD when the downsampling factor was less than 20× ). The maximum acceleration was about threefold from randomized spatial downsampling, and approximately another threefold from rSVD. An in vivo rabbit kidney perfusion study showed that rSVD provided comparable performance to full SVD in clutter rejection in vivo (maximum difference of blood to clutter ratio was less than 0.6 dB), and random downsampling provided artifact-free perfusion imaging results when combined with both full SVD and rSVD. The blood to clutter ratio was still above 10 dB with a downsampling factor of 60× . We also demonstrated real-time microvessel imaging feasibility (~40-ms processing time) by combining rSVD with random downsampling. The findings and methods presented in this paper may greatly facilitate the new area of ultrafast microvessel imaging research.

Post-contrast acute kidney injury in intensive care unit patients: a propensity score-adjusted study

PURPOSE

To examine the association of intravenous iodinated contrast material administration with the subsequent development of post-contrast AKI (PC-AKI), emergent dialysis, and short-term mortality using a propensity score-adjusted analysis of a cohort of intensive care unit (ICU) patients who underwent CT examination.

METHODS

All ICU patients at our institution who received a contrast-enhanced (contrast group) or unenhanced (noncontrast group) CT scan from January 2006 to December 2014 were identified. Patients were subdivided into pre-CT eGFR > 45 and eGFR ≤ 45 subsets and separately underwent propensity score analysis. Rates of KDIGO-defined AKI, dialysis, and mortality were compared between contrast and noncontrast groups. Separate analyses of eGFR ≥ 60, 30-59, and <30 subsets were also performed.

RESULTS

A total of 6877 ICU patients (4351 contrast, 2526 noncontrast) were included in the study. Following propensity score adjustment, the rates of AKI (31 vs. 34%, OR .88 (95% CI .75-1.05), p = .15), dialysis (2.0 vs. 1.7%, OR 1.20 (.66-2.17), p = .55), and mortality (12 vs. 14%, OR .87 (.69-1.10), p = .23) were not significantly higher in the contrast versus noncontrast group in the matched eGFR > 45 subset. Significantly higher rates of dialysis (6.7 vs. 2.5%, OR 2.72 (1.14-6.46), p = .0240) were observed in the contrast versus noncontrast group in the matched eGFR ≤ 45 subset.

CONCLUSIONS

Intravenous contrast material administration was not associated with an increased risk of AKI, emergent dialysis, and short-term mortality in ICU patients with pre-CT eGFR > 45. An increased risk of dialysis was observed in patients with pre-CT eGFR ≤ 45.

Association of h-index of Editorial Board Members and Impact Factor among Radiology Journals

RATIONALE AND OBJECTIVES

h-Index has been proposed as a useful bibliometric measure for quantifying research productivity. In this current study, we analyzed h-indices of editorial board members of Radiology journals and tested the hypothesis that editorial board members of Radiology journals with higher impact factors (IF) have higher h-indices.

MATERIALS AND METHODS

Sixty-two Radiology journals with IF >1 were included. Editorial board members were identified using the journals' websites. Editors' affiliations and research fields of interest were used to distinguish investigators with similar names. Bibliometric indices including number of publications, total citations, citations per publication, and h-index for each editorial board member were obtained using the Web of Science database. Chi-square or Wilcoxon rank-sum tests were used to test for differences in bibliographic measures or demographics between groups.

RESULTS

Among the editorial boards of 62 journals, the median [interquartile range] board h-index was 26 [18, 31] and had 36 [17, 56] members. The median journal IF was 2.27 [1.74, 3.31]. We identified a total of 2204 distinct editors; they had a median [interquartile range] h-index of 23 [13, 35], 120 [58, 215] total publications, 1938 [682, 4634] total citations, and an average of 15.7 [9.96, 24.8] citations per publication. The boards of journals with IF above the median had significantly higher h-indices (P = .002), total publications (P = .01), and total and average citations (both any [P = .003, .009] and nonself-citations [P = .001, .002]) than journals below the median.

CONCLUSIONS

Our data indicate that board members of Radiology journals with higher IF have greater h-indices compared to lower IF journals.

GEL THE NEC: a prospective registry evaluating the safety, ease of use, and efficacy of the HydroSoft coil as a finishing device

Background and purpose

The HydroSoft coil was developed as a finishing coil, ideally to be placed along the aneurysm neck to enhance intracranial aneurysm healing. The GEL THE NEC (Gaining Efficacy Long Term: Hydrosoft, an Emerging, New, Embolic Coil) multicenter registry was developed to assess the safety and efficacy of HydroSoft coils in treating intracranial aneurysms. We report angiographic and clinical results of this prospective registry.

Materials and methods

GEL THE NEC was performed at 27 centers in five countries. Patients aged 21–90 years with a ruptured or unruptured aneurysm 3–15 mm in size were eligible for enrollment. The following variables were obtained: demographics/comorbidities, aneurysm geometry, adjunctive devices used, proportion of patients in whom HydroSoft coils were successfully placed, and long-term angiographic outcomes (graded by an independent core laboratory using the Modified Raymond Scale), and procedure-related adverse events. Predictors of good angiographic outcome were studied using χ2 and t-tests.

Results

A total of 599 patients with 599 aneurysms were included in this study. HydroSoft coils were successfully deployed in 577 (96.4%) patients. Procedure-related major morbidity and mortality were 0.5% (3/599) and 1.3% (8/599), respectively. The most common perioperative complications were iatrogenic vasospasm (30/599, 5.0%), thromboemboli (27/599, 4.5%), and aneurysm perforation (16/599, 2.7%). At last angiographic follow-up (mean 9.0±6.3 months), the complete occlusion rate was 63.2% (280/442) and near complete occlusion rate was 25.2% (107/442). The core laboratory read recanalization rate was 10.8% (46/425) and the retreatment rate was 3.4% (20/599).

Conclusions

Endovascular treatment of intracranial aneurysms with HydroSoft coils resulted in complete/near complete occlusion rates of 88% and a major complication rate of 1.8%.

Trial registration number

NCT01000675.

Autologous adipose-derived mesenchymal stem cells improve healing of coiled experimental saccular aneurysms: an angiographic and histopathological study

PURPOSE

Long-term occlusion of coiled aneurysms frequently fails, probably because of poor intrasaccular healing and inadequate endothelialization across the aneurysm neck. The purpose of this study was to determine if attachment of autologous mesenchymal stem cells (MSCs) to platinum coils would improve the healing response in an elastase-induced aneurysm model in rabbits.

MATERIALS AND METHODS

With approval from the institutional animal care and use committee, aneurysms were created in rabbits and embolized with control platinum coils (Axium; Medtronic) (n=6) or coils seeded ex vivo with autologous adipose-tissue MSCs (n=7). Aneurysmal occlusion after embolization was evaluated at 1 month with angiography. Histological samples were analyzed by gross imaging and graded on the basis of neck and dome healing on H&E staining. Fibrosis was evaluated using a ratio of the total area presenting collagen. Endothelialization of the neck was quantitatively analyzed using CD31 immunohistochemistry. χ² and Student's t-test were used to compare groups.

RESULTS

Healing score (11.5 vs 8.0, p=0.019), fibrosis ratio (10.3 vs 0.13, p=0.006) and endothelialization (902 262 μm² vs 31 810 μm², p=0.041) were significantly greater in the MSC group. The MSC group showed marked cellular proliferation and thrombus organization, with a continuous membrane bridging the neck of the aneurysm. Angiographic stable or progressive occlusion rate was significantly lower in the MSC group (0.00, 95% CI 0.00 to 0.41) compared with controls (0.67, 95% CI 0.22 to 0.96) (p=0.02).

CONCLUSIONS

Autologous MSCs attached to platinum coils significantly improve histological healing, as they result in improved neck endothelialization and collagen matrix formation within the aneurysm sac.

Capillary Index Score and Correlation with Outcomes in Acute Ischemic Stroke: A Meta-analysis

BACKGROUND AND PURPOSE

The capillary index score (CIS) has been recently introduced as a metric for rating the collateral circulation of ischemic stroke patients. Multiple studies in the last five years have evaluated the correlation of good CIS with clinical outcomes and suggested the use of CIS in selecting patients for endovascular treatment. We performed a meta-analysis of these studies comparing CIS with clinical outcomes.

METHODS

We conducted a computerized search of three databases from January 2011 to November 2015 for studies related to CIS and outcomes. A CIS = 0 or 1 is considered poor (pCIS) and a CIS = 2 or 3 is considered favorable (fCIS). Using random-effect meta-analysis, we evaluated the relationship of CIS to neurological outcome (modified Rankin scale score ≤ 2), recanalization, and post-treatment hemorrhage. Meta-regression analysis of good neurological outcome was performed for adjusting baseline National Institutes of Health Stroke Scale (NIHSS) between groups.

RESULTS

Six studies totaling 338 patients (212 with fCISs and 126 with pCISs) were included in the analysis. Patients with fCIS had higher likelihood of good neurological outcome [relative risk (RR) = 3.03; confidence interval (CI) = 95%, 2.05-4.47; p < 0.001] and lower risk of post-treatment hemorrhage (RR = 0.38; CI = 95%, 0.19-0.93; p = 0.04) as compared with patients in the pCIS group. When adjusting for baseline NIHSS, patients with fCIS had higher RR of good neurological outcome when compared with those with pCIS (RR = 2.94; CI = 95%, 1.23-7, p < 0.0001). Favorable CIS was not associated with higher rates of recanalization.

CONCLUSIONS

Observational evidence suggests that acute ischemic stroke patients with fCIS may have higher rates of good neurological outcomes compared with patients with pCIS, independent of baseline NIHSS. CIS may be used as another tool to select patients for endovascular treatment of acute ischemic stroke.

Utility of single-energy and dual-energy computed tomography in clot characterization: An in-vitro study

Background and purpose Because computed tomography (CT) is the most commonly used imaging modality for the evaluation of acute ischemic stroke patients, developing CT-based techniques for improving clot characterization could prove useful. The purpose of this in-vitro study was to determine which single-energy or dual-energy CT techniques provided optimum discrimination between red blood cell (RBC) and fibrin-rich clots. Materials and methods Seven clot types with varying fibrin and RBC densities were made (90% RBC, 99% RBC, 63% RBC, 36% RBC, 18% RBC and 0% RBC with high and low fibrin density) and their composition was verified histologically. Ten of each clot type were created and scanned with a second generation dual source scanner using three single (80 kV, 100 kV, 120 kV) and two dual-energy protocols (80/Sn 140 kV and 100/Sn 140 kV). A region of interest (ROI) was placed over each clot and mean attenuation was measured. Receiver operating characteristic curves were calculated at each energy level to determine the accuracy at differentiating RBC-rich clots from fibrin-rich clots. Results Clot attenuation increased with RBC content at all energy levels. Single-energy at 80 kV and 120 kV and dual-energy 80/Sn 140 kV protocols allowed for distinguishing between all clot types, with the exception of 36% RBC and 18% RBC. On receiver operating characteristic curve analysis, the 80/Sn 140 kV dual-energy protocol had the highest area under the curve for distinguishing between fibrin-rich and RBC-rich clots (area under the curve 0.99). Conclusions Dual-energy CT with 80/Sn 140 kV had the highest accuracy for differentiating RBC-rich and fibrin-rich in-vitro thrombi. Further studies are needed to study the utility of non-contrast dual-energy CT in thrombus characterization in acute ischemic stroke.

Correlation between clot density and recanalization success or stroke etiology in acute ischemic stroke patients

Background Predicting recanalization success for patients undergoing endovascular treatment for acute ischemic stroke is of significant interest. Studies have previously correlated the success of recanalization with the density of the clot. We evaluated clot density and its relationship to revascularization success and stroke etiology. Methods We conducted a retrospective review of 118 patients undergoing intra-arterial therapy for acute ischemic stroke. Mean and maximum thrombus density was measured by drawing a circular region of interest on an axial slice of a non-contrast computed tomography scan. T-tests were used to compare clot density to recanalization success or to stroke etiology, namely large artery atherosclerosis and cardioembolism. Recanalization success was compared in four device groups: aspiration, stent retriever, aspiration and stent retriever, and all other. Results There was no significant difference in the mean clot density in patients with successful ( n = 80) versus unsuccessful recanalization ( n = 38, 50.1 ± 7.4 Hounsfield unit (HU) vs. 53 ± 12.7 HU; P = 0.17). Comparing the large artery thromboembolism ( n = 35) to the cardioembolic etiology group ( n = 56), there was no significant difference in mean clot density (51.5 ± 7.7 HU vs. 49.7 ± 8.5 HU; P = 0.31). A subgroup analysis of middle cerebral artery occlusions ( n = 65) showed similar, non-statistically significant differences between groups. There was no difference in the rate of recanalization success in patients with a mean clot density greater than 50 HU or less than 50 HU in each of the four device groups. Conclusions There was no relationship between clot density and revascularization success or stroke etiology in our study. More research is needed to determine if clot density can predict recanalization rates or indicate etiology.

Hospital transfer associated with increased mortality after endovascular revascularization for acute ischemic stroke

Background

Patients with an acute ischemic stroke (AIS) due to large vessel occlusion often require transfer to an endovascular center for treatment.

Objective

To assess the effect of hospital transfer on outcomes after endovascular revascularization.

Methods

Outcomes of endovascular revascularization were compared between directly admitted and transferred patients using data from a national database and our own institution.

Results

118 institutions within the database reported outcomes of 8533 inpatient admissions for endovascular treatment of AIS. Mortality rate (14.9% vs 18.6%; p=0.049) and mortality index (1.1 vs 1.6; p=0.048) were significantly lower among directly admitted patients than among transferred patients. Within our institutional cohort of 140 patients who underwent endovascular therapy, directly admitted patients had a significantly faster time to revascularization than transferred patients (277.4 vs 420.4 min; p≤0.0001). Among transferred patients, an increasing distance of transferred hospital to our home institution was associated with an increasing risk of mortality (unit OR=1.26, 95% CI 1.07 to 1.54; p=0.0061).

Conclusions

Outcomes of revascularization may improve with methods to identify patients with large vessel occlusion before hospital admission, thus increasing the likelihood of initial triage to a comprehensive stroke center for patients eligible for endovascular intervention.

Differential Interstrain Susceptibility to Vertebrobasilar Dolichoectasia in a Mouse Model

BACKGROUND AND PURPOSE

Vetebrobasilar dolichoectasia is characterized by arterial elongation, dilation, and tortuosity and leads to high risks of ischemic stroke. Our aim was to investigate the differential susceptibility to elastase-induced vertebrobasilar dolichoectasia induction in 2 different mouse strains.

MATERIALS AND METHODS

Elastase (25 mU) was injected into the cisterna magna in C57BL/6J (n = 36) and 129/SvEv (SV129) (n = 36) mice. Control animals were injected with heat-inactivated elastase (n = 12 for each strain). At 3, 7, 14, and 28 days after elastase injection, MICROFIL polymer perfusion was performed. The arterial tortuosity index and the percentage increase in diameter were calculated for the basilar artery. Arterial samples were processed for conventional histologic examination, immunostaining, and matrix metalloproteinase expression. A ≥50% increase in diameter and a tortuosity index of ≥10 for the basilar artery were used to indicate success in achieving vertebrobasilar dolichoectasia.

RESULTS

Successful vertebrobasilar dolichoectasia induction was noted in 67% (18 of 27) of the C57BL/6J strain versus 0% (0 of 19) of the SV129 strain (P < .001). Vertebrobasilar dolichoectasia was not observed in sham-operated controls. Both the tortuosity index and diameter increase for the basilar artery were greater in the C57BL/6J strain compared with the SV129 strain (56.3% ± 16.4% versus 21.1% ± 21.6% for diameter, P < .001; 17.4 ± 7.6 versus 10.4 ± 3.8 for tortuosity index, P < .001). Expression of pro-matrix metalloproteinase-2 and pro- and active matrix metalloproteinase-9 was increased in elastase-injected C57BL/6J animals compared with elastase-injected SV129 animals (P = .029, 0.029, and 0.029, respectively). Inflammation scores were significantly higher in C57BL/6J animals versus SV129 animals (P < .001). C57BL/6J subjects demonstrated arterial wall dilation and elongation characterized by internal elastic lamina disruption, muscular layer discontinuity, inflammatory cell infiltration, and high matrix metalloproteinase expression in the media.

CONCLUSIONS

C57BL/6J mice demonstrated greater susceptibility to vertebrobasilar dolichoectasia induction than SV129 mice.

Opercular Index Score: a CT angiography-based predictor of capillary robustness and neurological outcomes in the endovascular management of acute ischemic stroke

BACKGROUND

Many CT angiography (CTA) collateral scoring systems are either subjective or complex and time consuming.

OBJECTIVE

To evaluate the correlation between a CTA collateral scoring system-the Opercular Index Score (OIS)-with neurological outcomes at 90 days following endovascular treatment for acute ischemic stroke (AIS) secondary to large vessel occlusion.

METHODS

Fifty-five patients with AIS due to distal internal carotid artery, M1, or proximal M2 occlusions who underwent endovascular treatment were included. OIS was retrospectively calculated from CTA images, reconstructed from CT perfusion imaging, as the ratio of opacified M3 opercular branches in the Sylvian fissure on the unaffected side to those on the stroke side and dichotomized into favorable (OIS≤2) and poor (OIS>2). The ability of OIS to predict good neurological outcomes (modified Rankin Scale score ≤2 at 90 days) was assessed using sensitivity, specificity, and area under the curve (AUC) with receiver operating characteristic analysis.

RESULTS

Thirty-five patients had a favorable OIS and 20 patients had a poor OIS. Patients with favorable OIS had an 80.0% (n=28) rate of good neurological outcomes compared with 15.0% (n=3) of patients with a poor OIS (p<0.0001). On multivariate logistic regression analysis adjusting for baseline National Institutes of Health Stroke Scale score, OIS, and device used, favorable OIS was the only variable independently associated with good neurological outcome (OR=17.2, 95% CI 3.8 to 104.3) and demonstrated a sensitivity of 90.3% and specificity of 70.8% with an AUC of 0.822.

CONCLUSIONS

OIS is a simple and practical non-invasive scoring system that can be used to predict collateral robustness and good neurological outcome among patients with AIS undergoing endovascular treatment.

Long-Term Clinical and Angiographic Outcomes Following Pipeline Embolization Device Treatment of Complex Internal Carotid Artery Aneurysms: Five-Year Results of the Pipeline for Uncoilable or Failed Aneurysms Trial

BACKGROUND: Early and mid-term safety and efficacy of aneurysm treatment with the Pipeline Embolization Device (PED) has been well demonstrated in prior studies.

OBJECTIVE: To present 5-yr follow-up for patients treated in the Pipeline for Uncoilable or Failed Aneurysms clinical trial.

METHODS: In our prospective, multicenter trial, 109 complex internal carotid artery (ICA) aneurysms in 107 subjects were treated with the PED. Patients were followed per a standardized protocol at 180 d and 1, 3, and 5 yr. Aneurysm occlusion, in-stent stenosis, modified Rankin Scale scores, and complications were recorded.

RESULTS: The primary endpoint of complete aneurysm occlusion at 180 d (73.6%) was previously reported. Aneurysm occlusion for those patients with angiographic follow-up progressively increased over time to 86.8% (79/91), 93.4% (71/76), and 95.2% (60/63) at 1, 3, and 5 yr, respectively. Six aneurysms (5.7%) were retreated. New serious device-related events at 1, 3, and 5 yr were noted in 1% (1/96), 3.5% (3/85), and 0% (0/81) of subjects. There were 4 (3.7%) reported deaths in our trial. Seventy-eight (96.3%) of 81 patients with 5-yr clinical follow-up had modified Rankin Scale scores ≤2. No delayed neurological deaths or hemorrhagic or ischemic cerebrovascular events were reported beyond 6 mo. No recanalization of a previously occluded aneurysm was observed.

CONCLUSION: Our 5-yr findings demonstrate that PED is a safe and effective treatment for large and giant wide-necked aneurysms of the intracranial ICA, with high rates of complete occlusion and low rates of delayed adverse events.

Diffusion-Weighted Imaging-Detected Ischemic Lesions following Endovascular Treatment of Cerebral Aneurysms: A Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE

Endovascular treatment of intracranial aneurysms is associated with the risk of thromboembolic ischemic complications. Many of these events are asymptomatic and identified only on diffusion-weighted imaging. We performed a systematic review and meta-analysis to study the incidence of DWI positive for thromboembolic events following endovascular treatment of intracranial aneurysms.

MATERIALS AND METHODS

A comprehensive literature search identified studies published between 2000 and April 2016 that reported postprocedural DWI findings in patients undergoing endovascular treatment of intracranial aneurysms. The primary outcome was the incidence of DWI positive for thromboembolic events. We examined outcomes by treatment type, sex, and aneurysm characteristics. Meta-analyses were performed by using a random-effects model.

RESULTS

Twenty-two studies with 2148 patients and 2268 aneurysms were included. The overall incidence of DWI positive for thromboembolic events following endovascular treatment was 49% (95% CI, 42%-56%). Treatment with flow diversion trended toward a higher rate of DWI positive for lesions than coiling alone (67%; 95% CI, 46%-85%; versus 45%; 95% CI, 33%-56%; P = .07). There was no difference between patients treated with coiling alone and those treated with balloon-assisted (44%; 95% CI, 29%-60%; P = .99) or stent-assisted (43%; 95% CI, 24%-63%; P = .89) coiling. Sex, aneurysm rupture status, location, and size were not associated with the rate of DWI positive for lesions.

CONCLUSIONS

One in 2 patients may have infarcts on DWI following endovascular treatment of intracranial aneurysms. There is a trend toward a higher incidence of DWI-positive lesions following treatment with flow diversion compared with coiling. Patient demographics and aneurysm characteristics were not associated with DWI-positive thromboembolic events.

Impact of sleep disordered breathing on carotid body size

We tested the hypotheses that: (1) carotid body size can be measured by computed tomographic angiography (CTA) with high inter-observer agreement, and (2) patients with sleep apnea exhibit larger carotid bodies than those without sleep apnea. A chart review was conducted from patients who underwent neck CTA and polysomnography at the Mayo Clinic between January 2000 and February 2015. Widest axial measurements of the carotid bodies, performed independently by two radiologists, were possible in 81% of patients. Intra-class correlation coefficients ranged from 0.93 to 0.95 (Right carotid body: 0.93; Left: 0.94; Average: 0.95). Widest axial measurements of the carotid bodies were greater in patients with sleep apnea (n=32) compared to controls (n=46, P-value range 0.02-0.04). After adjusting for age, no differences in carotid body size were observed between the patient groups (P-value range 0.45-0.59). We conclude carotid body size can be detected by CTA with high inter-observer agreement; however, carotid body size is not increased in patients with sleep apnea.

Effect of Systemic Therapies on Outcomes following Vertebroplasty among Patients with Multiple Myeloma

BACKGROUND AND PURPOSE

The role of vertebroplasty in patients with myeloma remains relatively undefined. Accordingly, we sought to better define the efficacy of vertebroplasty for myeloma-associated fractures and determine the effect of procedure timing relative to the initiation of systemic therapy on outcomes and complication rates.

MATERIALS AND METHODS

Clinical, laboratory, and medication data were retrieved for 172 patients with multiple myeloma treated with vertebroplasty since October 2000. Quantitative outcome data (Roland-Morris Disability Questionnaire [scale, 0-24] and the Numeric Rating Scale [0-10] for pain at rest and with activity) were collected immediately pre- and postoperatively and at 1 week, 1 month, 6 months, and 1 year following vertebroplasty. Patients with ≥50% improvement on the Numeric Rating Scale and ≥40% improvement on the Roland-Morris Disability Questionnaire were classified as "responders." Peri- and postoperative complications were also collected.

RESULTS

Significant median improvement in the Roland-Morris Disability and rest and activity Numeric Rating Scale scores (15, 2, and 6 points, respectively; P < .0001) persisted at 1 year without significant change from the immediate postoperative scores (P > .36). Patients on systemic therapy at the time of vertebroplasty were more likely to achieve "responder status," compared with patients not on systemic therapy, for the Numeric Rating Scale pain at rest score (P < .01) and the Roland-Morris Disability Questionnaire score (P < .003), with no difference in complication rates (χ² = 0.17, P = .68).

CONCLUSIONS

Vertebroplasty is an effective therapy for patients with myeloma with symptomatic compression fractures. Favorable outcomes are more likely to be achieved when spinal augmentation is performed after systemic therapy is initiated. Complication rates were not affected by the timing of systemic therapy.

Flow Diversion for Ophthalmic Artery Aneurysms

Endovascular treatments of ophthalmic segment aneurysms are commonly used but visual outcomes remain a concern. We performed a retrospective review of patients with carotid-ophthalmic aneurysms treated with flow diversion from June 2009 to June 2015. The following outcomes were studied through chart review: visual outcomes, complications, postoperative stroke and intraparenchymal hemorrhage, and clinical outcomes. Angiographic outcomes were studied with angiography and MRA at 6 months, 1 year, and 3 years. We evaluated 50 carotid-ophthalmic aneurysms in 48 patients, among whom 44 patients with 46 aneurysms underwent treatment. The mean clinical follow-up was 29 ± 22 months (range, 0-65 months). There were no permanent adverse visual outcomes. There was 1 death because of late intraparenchymal hemorrhage (2.2%). Six-month angiography showed complete occlusion in 24 of 37 patients (64.9%), and 3-year angiography results showed occlusion in 24 of 25 patients (96%). In conclusion, flow diversion is a safe and effective treatment for carotid-ophthalmic aneurysms in carefully selected patients. The risk of adverse visual outcomes is low, and most aneurysms progress to complete occlusion.

Clinical interpretation of high-resolution vessel wall MRI of intracranial arterial diseases

Intracranial arterial pathology has traditionally been evaluated with luminal imaging. Recently, high-resolution vessel wall imaging (HR-VWI) with MRI has facilitated submillimetre evaluation of the arterial walls. This technique can help differentiate various causes of intracranial steno-occlusive disease, identify culprit atherosclerotic plaques with a recent cerebral infarct, locate vessel wall pathology in areas with minimal or no narrowing on luminal imaging, predict aneurysm stability and identify a ruptured aneurysm when multiple aneurysms are present. Interpretation of HR-VWI examinations requires a solid understanding of the pathophysiology, clinical features, serum and cerebrospinal fluid laboratory findings, treatment administered and fundamental patterns of VWI abnormalities that may be encountered with the intracranial vasculopathies. This pictorial essay aimed to illustrate the essential findings of common conditions encountered with HR-VWI including intracranial atherosclerosis, moyamoya disease, intracranial vasculitis, varicella zoster vasculopathy, reversible cerebral vasoconstriction syndrome and aneurysms.

Endovascular Coiling of Wide-Neck and Wide-Neck Bifurcation Aneurysms: A Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE

We present the results of a systematic review and meta-analysis examining outcomes of endovascular coiling of wide-neck and wide-neck bifurcation aneurysms with and without stent assistance. The aim of our study was to assess angiographic and clinical outcomes.

MATERIALS AND METHODS

We performed a comprehensive literature search for all articles on the endovascular coiling of wide-neck and wide-neck bifurcation aneurysms. Studies meeting our inclusion criteria and abstracted data were selected by 2 independent reviewers. Primary outcomes were >6-month complete or near-complete angiographic occlusion, aneurysm recanalization, and aneurysm retreatment. Secondary outcomes included initial complete or near-complete occlusion, long-term good neurologic outcome, procedure-related morbidity, and procedure-related mortality. Data were analyzed by using random-effects meta-analysis.

RESULTS

In total, 38 studies including 2446 patients with 2556 aneurysms were included. For all wide-neck aneurysms, immediate complete or near-complete occlusion rate was 57.4% (95% CI, 48.1%-66.8%). Follow-up near-complete occlusion rate was 74.5% (95% CI, 68.0%-81.0%). Recanalization and retreatment rates were 9.4% (95% CI, 7.1%-11.7%) and 5.8% (95% CI, 4.1%-7.5%), respectively. Long-term good neurologic outcome was 91.4% (95% CI, 88.5%-94.2%). For wide-neck bifurcation aneurysms, initial complete or near-complete occlusion rate was 60.0% (95% CI, 42.7%-77.3%), long-term complete or near-complete occlusion rate was 71.9% (95% CI, 52.6%-91.1%), and the recanalization and retreatment rates were 9.8% (95% CI, 7.1%-12.5%) and 5.2% (95% CI, 1.9%-8.4%), respectively.

CONCLUSIONS

Our study of angiographic and clinical outcomes for patients with wide-neck aneurysms demonstrates that endovascular coiling with or without stent-assisted coiling is safe, with low rates of perioperative morbidity and mortality. Initial and long-term angiographic outcomes were generally satisfactory, but not ideal. These data provide some baseline comparisons against which emergent technologies can be assessed.

Nonaneurysmal Perimesencephalic Hemorrhage Is Associated with Deep Cerebral Venous Drainage Anomalies: A Systematic Literature Review and Meta-Analysis

BACKGROUND AND PURPOSE

Mechanisms underlying bleeding in nonaneurysmal perimesencephalic SAH remain unclear. Previous investigators have suggested a relationship between nonaneurysmal perimesencephalic SAH and primitive venous drainage of the basal vein of Rosenthal. We performed a meta-analysis to evaluate the relation between primitive basal vein of Rosenthal drainage and nonaneurysmal perimesencephalic SAH.

MATERIALS AND METHODS

We performed a comprehensive literature search of all studies examining the prevalence of primitive basal vein of Rosenthal drainage in patients with aneurysmal SAH and nonaneurysmal perimesencephalic SAH. Data collected were primitive basal vein of Rosenthal drainage (direct connection of perimesencephalic veins into the dural sinuses instead of the Galenic system) in at least 1 cerebral hemisphere, normal bilateral basal vein of Rosenthal drainage systems, and the number of overall primitive venous systems in the nonaneurysmal perimesencephalic SAH and aneurysmal SAH groups. Statistical analysis was performed by using a random-effects meta-analysis.

RESULTS

Eight studies with 888 patients (334 with nonaneurysmal perimesencephalic SAH and 554 with aneurysmal SAH) and 1657 individual venous systems were included. Patients with nonaneurysmal perimesencephalic SAH were more likely to have a primitive basal vein of Rosenthal drainage in at least 1 hemisphere (47.7% versus 22.1%; OR, 3.31; 95% CI, 2.15-5.08; P < .01) and were less likely to have bilateral normal basal vein of Rosenthal drainage systems than patients with aneurysmal SAH (18.3% versus 37.4%; OR, 0.27; 95% CI, 0.14-0.52; P < .01). When we considered individual venous systems, there were higher rates of primitive venous systems in patients with nonaneurysmal perimesencephalic SAH than in patients with aneurysmal SAH (34.9% versus 15.3%; OR, 3.90; 95% CI, 2.37-6.43; P < .01).

CONCLUSIONS

Patients with nonaneurysmal perimesencephalic SAH have a higher prevalence of primitive basal vein of Rosenthal drainage in at least 1 hemisphere than patients with aneurysmal SAH. This finding suggests a venous origin of some nonaneurysmal perimesencephalic SAHs. A primitive basal vein of Rosenthal pattern is an imaging finding that has the potential to facilitate the diagnosis of nonaneurysmal perimesencephalic SAH.