Negative Susceptibility Vessel Sign and Underlying Intracranial Atherosclerotic Stenosis in Acute Middle Cerebral Artery Occlusion

BACKGROUND AND PURPOSE

The role of MR imaging in predicting underlying intracranial atherosclerotic stenosis before endovascular stroke therapy has not been studied. Our aim was to determine the diagnostic value of the negative susceptibility vessel sign on T2*-weighted gradient-echo MR imaging for predicting underlying intracranial atherosclerotic stenosis in patients with acute MCA occlusion.

MATERIALS AND METHODS

Ninety-one consecutive patients with acute stroke because of MCA occlusion underwent gradient-echo MR imaging and MRA before endovascular therapy. The negative susceptibility vessel sign was defined as an absence of a hypointense signal change within the occluded MCA on gradient-echo imaging. Underlying intracranial atherosclerotic stenosis was determined by conventional angiography. The sensitivity, specificity, predictive values, and accuracy of the negative susceptibility vessel sign for predicting the presence of underlying intracranial atherosclerotic stenosis were assessed.

RESULTS

The negative susceptibility vessel sign was identified in 42 (46.1%) of 91 patients, and 18 (19.8%) patients had an underlying intracranial atherosclerotic stenosis responsible for acute ischemic symptoms. The negative susceptibility vessel sign was more frequently observed in patients with intracranial atherosclerotic stenosis than in those without it (100% versus 32.9%, P < .001). In the prediction of an underlying intracranial atherosclerotic stenosis, the negative susceptibility vessel sign had 100% sensitivity, 67.1% specificity, 42.9% positive predictive value, 100% negative predictive value, and an accuracy of 73.6%.

CONCLUSIONS

The negative susceptibility vessel sign on gradient-echo MR imaging is a sensitive marker with a high negative predictive value for the presence of an underlying intracranial atherosclerotic stenosis in patients with acute ischemic stroke because of MCA occlusions. The susceptibility vessel sign can be used in decision-making when performing subsequent endovascular revascularization therapy in patients with acute MCA occlusions.

Acute basilar artery occlusion: outcome of mechanical thrombectomy with Solitaire stent within 8 hours of stroke onset

BACKGROUND AND PURPOSE

Mechanical thrombectomy with a stent retriever applied shortly after symptom onset could increase good functional outcomes and improve survival in patients with acute basilar artery occlusion, but this has not yet been studied. This study evaluated the efficacy and safety of mechanical thrombectomy with a Solitaire stent within 8 hours of stroke onset in patients with acute basilar artery occlusion.

MATERIALS AND METHODS

We analyzed 25 consecutive patients with acute basilar artery occlusion who were treated with mechanical thrombectomy by use of the Solitaire stent within 8 hours of stroke symptom onset. Successful recanalization was defined as TICI grade 2b or 3. Good outcome was defined as mRS score of 0-2 at 3 months. Clinical and radiologic data in patients with good outcomes were compared with those with poor outcomes.

RESULTS

Successful recanalization was achieved in 96% (24/25) of patients, and 48% (12/25) of patients had good outcomes. Eighty-eight percent (22/25) of patients survived to 3 months. The median NIHSS score on admission was significantly lower in patients with good outcomes than in those with poor outcomes (9.5 versus 14, P = .005). Procedure-related complications occurred in 2 patients (8%). No symptomatic intracerebral hemorrhages occurred.

CONCLUSIONS

The current study suggests that mechanical thrombectomy by use of a Solitaire stent within 8 hours of stroke onset increases good outcomes and improves survival in patients with acute basilar artery occlusion.

Safety of protected carotid artery stenting in patients with severe carotid artery stenosis and carotid intraplaque hemorrhage

BACKGROUND AND PURPOSE

Carotid IPH can be detected with MR imaging. The aim of this study was to determine the safety of CAS using an emboli protection device in patients with severe carotid artery stenosis and MR imaging-depicted carotid IPH.

MATERIALS AND METHODS

We retrospectively reviewed a prospective data base that included 91 consecutive patients with severe carotid stenosis and high-risk features who were treated with CAS by using an emboli protection device. Seventy-eight of the included patients underwent prestenting 3D TOF MRA. IPH was defined as the presence of high signal intensity within the carotid plaque, greater than 150% of the signal intensity of the adjacent neck muscle on TOF source images. The primary outcome measure was the combined incidence of stroke, MI, and death within 30 days of CAS. Associations between IPH and the primary outcome were investigated.

RESULTS

IPH was detected on TOF MRA in 30 patients. Symptomatic patients were more common in the IPH group than in the non-IPH group (66.7% vs 41.7%; P = .032). Overall, 30-day stroke, MI, or death rates were 6.6%. There was no significant difference in the primary outcome between the IPH and non-IPH groups (10% and 6.25%, respectively; hazard ratio for IPH, 1.151; 95% CI, 0.035 to 37.500; P = .937). A logistic regression showed there was no independent variable associated with the primary outcome.

CONCLUSIONS

The results of this study indicate that protected CAS seems to be safe in patients with severe carotid stenosis and IPH.

De novo appearance of primitive neuroectodermal tumor in a patient with systemic lupus erythematosus and moyamoya disease

Primitive neuroectodermal tumor is a rare brain tumor composed of undifferentiated or poorly differentiated neuroepithelial cells with a high malignant potential that usually occurs in children, and which is only occasionally encountered in adults. A 19-year-old female with systemic lupus erythematosus presented with right hemiparesis and a headache of 10 days duration. Brain magnetic resonance imaging showed a large solid mass with necrotic portions in the left frontoparietal lobe. Primitive neuroectodermal tumor was confirmed by a neuronavigator-guided brain biopsy. This is the first case report of primitive neuroectodermal tumor associated with systemic lupus erythematosus and moyamoya disease. This case demonstrates that brain tumors, such as primitive neuroectodermal tumor, should be included in the differential diagnosis of neurological manifestations in children and adolescent patients with systemic lupus erythematosus.

Low-dose intra-arterial urokinase and aggressive mechanical clot disruption for acute ischemic stroke after failure of intravenous thrombolysis

BACKGROUND AND PURPOSE

Intravenous (IV) thrombolysis often fails to achieve recanalization of occluded cerebral arteries, especially in patients with proximal large arterial occlusions. The goal of this study was to assess the feasibility, safety, and efficacy of low-dose intra-arterial (IA) urokinase and aggressive mechanical clot disruption (AMCD) after failure of IV thrombolysis for acute ischemic stroke.

MATERIALS AND METHODS

We prospectively enrolled 12 patients with acute ischemic stroke who initially received IV recombinant tissue plasminogen activator (rtPA) and were subsequently treated with combined low-dose IA urokinase and AMCD. Time to treatment, urokinase dose, duration of the procedure, recanalization rates, and symptomatic hemorrhage were analyzed. Clinical outcome measures were assessed on admission and at discharge (National Institutes of Health Stroke Scale [NIHSS]), and at 3 months after treatment (modified Rankin Scale [mRS]).

RESULTS

Median NIHSS score on admission was 17. Median time from symptom onset to IV rtPA was 120 minutes, and median time from symptom onset to IA therapy was 230 minutes. The median duration of IA therapy was 55 minutes. Median dose of urokinase was 300,000 U. Recanalization (thrombolysis in cerebral ischemia grade II or III) was achieved in all patients. No procedure-related complications were observed. There was no symptomatic hemorrhage. At discharge, median NIHSS score was 3. The 3-month outcome was excellent (mRS, 0-1) in 8 patients, good (mRS, 2) in 1 patient, and poor (mRS, 3-5) in 3 patients. There was no hospital or 3-month mortality.

CONCLUSIONS

In this study, combination therapy with low-dose IA urokinase and AMCD is safe and effective after failed IV thrombolysis in patients with acute ischemic stroke. A high rate of recanalization, low rate of symptomatic hemorrhage, and excellent functional outcome can be achieved.

An uncommon anastomosis of the posterior inferior cerebellar artery and the external carotid artery with the patent vertebrobasilar system

The hypoglossal artery arises as a branch of the internal carotid artery and traverses the hypoglossal canal. However, the hypoglossal artery arising from the external carotid artery (ECA) and connecting directly with the posterior inferior cerebellar artery (PICA), instead of the basilar artery or the vertebral artery, is very rare. We present a case of an uncommon variant of the hypoglossal artery arising from the ECA that connected directly with the PICA.

Lupus-associated pancreatitis complicated by pancreatic pseudocyst and central nervous system vasculitis

Pancreatitis is an uncommon manifestation of systemic lupus erythematosus (SLE), but this can occasionally cause major complications. We report in this article, a case of 33-year-old female patient who developed lupus-associated pancreatitis that was subsequently complicated by pancreatic pseudocyst and central nervous system (CNS) vasculitis. Abdominal computed tomography (CT) showed an oedematous swelling of the pancreas and a pseudocyst measuring 4 x 3 cm2. Brain magnetic resonance imaging (MRI) showed multiple high-signal intensity lesions in both cerebral hemispheres. The pseudocyst did not completely resolve with high-dose steroid therapy, and it was later complicated by infection and rupture. After a surgical drainage for the complicated pseudocyst, her clinical symptoms and signs were markedly improved. This case shows the importance of performing early drainage rather than conservative treatment for a pancreatic pseudocyst in a patient with lupus-associated pancreatitis.

A curved image-plate detector system for high-resolution synchrotron X-ray diffraction

The developed curved image plate (CIP) is a one-dimensional detector which simultaneously records high-resolution X-ray diffraction (XRD) patterns over a 38.7 degrees 2theta range. In addition, an on-site reader enables rapid extraction, transfer and storage of X-ray intensity information in </=30 s, and further qualifies this detector to study kinetic processes in materials science. The CIP detector can detect and store X-ray intensity information linearly proportional to the incident photon flux over a dynamical range of about five orders of magnitude. The linearity and uniformity of the CIP detector response is not compromised in the unsaturated regions of the image plate, regardless of saturation in another region. The speed of XRD data acquisition together with excellent resolution afforded by the CIP detector is unique and opens up wide possibilities in materials research accessible through X-ray diffraction. This article presents details of the basic features, operation and performance of the CIP detector along with some examples of applications, including high-temperature XRD.

Moyamoya syndrome associated with systemic lupus erythematosus

Abstract

Moyamoya disease is a rare, progressive cerebrovascular disorder that is characterized by a stenosis or occlusion of the bilateral internal carotid arteries and the development of collateral vessels. Transient ischemic attacks or seizures are the usual presentation of moyamoya disease in children, whereas cerebral hemorrhage is the most common symptom in adults. We report an 18-year-old female patient with active lupus nephritis who presented with the sudden onset of left hemiparesis. Brain magnetic resonance imaging showed acute infarctions in the right basal ganglia and subcortical white matter of the right frontal lobe. Cerebral angiography showed the stenosis of the bilateral internal carotid arteries with rich basal collateral vessels (moyamoya vessels). There was no evidence of atherosclerosis or antiphospholipid syndrome. Glucocorticoid therapy was used to control the systemic lupus erythematosus. Prophylactic bypass surgery was performed to prevent recurrent ischemic attacks. This case report shows that an underlying cerebrovascular lesion of moyamoya vessels in a patient with systemic lupus erythematosus is susceptible to cerebrovascular accidents.

Diagnostic accuracy of panoramic radiography in the detection of calcified carotid artery

OBJECTIVES

The purpose of this study was to assess the diagnostic accuracy of the panoramic radiograph in the detection of carotid artery calcification using CT as the gold standard.

METHODS

110 dental patients (average age 65.2 years, range 50-82 years) with both panoramic radiographs and CT scans available were selected for the evaluation of carotid artery calcification. Two oral and maxillofacial radiologists interpreted the panoramic radiographs for the presence of carotid artery calcification. CT scans were independently interpreted by a neuroradiologist.

RESULTS

The accuracy of panoramic radiographs in the detection of carotid artery calcification was 62.3%. The sensitivity and the specificity were 22.2% and 90.0%, respectively.

CONCLUSIONS

Panoramic radiography has a moderate diagnostic accuracy in the detection of carotid artery calcification, but the sensitivity is low.

Neuronavigation-Assisted Surgery for Distal Anterior Cerebral Artery Aneurysm

OBJECTIVE

We present our experience with the neuronavigation system as used for surgery of distal anterior cerebral artery (DACA) aneurysm.

METHODS

Between 2001 and 2004, 12 patients with a DACA aneurysm were consecutively treated with direct clipping assisted by the neuronavigation system. We used the BrainLAB Vector Vision neuronavigation system (BrainLAB, Heimstetten, Germany). Seven out of 12 patients presented with subarachnoid hemorrhage. Aneurysms were located at distal A2 in 10 patients and distal A3 in two patients. The size of the aneurysms ranged from 3-10 mm.

RESULTS

There were no procedure-related complications or technical problems during application of the neuronavigation system. The registration accuracy ranged from 0.5-1.5 mm (mean: 0.88 mm). The neuronavigation system provided real-time presentation of the DACA and the aneurysm, and allowed for identification of the DACA aneurysm in all patients. No surgical complications developed, and all 12 patients had a good recovery after direct clipping.

CONCLUSION

Although current neuronavigation systems are not available for all intracranial aneurysms, we believe that the DACA aneurysm is a good candidate for its use. The additional benefits of a small craniotomy and precise intraoperative orientation during surgery result in a minimally invasive aneurysm procedure.

Neuronavigation-Assisted Surgery for Distal Anterior Cerebral Artery Aneurysm

OBJECTIVE

We present our experience with the neuronavigation system used for surgery of distal anterior cerebral artery (DACA) aneurysms.

METHODS

Between 2001 and 2004, 12 patients with a DACA aneurysm were consecutively treated with direct clipping assisted by the neuronavigation system. We used the BrainLAB Vector Vision2 neuronavigation system (BrainLAB, Heimstetten, Germany). Seven out of 12 patients presented with subarachnoid hemorrhage. Aneurysms were located at distal A2 in 10 patients and distal A3 in two patients. The size of the aneurysms ranged from 3 to 10 mm.

RESULTS

There were no procedure-related complications or technical problems during application of the neuronavigation system. The registration accuracy ranged from 0.5 to 1.5 mm (mean: 0.88). The neuronavigation system provided real-time presentation of the DACA aneurysm, and allowed for identification of the DACA aneurysm in all patients. No surgical complications developed, and all 12 patients had a good recovery after direct clipping.

CONCLUSION

Although current neuronavigation systems are not available for all intracranial aneurysms, we believe that the DACA aneurysm is a good candidate for its use. The additional benefits of a small craniotomy and precise intraoperative orientation during surgery result in a minimally invasive aneurysm procedure.