Hirayama-like disease in the thoracic spine

Hirayama disease is a cervical flexion myelopathy that typically causes upper extremity weakness in young male patients. We present two male patients (age 15 and 29) with MRI findings of thoracic ligamentous laxity similar in appearance to Hirayama disease. However, patients presented with atypical symptoms, specifically back pain and paresthesia of the upper and/or lower extremities, likely correlating to the abnormal thoracic spinal levels involved. Flexion/extension MRI sequences demonstrated the forward displacement of the dorsal dura and compression the thoracic cord with prominence of the posterior epidural space and venous plexus. Follow-up MRAs were negative for a spinal vascular malformation. Patients were managed conservatively with no surgical intervention. Clinical history, thoracic MRI, and follow-up flexion and angiographic imaging sequences may help confirm a diagnosis of Hirayama-like thoracic ligamentous laxity.

Radiology, Sexual Harassment, and the #MeToo Movement

The rise of the #MeToo movement has sparked renewed conversations about sexual harassment in the workplace. All medical fields, including radiology, can benefit from reflecting on workplace culture, reviewing policies, and committing to change. This review provides an overview of the #MeToo movement, describes the prevalence of sexual harassment in medicine and radiology, summarizes barriers to reporting incidents of sexual harassment, evaluates the backlash to the #MeToo movement, and discusses policies and procedures to aid in preventing sexual harassment in the #MeToo era.

Computer-Assisted Measurement of Traumatic Brain Hemorrhage Volume Is More Predictive of Functional Outcome and Mortality than Standard ABC/2 Method: An Analysis of Computed Tomography Imaging Data from the Progesterone for Traumatic Brain Injury Experimental Clinical Treatment Phase-III Trial

Hemorrhage volume is an important variable in emergently assessing traumatic brain injury (TBI). The most widely used method for rapid volume estimation is ABC/2, a simple algorithm that approximates lesion geometry as perfectly ellipsoid. The relative prognostic value of volume measurement based on more precise hematoma topology remains unknown. In this study, we compare volume measurements obtained using ABC/2 versus computer-assisted volumetry (CAV) for both intra- and extra-axial traumatic hemorrhages, and then quantify the association of measurements using both methods with patient outcome following moderate to severe TBI. A total of 517 computer tomography (CT) scans acquired during the Progesterone for Traumatic Brain Injury Experimental Clinical Treatment Phase-III (ProTECTIII) multi-center trial were retrospectively reviewed. Lesion volumes were measured using ABC/2 and CAV. Agreement between methods was tested using Bland-Altman analysis. Relationship of volume measurements with 6-month mortality, Extended Glasgow Outcome Scale (GOS-E), and Disability Rating Scale (DRS) were assessed using linear regression and area under the curve (AUC) analysis. In subdural hematoma (SDH) >50cm3, ABC/2 and CAV produce significantly different volume measurements (p < 0.0001), although the difference was not significant for smaller SDH or intra-axial lesions. The disparity between ABC/2 and CAV measurements varied significantly with hematoma size for both intra- and extra-axial lesions (p < 0.0001). Across all lesions, volume was significantly associated with outcome using either method (p < 0.001), but CAV measurement was a significantly better predictor of outcome than ABC/2 estimation for SDH. Among large traumatic SDH, ABC/2 significantly overestimates lesion volume compared with measurement based on precise bleed topology. CAV also offers significantly better prediction of patient functional outcofme and mortality.

Reduced gray-white matter contrast localizes the motor cortex on double inversion recovery (DIR) 3T MRI

PURPOSE

Reduced gray-white matter contrast along the central sulcus has been described on T1- and T2-weighted magnetic resonance imaging (MRI). The purpose of this study was to assess the gray-white matter contrast of the motor cortex on double inversion recovery (DIR), a sequence with superior gray-white matter differentiation.

METHODS

The gray-white matter signal on DIR was retrospectively compared to T1-weighted magnetization-prepared rapid gradient echo (T1-MPRAGE) using normal (n = 25) and abnormal (n = 25) functional MRI (fMRI) exams. Quantitative gray-white matter contrast ratios (CR) of the precentral and adjacent gyri were obtained on normal exams. Two neuroradiologists qualitatively rated reduced gray-white matter contrast of the hemispheres of both normal and abnormal exams. Hand motor functional mapping was used as a reference.

RESULTS

In normal hemispheres (n = 50), the mean CR was significantly lower on DIR (0.44) vs T1-MPRAGE (0.63, p < 0.001). Reduced gray-white matter contrast was categorized as "definitely present" more frequently on DIR than T1-MPRAGE by reviewers in both normal (n = 50; reviewer 1 DIR 88% and MPRAGE 68%, p = 0.02; reviewer 2 DIR 86% and T1-MPRAGE 64%; p=0.01) and abnormal hemispheres (n = 50; reviewer 1 DIR 80% and T1-MPRAGE 38%, p < 0.001; reviewer 2 DIR 74% and T1-MPRAGE 46%, p = 0.005).

CONCLUSION

Reduced gray-white matter contrast of the motor cortex is more pronounced on DIR compared to T1-MPRAGE on quantitative and qualitative assessments of normal MRI exams. In abnormal cases, reviewers more definitively identified the motor cortex on DIR. In cases with distorted brain anatomy, DIR may be a useful adjunct sequence to localize the motor cortex.

Appearance of an unusual ring enhancing brain capillary telangiectasia on 3.0T MRI with dynamic susceptibility contrast perfusion

We present the appearance of brain capillary telangiectasia on 3.0T magnetic resonance imaging (MRI) perfusion. A 42-year-old female presented with intermittent left arm weakness and paresthesia. Initial 1.5T MRI obtained 2 months after presentation demonstrated a 6 mm right caudate head lesion with ring-like enhancement, and no significant surrounding edema or mass effect. On gradient echo there was mild associated susceptibility artifact. Follow-up 3.0T MRI demonstrated increased blooming on 3.0T imaging relative to prior 1.5T imaging. The lesion also demonstrated increased blood volume on dynamic susceptibility contrast perfusion. Given these imaging findings and interval stability, a definitive imaging diagnosis of capillary telangiectasia was made. Recognition of the MRI findings of capillary telangiectasia is imperative to avoid misdiagnosis and prevent unnecessary intervention.

The Use of Descriptive Terms for Ventricular Size on Noncontrast Head CT Radiology Reports

BACKGROUND AND PURPOSE

Multiple radiographic terms can be used to describe enlarged ventricles on noncontrast head computed tomography (CTs); however, precise terminology is important to determine etiology and clinical management. The purpose of this study was to characterize how ventricular size was described in radiology reports, especially in the setting of hydrocephalus.

MATERIALS AND METHODS

A retrospective review of adult patients with at least 2 consecutive noncontrast head CTs from 2010 to 2016 was performed. Reports were grouped based on ventricular descriptions into 3 categories: "acceptable," "unclear," and "not acceptable." An additional subgroup was created for an examination indication of "hydrocephalus." Descriptive statistics and subgroup analysis were performed.

RESULTS

A total of 270 patients with noncontrast head CTs were included, of which 53.3% (n = 144) used "acceptable" terms, 18.2% (n = 49) "unclear," and 28.5% (n = 77) "not acceptable." Ventricle size was reported as normal in 21.1% (n = 57) of cases. "Hydrocephalus" was given as an indication for 57 exams, of which 84.2% (n = 48) were categorized as "acceptable," 7.0% (n = 4) "unclear," and 8.8% (n = 5) "not acceptable." Chi-square test of independence revealed a significant relation between "acceptable" terminology and "hydrocephalus" indication (χ² = 27.68, P< 0.001).

CONCLUSION

Approximately half of radiology reports had an "acceptable" description of the ventricles. When "hydrocephalus" was in the indication, the report was more likely to have an "acceptable" description. Accurate clinical indications, and standardized terminology may improve the clinical utility of radiology reports for patients with hydrocephalus.

Altered trajectories of neurodevelopment and behavior in mouse models of Rett syndrome

Rett Syndrome (RTT) is a genetic disorder that is caused by mutations in the x-linked gene coding for methyl-CpG-biding-protein 2 (MECP2) and that mainly affects females. Male and female transgenic mouse models of RTT have been studied extensively, and we have learned a great deal regarding RTT neuropathology and how MeCP2 deficiency may be influencing brain function and maturation. In this manuscript we review what is known concerning structural and coinciding functional and behavioral deficits in RTT and in mouse models of MeCP2 deficiency. We also introduce our own corroborating data regarding behavioral phenotype and morphological alterations in volume of the cortex and striatum and the density of neurons, aberrations in experience-dependent plasticity within the barrel cortex and the impact of MeCP2 loss on glial structure. We conclude that regional structural changes in genetic models of RTT show great similarity to the alterations in brain structure of patients with RTT. These region-specific modifications often coincide with phenotype onset and contribute to larger issues of circuit connectivity, progression, and severity. Although the alterations seen in mouse models of RTT appear to be primarily due to cell-autonomous effects, there are also non-cell autonomous mechanisms including those caused by MeCP2-deficient glia that negatively impact healthy neuronal function. Collectively, this body of work has provided a solid foundation on which to continue to build our understanding of the role of MeCP2 on neuronal and glial structure and function, its greater impact on neural development, and potential new therapeutic avenues.

Making Learning Fun: Gaming in Radiology Education

With continued technologic advances, it is not surprising that gaming techniques are increasingly being used in radiology residency programs. This comprehensive review on gaming in radiology education offers insight into the importance of gaming, types of games and principles utilized in gaming, as well as applications that are inherent in artificial intelligence and continued medical education. The advantages and disadvantages of gaming will be considered, as well as barriers to successful adoption of gaming.

Structured Curriculum Vitae Scoring as a Standardized Tool for Selecting Interview Candidates for Academic Neuroradiology Faculty Positions

BACKGROUND AND PURPOSE

Interview selection of candidates for academic radiology faculty positions is variable and subject to unconscious biases. The purpose of this study was to retrospectively apply a quantitative curriculum vitae (CV) rubric as a screening tool to identify qualified candidates for further consideration in the hiring process.

MATERIALS AND METHODS

Archived CVs submitted by applicants between 2012 and 2017 for neuroradiology faculty positions at our institution were anonymized. One blinded reviewer scored resumes based on categories that included education, work experience, extracurricular/teaching experience, and research. Logistic regression and receiver operating characteristics analysis were performed. This study was IRB exempted.

RESULTS

Of the total 102 applicants, 17 interviews were conducted and 10 candidates were offered a position. Maximum score of the model was 24 points. Mean score was 14 ± 4 (n = 102, range 5-22). Higher total CV score (P = 0.01), medical school ranking (P = 0.03), and number of published manuscripts (P = 0.03) were significantly associated with interview selection. The area under the curve in the ROC analysis for differentiating interview selection based on total CV scoring was 0.69 (95% confidence interval 0.56-0.82). At a cutoff of 14, the model is 82.4% sensitive, and 54.1% specific.

CONCLUSION

Standardized CV scoring is feasible with a cut-off score of 14 points providing high sensitivity in identifying candidates eligible for interview. This tool can potentially be applied in the future to the hiring process as it is neutral to factors such as gender and race and provides an opportunity to address diversity in academic medicine.

Assessment of Explicitly Stated Interval Change on Noncontrast Head CT Radiology Reports

BACKGROUND AND PURPOSE

Consistent and standardized reporting of interval change for certain diagnoses may improve the clinical utility of radiology reports. The purpose of this study was to assess explicitly stated interval change of various findings in noncontrast head CT reports.

MATERIALS AND METHODS

A retrospective review was performed on successive noncontrast head CT radiology reports from the first 2 weeks of January 2014. Reports with at least 1 prior comparison CT scan were included. Reports with normal examination findings and those that made comparison with only other types of examinations (eg, MR imaging) were excluded. Descriptive and subgroup statistical analyses were performed.

RESULTS

In total, 200 patients with 230 reports and 979 radiographic findings were identified. The average interval between reports was 344.9 ± 695.9 days (range, 0-3556 days). Interval change was mentioned 67.3% (n = 659) of the time for all findings (n = 979). Explicitly stated interval change was significantly associated with nonremote findings (P < .001) and generalized statements of interval change (P < .001). The proportion of interval change reported ranged from 95.3% of the time for hemorrhagic to 36.4% for soft-tissue/osseous categorizations.

CONCLUSIONS

Interval change reporting was variable, mentioned for 67.3% of noncontrast head CT report findings with a prior comparison CT scan. Structured radiology reports may improve the consistent and clear reporting of interval change for certain findings.

Pre-operative MRI predictors of hormonal remission status post pituitary adenoma resection

INTRODUCTION

Contrast-enhanced (CE) Constructive Interference in Steady State (CISS) and Volumetric Interpolated Breath-hold Examination (VIBE) are MRI sequences used to improve the detection of pituitary adenomas and adjacent cranial nerves. The purpose of this study was to assess image quality and identify imaging predictors of postoperative hormonal remission of functioning pituitary adenomas using CE-T1 weighted image (WI), T2WI, CE-CISS, and CE-VIBE MRI sequences.

MATERIALS AND METHODS

Patients with pre-operative CE-T1WI, T2WI, CE-CISS, and CE-VIBE pituitary MRI sequences were included in this institutional retrospective review. Three raters independently reviewed randomized sequences in a blinded fashion for adenoma characteristics and parasellar invasion. Subgroup analysis of hormonal remission was performed.

RESULTS

A total of 34 functioning pituitary adenoma patients were included (average age 39.3 ± 12.2; female n = 27), 30 of which had post-operative hormonal remission (n = 34; 88.2%). Compared to CE-T1WI, CE-CISS has significantly higher number of sequences rated "good" image quality (p = 0.02). Hormone remission was associated with decreased degrees of pre-operative internal carotid artery (ICA) contact and Knosp score (p ≤ 0.02) on all sequences except for Knosp score on T2WI. On receiver operating characteristic analysis, the area under curve for differentiating endocrine remission ranged from 0.88 to 0.92 for Knosp score and 0.85-0.93 for ICA contact, depending on sequence.

CONCLUSION

Extent of pituitary adenoma cavernous sinus invasion as measured by degrees of ICA contact and Knosp score is associated with postoperative endocrine outcomes. Given improved image quality, inclusion of CE-CISS may be helpful for pre-surgical planning.

Differences in Functional Outcome Across Subtypes with Spetzler-Martin Grade II Arteriovenous Malformations

BACKGROUND

The Spetzler-Martin grading system for brain arteriovenous malformations (AVMs) is based on size (S), eloquence (E), and deep venous drainage (V). However, variation exists due to subgroup heterogeneity. While previous studies have demonstrated variations in outcomes within grade III AVMs, no studies have focused on grade II AVM subtypes.

OBJECTIVE

We aim to delineate how functional outcomes differ among patients with subtypes of grade II AVMs.

METHODS

We retrospectively reviewed patients with AVMs evaluated at our institution from 1990 to 2013. Grade II AVMs were divided into 3 subtypes: group 1 (S2V0E0), group 2 (S1V0E1), and group 3 (S1V1E0). Baseline characteristics were compared, and functional status was assessed using the modified Rankin Scale (mRS) at pretreatment and last follow-up. Differences in mRS between the 2 time points were compared.

RESULTS

A total of 208 grade II patients (34.0%) were retrieved from 611 graded patients. After accounting for missing data, our cohort consisted of 137 patients. Mean age of all patients was 37.2 years, with 74 females (54.0%). No significant difference was observed across subgroups for pretreatment mRS ( P = .096), treatment modalities ( P = .943), follow-up durations ( P = .125), and mRS at last follow-up ( P = .716). In a subgroup analysis between group 1 and group 3, more patients with worsened mRS were observed in group 3 ( P = .039). This distinction was further confirmed in surgically treated patients ( P = .049), but not in patients treated with radiosurgery ( P = .863).

CONCLUSION

Subtypes of grade II AVMs portend different posttreatment gains in functional outcome. Group 1 (S2V0E0) patients had the best functional outcome gain from treatment, while group 3 (S1V1E0) patients fared less well, particularly with surgical treatment.

Primary intramedullary spinal cord lymphoma: a population-based study

Background

Primary intramedullary spinal cord lymphoma (PISCL) is a rare diagnosis with poorly understood disease progression. Clarification of the factors associated with survival in PISCL patients is warranted.

Methods

We conducted a population-based cohort study utilizing prospectively collected data from the Surveillance, Epidemiology, and End Results (SEER) database. Patients with histological diagnosis of primary lymphoma in spinal cord (C72.0) from 1973 to 2012 in the SEER database were included. Multivariable survival analysis between patient, lesion characteristics, and PISCL-related death was performed to adjust for confounding factors.

Results

We included 346 PISCL patients in our study. Average age was 56.5 ± 17.8 years, with 62.7% being male. Racial distribution of these patients was white (87.6%), black (8.0%), and other (4.3%). More than half (55.8%) of patients were married. The most prevalent histology of PISCL was diffuse B-cell (46.2%), and the majority (55.2%) were low stage (Ann Arbor stage I/II). Most patients (67.9%) received radiation therapy. Average survival interval of patients with PISCL-related death (n=135, 39.0%) was 27.8 months. General cumulative survival probability at 1 year, 2 years, and 5 years was 73.8%, 67.9%, and 63.1%, respectively. Multivariable accelerated failure time (AFT) regression showed follicular lymphoma (HR:0.25, P=.008) and more recent diagnosis (HR:0.96, P<.001) was positively associated with PISCL-related survival. Conversely, nonwhite race (HR:1.69, P=.046), older age (HR:1.02, P<.001), unmarried status (HR:2.14, P<.001), and higher stage (HR:1.54, P=.022) were negatively associated with survival.

Conclusions

Age, race, marital status, tumor histology, tumor stage, and year of diagnosis were associated with survival of PISCL. While most PISCL-related deaths occur within a 1-year period, subsequent slow progression was observed after the first year of survival.

Risk Assessment of Hemorrhage of Posterior Inferior Cerebellar Artery Aneurysms in Posterior Fossa Arteriovenous Malformations

BACKGROUND

Posterior fossa arteriovenous malformations (AVMs) are associated with increased risk of rupture and severe consequences from such rupture. The hemorrhagic risk of prenidal aneurysms (anr) on the posterior inferior cerebellar artery (PICA) may exceed that of the AVM in posterior fossa AVMs fed by PICA (PICA-AVM).

OBJECTIVE

To characterize the relative risks of aneurysm and AVM hemorrhage in patients with posterior fossa AVMs.

METHODS

We retrospectively reviewed patients diagnosed with AVM. Patients with posterior fossa AVMs were divided into 3 groups: PICA-AVM with prenidal aneurysm (PICA-AVM-anr group), PICA-AVM without prenidal aneurysm (PICA-AVM group), and AVMs without PICA feeder with/without aneurysm (AVM-only group). Patient and lesion characteristics and treatment outcomes were compared. ANOVA and chi squared tests were used for statistical analyses.

RESULTS

Our cohort included 85 patients. Mean age was 45.3 ± 18.1 yr, with 43(50.6%) female patients. Fifty-one patients (60.0%) had hemorrhagic presentation, and 27 (31.8%) experienced acute hydrocephalus. Patients in the PICA-AVM-anr group (n = 11) were more likely to present with aneurysmal subarachnoid hemorrhage (SAH; P = .005) and less likely to have AVM rupture (P &lt; .001). Ten (90.9%) patients presented with hemorrhage, 6 (60.0%) of which resulted from aneurysm rupture. Of these 6, 5 (83.3%) had acute hydrocephalus. No patients with AVM rupture had hydrocephalus. Eight (72.7%) received aneurysm treatment prior to AVM treatment. There were no significant differences in post-treatment outcomes dependent on treatment order.

CONCLUSION

In addition to relatively higher risk of AVM rupture from infratentorial location and prenidal aneurysm, a higher risk of aneurysm rupture rather than AVM rupture was observed in patients with PICA-AVM-anr complex.

Comparison of Hemorrhagic Risk in Intracranial Arteriovenous Malformations Between Conservative Management and Embolization as the Single Treatment Modality

BACKGROUND

Embolization has been discussed as a feasible single modality treatment for intracranial arteriovenous malformations (AVMs).

OBJECTIVE

To compare hemorrhagic risk between embolization and conservative management in a multivariate survival analysis.

METHODS

We retrospectively reviewed records of patients with intracranial AVMs evaluated at our institution from 1990 to 2013. We included patients recommended to undergo embolization without other treatment modalities and patients managed conservatively. Multivariate Cox regression analysis of hemorrhage-free survival was performed, with the survival interval right-censored to date of either last follow-up or salvage treatment.

RESULTS

We identified 205 patients matching our inclusion criteria, with 160 patients in the noninterventional group and 45 in the embolization group. The average age of all patients was 40.2 ± 19.5 yr, with younger patients undergoing embolization more often (P = .026). Fifty-one (31.9%) conservatively managed patients and 13 (28.9%) patients treated by embolization (P = .703) presented with hemorrhage. Other baseline characteristics were similar between the 2 management groups. During an average follow-up period of 7.7 yr, 30 patients (14.6%) experienced hemorrhage recurrence. Multivariate Cox regression revealed older age (P = .031) and hemorrhagic presentation (P &lt; .001) to be statistically associated with follow-up hemorrhage. In a subset analysis of unruptured AVMs, embolization was associated with a 4-fold hazard ratio of hemorrhage compared to conservative management (P = .044).

CONCLUSION

Older age and initial presentation with hemorrhage were associated with increased risk of hemorrhage during follow-up. Treatment of AVMs with embolization as the sole modality may increase hemorrhagic risk compared with conservative management, especially in unruptured AVMs.

Lower Risk of Intracranial Arteriovenous Malformation Hemorrhage in Patients With Hereditary Hemorrhagic Telangiectasia

BACKGROUND

Patients diagnosed with hereditary hemorrhagic telangiectasia (HHT) are at risk of developing intracranial arteriovenous malformations (AVM). However, the clinical manifestations and natural history of HHT-related AVMs remain unclear due to the rarity of these lesions.

OBJECTIVE

To clarify the clinical characteristics and hemorrhagic risk in HHT-related AVMs.

METHODS

We performed a retrospective review of all patients diagnosed with both HHT and intracranial AVMs who were evaluated at our institution from 1990 to 2013. Patients with missing data or lost to follow-up were excluded. Baseline characteristics and subsequent hemorrhagic risk were evaluated.

RESULTS

In an AVM database of 531 patients with 542 AVMs, a total of 12 HHT patients (2.3%) with 23 AVMs were found. Mean age at diagnosis was 36.5 years, with 41.7% male. Compared to patients with sporadic AVMs, patients with HHT were less likely to present with ruptured AVM (P = .04), headaches (P = .02), and seizures (P = .02), and presented with better modified Rankin scores (P < .01). HHT-related AVMs were smaller in size (P < .01), of lower Spetzler-Martin grade (P = .01), and had less temporal lobe involvement (P = .02) compared to sporadic AVMs. Six HHT patients (50.0%) were found with multiple intracranial AVMs. One hemorrhage was found during an observation period of 149.6 patient-years and 297.5 lesion-years, translating to 1.3% per patient per year or 0.7% per AVM per year.

CONCLUSION

HHT-related AVMs are smaller in size with lower Spetzler-Martin grade and less temporal lobe involvement than sporadic AVMs. Patients with HHT frequently present with multiple intracranial AVMs. Conservative management is generally recommended due to lesion multiplicity and relatively low hemorrhagic risk.

Interobserver Agreement on Arteriovenous Malformation Diffuseness Using Digital Subtraction Angiography

BACKGROUND

Arteriovenous malformation (AVM) diffuseness has been shown to be prognostic of treatment outcomes. We assessed interobserver agreement of AVM diffuseness among physicians of different specialty and training backgrounds using digital subtraction angiography (DSA).

METHODS

All research protocols were approved by the institutional review board for this retrospective chart review. In a single-blinded setting, 2 attending neurosurgeons, 1 attending interventional neuroradiologist, and 1 senior neurosurgical resident rated 80 DSA views of 36 AVMs as either compact or diffuse. Individual interobserver agreement and subgroup agreement were analyzed using κ agreement and intraclass correlation coefficient.

RESULTS

Disagreement regarding AVM diffuseness occurred in 43.8% of all DSA views (n = 80). Interobserver κ agreement on AVM diffuseness using DSA views among 4 physicians ranged from fair (κ = 0.40 [95% confidence interval (CI) = 0.22-0.58]) to substantial (κ = 0.65 [95% CI = 0.48-0.81]), whereas total intraclass correlation coefficient was 0.81 (95% CI = 0.73-0.87). For the 36 AVMs, κ agreement ranged from fair (κ = 0.36 [95% CI = 0.13-0.60]) to moderate (κ = 0.57 [95% CI = 0.35-0.79]), whereas intraclass correlation coefficient among all 4 physicians was 0.68 (95% CI = 0.47-0.82). Moderate agreement on AVM diffuseness (n = 80) was found between attending and resident assessments (κ = 0.57 [95% CI = 0.39-0.75]) and between neurosurgeon and interventional neuroradiologist assessments (κ = 0.55 [95% CI = 0.37-0.73]).

CONCLUSIONS

Agreement of individual physicians on AVM diffuseness varies from fair to substantial. Objective and three-dimensional measures of AVM diffuseness should be developed for consistent clinical application.

Long-term Outcomes of Patients With Giant Intracranial Arteriovenous Malformations

BACKGROUND:

Giant intracranial arteriovenous malformations (AVMs) are rare cerebrovascular lesions that pose management challenges.

OBJECTIVE:

To further clarify outcomes in patients with giant cerebral AVMs managed with conservative or interventional therapies.

METHODS:

We performed a retrospective review of all patients diagnosed with AVMs evaluated at our institution from 1990 to 2013. Patients with a single intracranial AVM &gt;6 cm were included. Patients were divided into 2 groups: conservative management or intervention (microsurgery, radiosurgery, or embolization). Functional outcome was assessed with the modified Rankin Scale (mRS) and compared between the 2 groups.

RESULTS:

A total of 55 patients with giant AVMs were included, and 35 patients (63.6%) had clinical follow-up with a mean of 11.8 years. Spetzler-Martin grades were as follows: grade III, n = 2 (3.6%); grade IV, n = 15 (27.3%); and grade V, n = 38 (69.1%). Twenty-four patients (43.6%) were conservatively managed. The patients in the conservatively managed group had larger AVMs (P &lt; .05) with more frequent involvement of the temporal lobe (P = .02). Five patients (26.3%) in the conservatively managed group and 5 (31.3%) in the intervention group experienced hemorrhage during follow-up, translating to an annualized risk of 2.7% and 4.1%, respectively. No significant difference in risk of first subsequent hemorrhage was observed (P = .78). Despite comparable mRS scores at presentation, we observed a trend toward better outcomes (mRS &lt; 2) in patients undergoing conservative management (P = .06) compared with the intervention group at last follow-up.

CONCLUSION

This study suggests that interventions for giant AVMs should be considered cautiously because hemorrhagic risk is similar regardless of management strategy and functional outcome is likely to be same or better in the conservatively managed population.

Imaging the spontaneous obliteration of a cerebral arteriovenous malformation using c-arm cone beam computed tomography: A case report

Background:

Spontaneous occlusion of a cerebral arteriovenous malformation (AVM) without treatment is a rare occurrence.

Case Description:

We report the case of a 56-year-old male who presented with aphasia and right hemiparesis secondary to intracerebral and intraventricular hemorrhage. Diagnostic digital subtraction angiography (DSA) and c-arm cone beam computed tomography (CBCT) demonstrated a 5 mm Spetzler-Martin Grade III left thalamic AVM drained by the internal cerebral vein. Subsequent DSA and CBCT studies confirmed the spontaneous obliteration of the AVM.

Conclusions:

In this case, CBCT provided high resolution imaging of the AVM. Future clinical use of CBCT as an adjunct to DSA may enhance the diagnostic and therapeutic imaging of vascular lesions.