Bilateral Simultaneous Magnetic Resonance-Guided Focused Ultrasound Pallidotomy for Life-Threatening Status Dystonicus

BACKGROUND

Invasive treatments like radiofrequency stereotactic lesioning or deep brain stimulation of the globus pallidus internus can resolve drug-resistant status dystonicus (SD). However, these open procedures are not always feasible in patients with SD.

OBJECTIVE

The aim was to report the safety and efficacy of simultaneous asleep bilateral transcranial magnetic resonance-guided focused ultrasound (MRgFUS) pallidotomy for life-threatening SD.

METHODS

We performed bilateral simultaneous MRgFUS pallidotomy under general anesthesia in 2 young patients with pantothenate kinase-associated neurodegeneration and GNAO1 encephalopathy. Both patients had medically refractory SD and severe comorbidities contraindicating open surgery.

RESULTS

SD resolved at 4 and 12 days after MRgFUS, respectively. Adverse events (intraoperative hypothermia and postoperative facial paralysis) were mild and transient.

CONCLUSION

Bilateral simultaneous MRgFUS pallidotomy under general anesthesia is safe and may be a valid alternative therapeutic option for fragile patients. Further studies are needed to assess long-term efficacy of the procedure. © 2024 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Focused ultrasound therapy in movement disorders: management roadmap toward optimal pathway organization

MRI-guided focused ultrasound (MRgFUS) lesioning is an innovative, safe and effective treatment which provides an innovative development in the field of minimally invasive stereotactic neurosurgery. Based on the application of focused ultrasound energy under full MR planning and thermal imaging control, unilateral lesioning of the thalamus, subthalamic nucleus, and globus pallidus is indicated for the treatment of movement disorders, including essential tremor, Parkinson's disease, and dystonia. We started to apply this technique in February 2019 for the treatment of patients with movement disorders. The authors developed a diagnostic therapeutic care pathway, which is herewith proposed and applied as an explication of standard clinical practice in use. The project was the result of the application of different methods such as Health Technology Assessment (HTA), Strengths, Weaknesses, Opportunities and Threats analysis (SWOT) and Demin -Plan, Do, Check, Act (PDCA) cycle. The aim of this project was to standardize the MRgFUS diagnostic-therapeutic pathway (DTP), describe its application and the appropriateness of different phases (patient selection, intervention phase and follow-up). Here, we described in detail our experience in the DTP application from 2019 up to now in 610 patients with movement disorders.

The Optimal Targeting for Focused Ultrasound Thalamotomy Differs between Dystonic and Essential Tremor: A 12-Month Prospective Pilot Study

BACKGROUND

Magnetic resonance-guided focused ultrasound (MRgFUS) thalamotomy is increasingly used to treat drug-resistant essential tremor (ET). Data on MRgFUS thalamotomy in dystonic tremor (DT) are anecdotal.

OBJECTIVES

To investigate efficacy, safety, and differences in target coordinates of MRgFUS thalamotomy in DT versus ET.

METHODS

Ten patients with DT and 35 with ET who consecutively underwent MRgFUS thalamotomy were followed for 12 months. Although in both groups the initial surgical planning coordinates corresponded to the ventralis intermediate (Vim), the final target could be modified intraoperatively based on clinical response.

RESULTS

Tremor significantly improved in both groups. The thalamic lesion was significantly more anterior in DT than ET. Considering both ET and DT groups, the more anterior the lesion, the lower the odds ratio for adverse events.

CONCLUSIONS

MRgFUS thalamotomy is safe and effective in DT and ET. Compared to classical Vim coordinates used for ET, more anterior targeting should be considered for DT.

Considering Psychological and Cognitive Factors in Interventional Neuroradiology: A Systematic Literature Review

BACKGROUND

Interventional neuroradiology is a relatively recent discipline that diagnoses and treats cerebral vascular diseases. However, specific literature on cognitive and psychological domains of patients undergoing interventional neuroradiology procedures is limited.

PURPOSE

Our aim was to review the existent literature on cognitive and psychological domains in patients undergoing interventional neuroradiology procedures to raise clinicians' awareness of their mental status.

DATA SOURCES

Articles were searched in PubMed, EMBASE, and Scopus from 2000 to 2022 using terms such as "interventional neuroradiology," "psychology," and "cognition" according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

STUDY SELECTION

Of 1483 articles in English, 64 were included and analyzed. Twelve focused on psychological aspects; 52, on cognitive ones.

DATA ANALYSIS

Regarding psychological aspects, it appears that early psychological consultations and "nonpharmacologic" strategies can impact the anxiety and depression of patients undergoing endovascular procedures. Regarding cognitive aspects, it appears that endovascular treatment is safe and generates similar or even fewer cognitive deficits compared with analogous surgical procedures.

DATA SYNTHESIS

Among the 12 articles on psychological aspects, 6/12 were retrospective with one, while 6/12 were prospective. Among the 52 articles on cognitive aspects, 7/54 were retrospective, while 45/52 were prospective.

LIMITATIONS

The main limitation derives from the inhomogeneity of the cognitive and psychological assessment tools used in the articles included in our analysis.

CONCLUSIONS

Our review highlights the need to include cognitive and psychological assessments in clinical practice in case patients eligible for interventional neuroradiology procedures. In the future, much more research of and attention to cognitive and psychologic aspects of neurovascular disease is needed. Systematic incorporation of strategies and tools to access and address pre, peri-, and postprocedural psychological and cognitive components could have major benefits in patient satisfaction, recovery, and the success of endovascular practice.

Association of the Careggi Collateral Score with 3-month modified Rankin Scale score after thrombectomy for stroke with occlusion of the middle cerebral artery

BACKGROUND

The Careggi Collateral Score (CCS) (qualitative-quantitative evaluation) was developed from a single-centre cohort as an angiographic score to describe both the extension and effectiveness of the pial collateral circulation in stroke patients with occlusion of the anterior circulation. We aimed to examine the association between CCS (quantitative evaluation) and 3-month modified Rankin Scale (mRS) score in a large multi-center cohort of patients receiving thrombectomy for stroke with occlusion of middle cerebral artery (MCA).

METHODS

We conducted a study on prospectively collected data from 1284 patients enrolled in the Italian Registry of Endovascular Treatment in Acute Stroke. According to the extension of the retrograde reperfusion in the cortical anterior cerebral artery (ACA)-MCA territories, CCS ranges from 0 (absence of retrograde filling) to 4 (visualization of collaterals until the alar segment of the MCA).

RESULTS

Using CCS of 4 as reference, CCS grades were associated in the direction of unfavourable outcome on 3-month mRS shift (0 to 6); significant difference was found between CCS of 0 and CCS of 1 and between CCS of 3 and CCS of 4. CCS ≥ 3 was the optimal cut-off for predicting 3-month excellent outcome, while CCS ≥ 1 was the optimal cut-off for predicting 3-month survival. CCS of 0 and CCS < 3 were associated in the direction of unfavourable recanalization on TICI shift (0 to 3) compared with CCS ≥ 1 and CCS ≥ 3, respectively. Compared with CCS ≥ 3 as reference, CCS of 0 and CCS 1 to 2 were associated in the direction of unfavourable recanalization on TICI shift. There was no evidence of heterogeneity of effects of successful recanalization and procedure time ≤ 60 min on 3-month mRS shift across CCS categories.

CONCLUSION

The CCS could provide a future advantage for improving the prognosis in patients receiving thrombectomy for stroke with M1 or M1-M2 segment of the MCA occlusion.

European Multicenter Study of ET-COVID-19

BACKGROUND AND PURPOSE

Acute ischemic stroke and large vessel occlusion can be concurrent with the coronavirus disease 2019 (COVID-19) infection. Outcomes after mechanical thrombectomy (MT) for large vessel occlusion in patients with COVID-19 are substantially unknown. Our aim was to study early outcomes after MT in patients with COVID-19.

METHODS

Multicenter, European, cohort study involving 34 stroke centers in France, Italy, Spain, and Belgium. Data were collected between March 1, 2020 and May 5, 2020. Consecutive laboratory-confirmed COVID-19 cases with large vessel occlusion, who were treated with MT, were included. Primary investigated outcome: 30-day mortality.

SECONDARY OUTCOMES

early neurological improvement (National Institutes of Health Stroke Scale improvement ≥8 points or 24 hours National Institutes of Health Stroke Scale 0-1), successful reperfusion (modified Thrombolysis in Cerebral Infarction grade ≥2b), and symptomatic intracranial hemorrhage.

RESULTS

We evaluated 93 patients with COVID-19 with large vessel occlusion who underwent MT (median age, 71 years [interquartile range, 59-79]; 63 men [67.7%]). Median pretreatment National Institutes of Health Stroke Scale and Alberta Stroke Program Early CT Score were 17 (interquartile range, 11-21) and 8 (interquartile range, 7-9), respectively. Anterior circulation acute ischemic stroke represented 93.5% of cases. The rate modified Thrombolysis in Cerebral Infarction 2b to 3 was 79.6% (74 patients [95% CI, 71.3-87.8]). Thirty-day mortality was 29% (27 patients [95% CI, 20-39.4]). Early neurological improvement was 19.5% (17 patients [95% CI, 11.8-29.5]), and symptomatic intracranial hemorrhage was 5.4% (5 patients [95% CI, 1.7-12.1]). Patients who died at 30 days exhibited significantly lower lymphocyte count, higher levels of aspartate, and LDH (lactate dehydrogenase). After adjustment for age, initial National Institutes of Health Stroke Scale, Alberta Stroke Program Early CT Score, and successful reperfusion, these biological markers remained associated with increased odds of 30-day mortality (adjusted odds ratio of 2.70 [95% CI, 1.21-5.98] per SD-log decrease in lymphocyte count, 2.66 [95% CI, 1.22-5.77] per SD-log increase in aspartate, and 4.30 [95% CI, 1.43-12.91] per SD-log increase in LDH).

CONCLUSIONS

The 29% rate of 30-day mortality after MT among patients with COVID-19 is not negligible. Abnormalities of lymphocyte count, LDH and aspartate may depict a patient's profiles with poorer outcomes after MT. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT04406090.

Neurovascular Perfusion Study With DynaPBV During Preoperative Balloon Test Occlusion: A Feasibility Study on Aneurysm and Tumor Lesions

To report feasibility, safety, and technical advantages of flat-detector computed tomography perfusion (FD-CTP) during balloon test occlusion (BTO) angiography studies, 10 patients patients scheduled for BTO were evaluated. Cerebral blood volume maps were extracted from FD-CTP images acquired during the test. The FD-CTP perfusion combined with BTO is feasible and safe in intracranial tumor, and aneurysm cases in which vessel sacrifice should be considered.

Indocyanine Green Videoangiographic-Guided Cannulation of the Superior Ophthalmic Vein for Endovascular Treatment of Carotid-Cavernous Fistulas

Direct exposure and cannulation of the superior ophthalmic vein (SOV) provides an alternative access to reach the cavernous sinus for carotid-cavernous fistula (CCF) embolization, when classic transvenous routes through the inferior petrosal sinus (IPS) or facial vein are not feasible. We have used indocyanine green (ICG)-videoangiography to study intraoperatively the flow inside the SOV in two cases of indirect CCF. In this paper, we report the operative technique and the result of ICG videoangiographic-guided cannulation of the SOV for endovascular treatment of CCF. Two male patients, of 59 and 66 years of age respectively, presented at our Institution with right decreased visual acuity, persistent binocular diplopia and painful ophthalmoplegia, chemosis and proptosis, due to right unilateral indirect CCF fistula. The endovascular transvenous approach failed in one case due to thrombosis of the inferior petrosal sinus (IPS) and the extreme tortuosity of the angular vein. In the other case, it was considered unfeasible due to an unfavourable vascular angioarchitecture. For this reason, an ICG videoangiographic-guided cannulation of the SOV, followed by endovascular obliteration of the CCF, was performed. CCF was cured in both cases with this approach. No additional neurological deficits and no complications due to SOV cannulation were registered during the hospital stay. There were no fistula recurrences during the mean follow-up of 18 months. ICG-videoangiography is a simple, fast and cost-effective technique that can be reliably applied in SOV cannulation for subsequent indirect CCF embolization.

Medial Tentorial Dural Arteriovenous Fistula Embolization: Single Experience with Embolic Liquid Polymer SQUID and Review of the Literature

BACKGROUND

Tentorial dural arteriovenous fistulas (DAVFs) are uncommon, complex fistulas located between the leaves of the tentorium cerebelli with a specific anatomic and clinical presentation characterized by high hemorrhagic risk. We present a rare case of a medial tentorial DAVF successfully managed via transarterial embolization using SQUID liquid polymer.

CASE DESCRIPTION

A 60-year-old woman presented with a history of left progressive hearing loss and tinnitus for >1 year. Cerebral angiography demonstrated the presence of a medial tentorial DAVF with multiple arterial feeders, including the artery of Davidoff and Schechter; reverse venous outflow was observed in the inferior sagittal sinus and in multiple cortical veins. The patient underwent transarterial embolization with SQUID liquid polymer, an embolic agent that provides 2 different viscous formulations to cast the DAVF. The procedure went well without any complication, and the patient regained her preoperative status. In the postprocedural period, the patient experienced complete resolution of tinnitus. At 6 months, she remained asymptomatic, and cerebral angiography confirmed complete, stable occlusion of the fistula and normalization of cerebral deep venous outflow.

CONCLUSIONS

Medial tentorial DAVFs are considered the most complex DAVFs because of their location and extensive vascular supply. Our literature review focused on endovascular treatment of tentorial DAVFs to highlight the usefulness of new embolic agents in management of these diseases. To our knowledge, we report the first successful use of SQUID liquid polymer in management of a tentorial DAVF.

Crying spells triggered by thumb-index rubbing after thalamic stroke: a case report

Background

Pathologic crying, devoid of any emotional counterpart, is known to occur as a consequence of various brain stem, cortical hemispheric and cerebellar lesions or, quite exceptionally, of “dacrystic” epilepsy. The case reported here suggests that thalamic lesions may also cause crying spells, under the special circumstances described below.

Case presentation

After a mild left thalamic stroke a caucasian 77 years old man presented with crying spells with no emotional counterpart, triggered by thumb-index rubbing of his right hand. Only a modest sensation loss on right infra-orbital and nose-labial areas and the first three right fingers could be detected at clinical examination. The circumstances and processes leading to the crying spells were investigated, together with their neural substrate. Brain computerized tomography (CT), magnetic resonance imaging (MRI) and functional magnetic resonance imaging (fMRI) were conducted. Neurophysiologic studies included Video-Electroencephalography, Electromyography, motor and sensory Evoked potentials. Active thumb-index rubbing, passive fingertips stimulation and interaction of sensory-motor stimulation with cognitive/speech activities were tested under different paradigms. A treatment with pregabalin (75 mg twice a day) was attempted. CT and MRI showed a small ischemic infarct in the left ventral postero-lateral thalamus, while fMRI led to the expected findings, i.e. a bilateral activation of the hand motor representation during the crying-triggering right-hand finger rubbing activity. Sensory potentials evoked from stimulation of the right upper limb were the only abnormal neurophysiologic test. Crying spells could be invariably evoked by both real and imagined active finger rubbing, in either the left of right hemi-space. Rubbing by an examiner was ineffective. Immersion in water (18 °C) but not oiling of the fingertips prevented the symptom. Administration and discontinuation of pregabalin 75 mg daily could be associated with suppression and reappearance of the symptom, respectively.

Conclusions

In this patient loss of sensation seemed to generate crying spells rather than the more common allodynia. As a matter of speculation, both symptoms might represent responses to a sensory loss, but in this case the pathway might have been selectively affected providing inhibition from the lateral to the medial segment of the VPLT, which is linked to the anterior cingulate (limbic) cortex engaged in emotional behaviour.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-017-2425-z) contains supplementary material, which is available to authorized users.

Republished: Advanced digital subtraction angiography and MR fusion imaging protocol applied to accurate placement of flow diverter device

In recent years there has been a progressive increase in interventional neuroradiology procedures, partially due to improvements in devices, but also to the simultaneous development of technologies and radiological images. Cone beam CT (Dyna-CT; Siemens) is a method recently used to obtain pseudo CT images from digital subtraction angiography (DSA) with a flat panel detector. Using dedicated software, it is then possible to merge Dyna-CT images with images from a different source. We report here the usefulness of advanced DSA techniques (Syngo-Dyna CT, three-dimensional DSA iPilot) for the treatment of an intracranial aneurysm with a flow diverter device. Merging MR and Dyna-CT images at the end of the procedure proved to be a simple and rapid additional method of verifying the success of the intervention.

Advanced digital subtraction angiography and MR fusion imaging protocol applied to accurate placement of flow diverter device

In recent years there has been a progressive increase in interventional neuroradiology procedures, partially due to improvements in devices, but also to the simultaneous development of technologies and radiological images. Cone beam CT (Dyna-CT; Siemens) is a method recently used to obtain pseudo CT images from digital subtraction angiography (DSA) with a flat panel detector. Using dedicated software, it is then possible to merge Dyna-CT images with images from a different source. We report here the usefulness of advanced DSA techniques (Syngo-Dyna CT, three-dimensional DSA iPilot) for the treatment of an intracranial aneurysm with a flow diverter device. Merging MR and Dyna-CT images at the end of the procedure proved to be a simple and rapid additional method of verifying the success of the intervention.

Three-dimensional sonohysterography for examination of the uterine cavity in women with abnormal uterine bleeding: Preliminary findings

INTRODUCTION

To compare the diagnostic values of three-dimensional sonohysterography (3DSH), transvaginal ultrasound (TVUS), and 2-dimensional sonohysterography (2DSH) in the work-up of abnormal uterine bleeding (AUB), in particular the ability of each method to identify intracavitary lesions arising from the endometrium or uterine wall.

MATERIALS AND METHODS

24 patients referred for AUB underwent TVUS followed by 2-D and 3-D HS in the same session. Three-dimensional data were acquired with a free-hand technique during maximal distention of the uterus. Within 10 days of the sonographic session, each patient underwent hysteroscopy, which was considered the reference standard. For each of the 3 imaging methods, we calculated sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy.

RESULTS

Hysteroscopy demonstrated the presence of an intrauterine lesion in 21/24 patients (87.5%). In 3/24 patients hysteroscopy was negative. For TVUS, 2DSH, and 3DSH, sensitivity was 76% (16/21), 90% (19/21), 100% (21/21), respectively; specificity was 100% (3/3), 100% (19/19), 100% (21/21); PPV was 100%, 100%, 100%; NPV was 37%, 60%, 100%; accuracy was 76%, 90%, 100%.

CONCLUSIONS

3DSH is more sensitive that 2DSH or TVUS in the detection of intrauterine lesions. If these preliminary results are confirmed in larger studies, 3DSH could be proposed as a valuable alternative to diagnostic hysteroscopy.