Brinjikji, Waleed

Background and purpose It is classically thought that the internal cerebral veins (ICV) do not communicate with the venous pouch of vein of Galen malformations (VGM). We report on the anatomy of the deep venous system in VGM with special emphasis on the drainage of the ICV and possible changes after endovascular treatment. Materials and methods We retrospectively analyzed DSA and 2D time-of-flight MR venograms of 55 children with VGM. We evaluated all pre- and post-operative images for the presence of the ICVs and determined their route of venous drainage. Results Of 55 children, pre-operative 2D MRV detected the ICVs in 19 cases (35%) compared with one case (2%) for pre-embolization DSA (2%) (P<0.0001). Of the cases in which the ICVs were seen preoperatively, in 15 cases (78.9%) the ICV drained directly into the VGM while in the other four cases, the ICV used alternative venous drainage routes. On post-operative MRV, the ICVs were seen in 17 cases (31%) on MRV and 10 cases (18.2%) on DSA with drainage into an adult-like vein of Galen in 13 cases (76%), respectively (P=0.08). In four cases normal ICV drainage into the vein of Galen was seen even when the venous sac was closed. In two cases there was a change in ICV drainage from the vein of Galen to the lateral mesencephalic vein. Conclusion The communication of the ICV with the VGM is a common phenomenon. Different changes of venous drainage routes do occur after treatment and are best seen on MRV.

Abstract BACKGROUND The optimal diagnostic evaluation for patients with angiographically negative subarachnoid hemorrhage (AN-SAH) remains controversial. OBJECTIVE To assess the utilization rate and diagnostic yield of imaging tests routinely obtained in identifying a structural cause for AN-SAH. METHODS In this retrospective multicenter study, consecutive adult patients admitted with nontraumatic, AN-SAH between 01/2010 and 12/2015 were included. Patients with intraparenchymal, subdural, or epidural hematomas in addition to SAH were excluded. Outcomes studied included utilization rate, diagnostic yield, and median time from admission for the following imaging tests: initial computed tomography angiography (CTA) and digital subtraction angiography (DSA), brain and cervical spine magnetic resonance imaging (MRI), and any repeat DSA or CTA performed either during initial admission or at long-term follow-up. RESULTS A total of 752 patients were included (mean age, 53 yr; 54% male). Initial CTA and DSA were performed in 89% and 100% of patients, respectively. Brain MRI was performed in 75% of patients and was positive in 0.7% of cases. Cervical spine MRI was performed in 61% of patients and was positive in 0.2% of cases. Repeat, same-admission follow-up DSA and CTA were performed in 48% and 51% of patients and were positive in 3.3% and 1% of cases, respectively. Delayed follow-up DSA and CTA after discharge were performed in 26% and 7% of patients and were positive in 2% and 3.7% of cases, respectively, all with negative prior imaging studies. CONCLUSION Cervical spine and brain MRI have extremely low diagnostic yield, both are commonly utilized in patients with AN-SAH; while repeat DSA and CTA are utilized less commonly and have slightly higher diagnostic yield.

Spontaneous intracranial hypotension (SIH) is an uncommon headache etiology, typically attributable to an unprovoked occult spinal CSF leak. Although frequently benign, serious complications may occur, including cerebral venous thrombosis (CVT). The objective of this study was to examine a highly complicated case of CVT attributable to SIH as a lens for understanding the heterogeneous literature on this rare complication, and to provide useful, evidence-based, preliminary clinical recommendations. A 43-year-old man presented with 1 week of headache, dizziness, and nausea, which precipitously evolved to hemiplegia. CT venography confirmed CVT, and therapeutic heparin was initiated. He suffered a generalized seizure due to left parietal hemorrhage, which subsequently expanded. He developed signs of mass effect and herniation, heparin was discontinued, and he was taken to the operating room for clot evacuation and external ventricular drain placement. Intraoperatively, the dura was deflated, suggesting underlying SIH. Ventral T-1 CSF leak was identified, which failed multiple epidural blood patches and required primary repair. The patient ultimately made a complete recovery. Systematic review identified 29 publications describing 36 cases of SIH-associated CVT. Among 31 patients for whom long-term neurological outcome was reported, 25 (81%) recovered completely. Underlying coagulopathy/risk factors were identified in 11 patients (31%). CVT is a rare and potentially lethal sequela occurring in 2% of SIH cases. Awareness of the condition is poor, risking morbid complications. Evaluation and treatment should be directed toward identification and treatment of occult CSF leaks. Encouragingly, good neurological outcomes can be achieved through vigilant multidisciplinary neurosurgical and neurocritical care.

Background and purpose Vertebrobasilar dolichoectatic and fusiform aneurysms (VBDAs) are known to have a poor natural history, with high rates of growth, rupture, and stroke. The purpose of this study was to identify hemodynamic characteristics that differ between VBDAs associated with growth, rupture, and stroke. Materials and methods VBDAs with CT angiography or MR angiography followed longitudinally without treatment were studied. Unstable aneurysms were defined as those that grew or ruptured during follow-up. Aneurysms associated with stroke were defined as those associated with posterior circulation infarct at follow-up. Baseline data, including demographics, comorbidities, and aneurysm morphology and size were collected. Image based computational fluid dynamics models were created and run under pulsatile flow conditions. Relevant hemodynamic and geometric variables were calculated and compared between groups (stable vs unstable and no stroke vs stroke) using the Wilcoxon test. Results A total of 37 VBDAs were included (24 stable, 13 unstable; 30 no stroke, 7 stroke). Unstable aneurysms had lower shear rates (P=0.05), blood flow velocity (P=0.03), and lower vorticity (P=0.049) than stable aneurysms. In addition, unstable aneurysms had higher mean oscillatory shear indices (P=0.001). There were no differences in the hemodynamic characteristics of aneurysms in the stroke group compared with the non-stroke group. Conclusion This small study suggests there may be hemodynamic differences between unstable and stable VBDAs. Unstable VBDAs appear to be under lower flow conditions with lower velocity, vorticity, and shear rates, and have more oscillatory flow. There was no difference in the hemodynamic characteristics of aneurysms in the stroke and no stroke group.

BackgroundCarotid plaque imaging with MRI is becoming more commonplace, but practical challenges exist in performing plaque imaging with surface coils.PurposeTo compare the diagnostic performance of a carotid plaque MRI protocol using a standard neurovascular coil (Neurovascular Coil Protocol) to a higher‐resolution carotid plaque MRI using carotid surface coils (Surface Coil Protocol) in characterizing carotid plaque.Study TypeProspective study comparing two MR techniques in plaque characterization.PopulationThirty‐eight consecutive carotid artery disease patients.Field Strength/SequencePatients underwent 3T MRI using 1) a Neurovascular Coil Protocol including the following sequences: 3D‐FSE T1 pre/postcontrast and precontrast 3D IR‐FSPGR, and 2) a Surface Coil Protocol using standard multicontrast MRI sequences.AssessmentPlaque characteristics analyzed by two independent neuroradiologists included intraplaque hemorrhage (IPH), lipid‐rich necrotic‐core (LRNC), and thin/ruptured fibrous cap (TRFC).Statistical TestsDiagnostic performance of the Neurovascular Coil Protocol was compared to the Surface Coil Protocol reference standard using receiver‐operating curves.ResultsFor IPH, sensitivity, specificity, and area under the curve (AUC) of the Neurovascular Coil Protocol were 91.1% (95% confidence interval [CI] = 78.8–97.5%), 87.0% (95% CI = 66.4–97.2%), and 0.92, respectively. For LRNC without IPH sensitivity, specificity, and AUC were 73.3% (95% CI = 44.9–92.2%), 85.7% (95% CI = 67.3–96.0%), and 0.84, respectively. For TRFC, sensitivity, specificity, and AUC were 35.3% (95% CI = 14.2–61.7%), 97.6% (95% CI = 87.4–99.9%), and 0.66 respectively. Interobserver agreement for IPH, LRNC, and TRFC using the Neurovascular Coil Protocol were k = 0.87 (95% CI = 0.75–0.99), k = 0.54 (95% CI = 0.29–0.80), and k = 0.41 (95% CI = 0.08–0.74), respectively.Data ConclusionOur Neurovascular Coil Protocol has high sensitivity, specificity, and accuracy in identifying IPH and LRNC but is limited in assessment of TRFC.Level of Evidence: 1Technical Efficacy: Stage 2J. Magn. Reson. Imaging 2018;47:1264–1272.

Background. There is little published literature regarding the impact of age on outcomes amongst hospitalized HHT (hereditary hemorrhagic telangiectasia) patients. Methods. The Nationwide Inpatient Sample (NIS) was used to obtain data on all hospital discharges occurring in HHT patients from 2000 to 2012. The association between admission age and HHT-related complications and outcomes were studied. Results. 10293 hospitalizations in HHT patients from 2000 to 2012 were included. Patients > 50 accounted for 77% of all admissions with 30% of admissions occurring in the 51–65 age group. Bleeding related complications were the most frequent (62.7%, n=6455 hospitalizations), followed by cardiovascular (41%, n=4216), neurological (12.4%, n=1276), and hepatobiliary (6.4%, n=660) complications. Patients older than 50 accounted for 83% of bleeding events, 90% of cardiovascular events, 58% of neurologic events, and 81% of hepatobiliary events. The vast majority (83%) of medical and surgical procedures were performed in those older than 50 years of age. Older patients also experienced higher rates of death. Conclusion. Aging has significant adverse impacts on rates of hospitalization, complications, and outcomes amongst HHT patients in the United States. Except for neurologic complications, the vast majority of this disease burden is borne by patients older than 50 years.

Background and purpose Spinal arterial aneurysms are a rare cause of spinal subarachnoid hemorrhage (SAH). We performed a retrospective review of spinal arterial aneurysms not associated with spinal arteriovenus shunts from three institutions in order to better understand the clinical and imaging characteristics of these lesions. Materials and methods We performed a retrospective review of spinal arterial aneurysms managed at three North American institutions. For each patient, the following information was collected: demographic data, clinical presentation, comorbidities, imaging findings, and neurological status at the last follow-up. Treatment strategies and outcomes were reported. Results 11 patients were included; 7 were women and median age was 60 years. The most common presentation was sudden back pain (81.8%). We found 3 aneurysms on the radiculomedullary artery and 8 along the radiculopial arteries. Of the 3 aneurysms on the radiculomedullary artery, 1 was treated conservatively, 1 was treated with coiling of the aneurysm and sacrifice of the radiculomedullary artery, and 1 was treated with surgical trapping. The 8 aneurysms on the radiculopial artery were treated endovascularly in 4 cases, surgically in 1 case, and conservatively in 3 cases. One surgically treated patient had a spinal subdural hematoma. There were no other complications. Mean clinical follow-up time was 20 months, and 87.5% of patients were functionally independent. Conclusions Spinal arterial aneurysms are lesions which commonly present with sudden back pain and spinal SAH. Conservative, surgical, and endovascular treatment options are safe and effective. Long term outcomes in these patients are generally good.