We aimed to compare flat detector computed tomography cerebral blood volume (FD-CBV) imaging to single-photon emission computed tomography (SPECT) as an adjunctive technique during balloon test ...occlusion (BTO) in patients with intracranial aneurysms or tumors.
Twelve patients who underwent SPECT (99mTc-ethyl cysteinate dimer) and FD-CBV imaging during BTO were enrolled. Color-coded cerebral blood flow (CBF) images and color-coded FD-CBV images were generated and visually inspected whether there were asymmetries between the ipsilateral and contralateral cerebral hemispheres. Region of interest measurements were performed on the color-coded images at the same locations for both modalities. The mean interhemispheric region of interest ratios were calculated, and the ratio between these were estimated using linear regression models.
Ten patients had no symptoms during BTO. Two patients developed subtle but inconclusive neurologic changes approximately 10 minutes after balloon inflation; their images showed asymmetric color-coded images with decreased CBF and FD-CBV in the ipsilateral hemisphere. The mean interhemispheric ratio of CBF was significantly smaller in patients with subtle changes than in those without (0.84 vs. 0.98; P < 0.001). Similarly, the mean interhemispheric ratio of FD-CBV was significantly smaller in patients with subtle changes than in those without (0.88 vs. 1.06; P = 0.01). No patient showed increased CBF or FD-CBV in the ipsilateral hemisphere.
The patients with decreased CBF on SPECT also showed decreased FD-CBV in the ipsilateral hemisphere. FD-CBV imaging may be useful as an adjunctive technique for BTO before potential therapeutic carotid artery occlusion.
Object A modified World Federation of Neurosurgical Societies scale (m-WFNS scale) for aneurysmal subarachnoid hemorrhage (SAH) recently has been proposed, in which patients with Glasgow Coma Scale ...(GCS) scores of 14 are assigned to grade II and those with GCS scores of 13 are assigned to grade III regardless of the presence of neurologic deficits. The study objective was to evaluate outcome predictability of the m-WFNS scale in a large cohort. Methods This was a multicenter prospective observational study conducted in Japan. A total of 1656 patients with SAH were registered during the 2.5-year study period, and the outcome predictability, using the Glasgow Outcome Scale (GOS) and modified Rankin Scale (mRS) scores at discharge and at 90 days after onset, was evaluated by comparing the m-WFNS with the original WFNS scale. We focused on whether significant differences in these scores were present between the neighboring grades. Results In the m-WFNS scale, significant difference between any neighboring grades was observed both in the mean GOS and mRS scores at 90 days except between grades III/IV. However, differences were not significant between grades II/III and between grades III/IV in the original WFNS scale. Conclusions SAH-induced brain injury may be substantially severer in patients with GCS 13 than those with GCS 14, which may explain why grade III patients faired significantly worse than grade II patients by the modified WFNS scale. Although further validation is necessary, the m-WFNS scale has a potential of providing neurosurgeons with simpler and more reliable prognostication of patients with SAH.
Coil compaction is directly related to the degree of cerebral aneurysmal recanalization. The degree of recanalization (DoR) was quantified by measuring the volume vacated by coil deformation. The ...purpose of this study was to clarify the hemodynamic and morphologic factors associated with coil compaction.
Computational fluid dynamics simulations were performed on 28 middle-size (5–10 mm) unruptured basilar artery tip aneurysms. The DoR was measured by comparing the coil mass shape obtained from three-dimensional digital subtraction angiography data immediately after coil embolization and again within 1–2 years of follow-up. Deployed coils were modeled using a virtual coiling technique for computational fluid dynamics simulations. Hemodynamic and morphologic factors to predict the DoR were derived using multiple linear regression.
Aneurysmal neck area, the maximum pressure generated on the neck surface after coil embolization, and the high-pressure position on the neck surface predicted DoR with statistic significance (P < 0.001, P < 0.001, P = 0.004, respectively). The DoR tended to increase when the neck area was large, the pressure generated on the coils was high, and the high-pressure position was close to the center of the neck surface. The volume embolization ratio was not statistically relevant for the DoR in the cases of this study.
Coil compaction occurs in cerebral aneurysms with a wide neck, high pressure generated on the coils, and high pressure in the center of the neck surface. Establishing the DoR can contribute to the prediction of recanalization after coil embolization.
A 40-year-old man presented with a severe headache, lower back pain, and lower abdominal pain 1 month after a head injury caused by falling. Computed tomography (CT) of the head demonstrated ...bilateral chronic subdural hematoma (CSDH) with a significant amount in the left frontoparietal region. At the same time, magnetic resonance imaging (MRI) of the lumbar spine also revealed CSDH from L2 to S1 level. A simple drainage for the intracranial CSDH on the left side was performed. Postoperatively, the headache was improved; however, the lower back and abdominal pain persisted. Aspiration of the liquefied spinal subdural hematoma was performed by a lumbar puncture under fluoroscopic guidance. The clinical symptoms were dramatically improved postoperatively. Concomitant intracranial and spinal CSDH is considerably rare so only 23 cases including the present case have been reported in the literature so far. The etiology and therapeutic strategy were discussed with a review of the literature. Therapeutic strategy is not established for these two concomitant lesions. Conservative follow-up was chosen for 14 cases, resulting in a favorable clinical outcome. Although surgical evacuation of lumbosacral CSDH was performed in seven cases, an alteration of cerebrospinal fluid (CSF) pressure following spinal surgery should be reminded because of the intracranial lesion. Since CSDH is well liquefied in both intracranial and spinal lesion, a less invasive approach is recommended not only for an intracranial lesion but also for spinal lesion. Fluoroscopic-guided lumbar puncture for lumbosacral CSDH following burr hole surgery for intracranial CSDH could be a recommended strategy.
Purpose
The transradial approach (TRA) in neuroendovascular treatment is known to have a lower risk of complications than the transfemoral approach (TFA). However, little research has focused on ...assessments of efficacy and risk of complications in the treatment of intracranial aneurysms. This study aimed to compare the efficacy and complications of TRA and TFA in coil embolization of unruptured intracranial aneurysms (UIAs) at our institution.
Methods
Consecutive patients who underwent endovascular surgery via TRA or TFA at a single institution from 1 April 2019, to 28 February 2022, were retrospectively analyzed. Patients were classified into TRA and TFA groups and assessed using propensity-adjusted analysis for outcomes including fluoroscopy time, volume embolization ratio (VER), and complications.
Results
A total of 163 consecutive UIAs were treated with coil embolization during the 35-months study period. The incidence of minor access site complications (ASCs) was significantly higher with TFA (20%, 25/126) than with TRA (2.7%, 1/37; p = 0.01). Propensity-adjusted analysis (matched for age, sex, aneurysm volume, embolization technique, and sheath size) revealed that TRA was associated with a lower risk of minor ASCs (odds ratio, 0.085; 95% confidence interval 0.0094–0.78; p = 0.029). However, TRA did not differ significantly from TFA with respect to fluoroscopy time, VER, major ASCs, and non-ASCs.
Conclusions
Coil embolization for UIAs via TRA can reduce risk of minor ASCs without increasing the risk of non-ASCs compared with conventional TFA, and can achieve comparable results in term of efficacy and fluoroscopy time.
Magnetic resonance image (MRI) is now widely used for imaging follow-up for post coiling brain aneurysms. However, the accuracy on the estimation of residual aneurysm, which is crucial for the ...retreatment planning, remains to be controversial. The purpose of this study is to evaluate a new post-processing technique that provides improved estimation of the residual aneurysm after coil embolization. One hundred aneurysms on 93 patients who underwent coil embolization for brain aneurysm were evaluated using the 1.5 Tesla time-resolved magnetic resonance angiography (TR-MRA) one year after the treatment. To minimize the inter-observer variability caused by the window level adjustment, an automatic post processing protocol using the full-width at half-maximum (FWHM) value was utilized. The result was then compared with that from the conventional cerebral angiography. Of the 97 aneurysms that underwent both TR-MRA and DSA, 23 (23.7%) showed residual neck / dome during follow-up. After window level adjustment, the size of the parent artery in the TR-MRA was consistent with that in the DSA. The reconstructed Volume Rendering images provided clear contours of the residual aneurysms and contributed to the understanding the configuration of residual aneurysm. The largest and the smallest diameter of the residual aneurysms was larger in the TR-MRA than in the DSA (8.05 vs. 7.72 mm, p = 0.0004; 4.99 vs. 4.19 mm, p = 0.007 respectively). The sensitivity, specificity, and positive and negative predictive values of TR-MRA compared to DSA were 100%, 97%, 73%, and 100%, respectively. Using the FWHM value to optimize the window level adjustment, the size of the residual component observed in the TR-MRA was larger compared to that in the DSA whereas the size of neck and the parent artery showed consistency between the two modalities. This image processing technique can be used as an effective screening tool for evaluating residual component in post-coiling brain aneurysms.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Background
Previously, we reported that bevacizumab (Bev) produces histological and neuroradiographic alterations including changes in tumor oxygenation, induction of an immunosupportive tumor ...microenvironment, and inhibition of stemness. To confirm how those effects vary during Bev therapy, paired samples from the same patients with newly diagnosed glioblastoma (GBM) who received preoperative neoadjuvant Bev (neoBev) were investigated with immunohistochemistry before and after recurrence.
Methods
Eighteen samples from nine patients with newly diagnosed GBM who received preoperative neoBev followed by surgery and chemoradiotherapy and then autopsy or salvage surgery after recurrence were investigated. The expression of carbonic anhydrase 9 (CA9), hypoxia-inducible factor-1 alpha (HIF-1α), nestin, and Forkhead box M1 (FOXM1) was evaluated with immunohistochemistry.
For comparison between neoBev and recurrent tumors, we divided the present cohort into two groups based on neuroradiographic response: good and poor responders (GR and PR, respectively) to Bev were defined by the tumor regression rate on T1-weighted images with gadolinium enhancement (T1Gd) and fluid-attenuated inversion recovery images. Patterns of recurrence after Bev therapy were classified as cT1 flare-up and T2-diffuse/T2-circumscribed. Furthermore, we explored the possibility of utilizing FOXM1 as a biomarker of survival in this cohort.
Results
A characteristic “pseudo-papillary”-like structure containing round-shaped tumor cells clustered adjacent to blood vessels surrounded by spindle-shaped tumor cells was seen only in recurrent tumors. Tumor cells at the outer part of the “pseudo-papillary” structure were CA9-positive (CA9+)/HIF-1α+, whereas cells at the inner part of this structure were CA9−/HIF-1α+ and nestin+/FOXM1+. CA9 and HIF-1α expression was lower in T1Gd-GR and decreased in the “T2-circumscribed/T2-diffuse” pattern compared with the “T1 flare-up” pattern, suggesting that tumor oxygenation was frequently observed in T1Gd-GR in initial tumors and in the “T2-circumscribed/T2-diffuse” pattern in recurrent tumors. FOXM1 low-expression tumors tended to have a better prognosis than that of FOXM1 high-expression tumors.
Conclusion
A “pseudo-papillary” structure was seen in recurrent GBM after anti-vascular endothelial growth factor therapy. Bev may contribute to tumor oxygenation, leading to inhibition of stemness and correlation with a neuroimaging response during Bev therapy. FOXM1 may play a role as a biomarker of survival during Bev therapy.
To date, no clinical observations have been reported for histopathological changes in human gliomas under antiangiogenic treatment.We collected six glioblastomas resected under bevacizumab treatment. ...Histopathological investigation was performed by hematoxilyn-eosin staining and immunohistochemistry for CD34, VEGF, VEGFR1/2, HIF-1α, CA9, and nestin as compared to eleven control glioblastomas to assess the differences in histological features, microvessel density, expression of VEGF and its receptors, tumor oxygenation, and status of glioma stem-like cells.In the six tumors resected under bevacizumab, microvascular proliferation was absent, and microvessel density had significantly decreased compared with that of the controls. The expressions of VEGF and its receptors were downregulated in two cases of partial response. HIF-1α or CA9 expression was decreased in five of the six tumors, whereas the decreased expression of these markers was noted in only one of the 11 control glioblastomas. The expression of nestin significantly decreased in the six tumors compared with that of the controls, with the remaining nestin-positive cells being relatively concentrated around vessels.We provide the first clinicopathological evidence that antiangiogenic therapy induces the apparent normalization of vascular structure, decrease of microvessel density, and improvement of tumor oxygenation in glioblastomas. These in situ observations will help to optimize therapy.
To investigate on three-dimensional (3D) fusion images the apposition of low-profile visualized intraluminal support (LVIS) stents in intracranial aneurysms after treatment and assess inter-rater ...reliability.
Records of all patients with unruptured intracranial aneurysms who were treated with the LVIS stent were retrospectively accessed and included in this study. Two neurosurgeons evaluated the presence of malapposition between the vessel walls and the stent trunk (crescent sign) and the vessel wall and the stent edges (edge malappostion) on 3D fusion images. These images were high-resolution cone-beam computed tomography images of the LVIS stent fused with 3D-digital subtraction angiography images of the vessels. Associations between malapposition and aneurysm location were assessed by Fisher's exact test, and inter-rater agreement was estimated using Cohen's kappa statistic.
Forty consecutive patients were included. In all patients, 3D fusion imaging successfully visualized the tantalum helical strands and the closed-cell structure of the nitinol material of the low-profile visualized intraluminal support. A crescent sign was observed in 27.5 % and edge malapposition in 47.5 % of the patients. Malapposition was not significantly associated with location (p = 0.23 crescent sign, p = 0.07 edge malapposition). Almost perfect (κ = 0.88) and substantial (κ = 0.76) agreements between the two raters were found for the detection of crescent signs and edge appositions, respectively.
3D fusion imaging provided clear visualization of the LVIS stent and parent arteries, and could detect malapposition with excellent inter-rater reliability. This technique may provide valuable guidance for surgeons in determining postoperative management.
Background
It is important to distinguish foramen magnum arachnoiditis (FMA) from Chiari malformation (CM) before surgery because the operative strategies for these diseases differ. In the current ...study, we compared pretreatment magnetic resonance imaging (MRI) of FMA with CM and investigated the MRI findings useful to differentiate between these diseases.
Methods
We retrospectively reviewed patients with FMA or CM aged ≥ 18 years who underwent surgeries at our institution between 2007 and 2019. The morphologies of the syrinx, neural elements, and posterior cranial fossa were preoperatively evaluated with MRI. We used the receiver operating characteristic (ROC) curve for the fourth ventricle-to-syrinx distance (FVSD).
Results
Ten patients with FMAs and 179 with CMs were included. FVSD in the FMA group was significantly shorter than that in the CM group (7.5 mm IQR, 2.8–10 mm in FMA vs. 29.9 mm IQR, 16.3–52.9 mm in CM,
p
< 0.0001). The other MRI findings that showed the height, size, and length of the syrinx; size of the foramen magnum; degree of cerebellar tonsillar descent; shape of the cerebellar tonsil; and dorsal subarachnoid space at the foramen magnum differed significantly between the two groups. The ROC curve analysis showed that patients whose FVSD was less than 11 mm could be diagnosed with FMA with a specificity of 90% and sensitivity of 96%.
Conclusions
A more cranial syrinx development (FVSD < 11 mm) appears to be the characteristic MRI finding in FMA.
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