Posterior reversible encephalopathy syndrome (PRES) is a radioclinical entity associating nonspecific neurological symptoms (headache, seizures, impairment of alertness, visual disturbances…) ...occurring in evocative clinical condition (hypertension, eclampsia, immunosuppressor agents, systemic lupus erythematosus…). In the acute stage, the typical imaging finding is a vasogenic edema predominant in the subcortical parietal-occipital white matter.
The purpose of this pictorial review is to illustrate the different neuroimaging features of PRES and present key radiological elements to assert diagnosis. In this overview, we examine the following points: the distributions of vasogenic edema, hemorrhage, the varying patterns in diffusion and perfusion, the different types of enhancement encountered and the vascular modifications demonstrated by angiography. The cause of PRES is still unknown. Nevertheless, catheter angiography, MR angiography and MR perfusion features in PRES render further insight into its pathophysiology.
Follow-up imaging shows evidence of radiologic improvement in the very large majority of cases in 1 or 2weeks, sometimes in up to 1month. Recurrent PRES attacks are uncommon.
Atypical imaging presentation should not reject the diagnosis of PRES in a compatible clinical situation.
•MRI is an efficient tool for early diagnosis and follow-up in PRES.•Hemorrhage is a common complication.•Decrease in ADC values does not always correlate with nonreversibility of the lesions.•Perfusion MR imaging can demonstrate increased or decreased perfusion.•Multifocal cerebral vasoconstriction is commonly observed.
Embolization of the middle meningeal artery (MMA) has emerged as a potential treatment of chronic subdural hematomas (CSDHs).
To evaluate the impact on recurrence rate of postsurgical embolization of ...CSDH in patients with a higher than average risk of recurrence.
A monocentric retrospective study was performed on retrospectively collected data. From March 2018 to December 2019, embolization of the MMA was proposed as an adjunct postoperative treatment after burr-hole surgery in patients operated for a recurrent CSDH or a CSDH with an independent recurrence risk factor, including antiplatelet therapy, full anticoagulation therapy, coagulation disorder, hepatopathy, or chronic alcoholism. Patients who had undergone postoperative embolization were compared with a historic group of patients operated between March 2016 and March 2018, selected based on the same inclusion criteria.
During the study period, 89 patients (with 74 unilateral and 15 bilateral CSDHs) were included and underwent an embolization procedure, leading to 91 out of a total of 104 MMA being embolized (88%). These were compared with 174 patients (138 unilateral and 36 bilateral CSDH) in the historic control group. One major procedure-related adverse event was registered. Four of the 89 patients (4%) required surgery for a CSDH recurrence in the embolization group, significantly less than the 24 of 174 patients (14%) in the control group (OR=0.28, 95% CI 0.07 to 0.86, p=0.02).
Postsurgical embolization of the MMA may reduce the recurrence rate of CSDHs with a risk factor of recurrence.
SEE BURGESS DOI101093/BRAIN/AWW092 FOR A SCIENTIFIC COMMENTARY ON THIS ARTICLE : Analogical reasoning is at the core of the generalization and abstraction processes that enable concept formation and ...creativity. The impact of neurological diseases on analogical reasoning is poorly known, despite its importance in everyday life and in society. Neuroimaging studies of healthy subjects and the few studies that have been performed on patients have highlighted the importance of the prefrontal cortex in analogical reasoning. However, the critical cerebral bases for analogical reasoning deficits remain elusive. In the current study, we examined analogical reasoning abilities in 27 patients with focal damage in the frontal lobes and performed voxel-based lesion-behaviour mapping and tractography analyses to investigate the structures critical for analogical reasoning. The findings revealed that damage to the left rostrolateral prefrontal region (or some of its long-range connections) specifically impaired the ability to reason by analogies. A short version of the analogy task predicted the existence of a left rostrolateral prefrontal lesion with good accuracy. Experimental manipulations of the analogy tasks suggested that this region plays a role in relational matching or integration. The current lesion approach demonstrated that the left rostrolateral prefrontal region is a critical node in the analogy network. Our results also suggested that analogy tasks should be translated to clinical practice to refine the neuropsychological assessment of patients with frontal lobe lesions.
Purpose
Mechanical thrombectomy (MT) failure is associated with very poor prognosis. Permanent intracranial stenting (PIS) may be useful in such refractory occlusions. However, this strategy requires ...an aggressive antithrombotic regimen that may be harmful in extended strokes. The aim of this study was to compare clinical outcomes between patients with refractory acute large vessel occlusions (LVOs) treated by PIS versus patients for whom the procedure was stopped without recanalization.
Methods
We conducted a systematic review by searching for articles in PubMed, the Cochrane Library, and
ClinicalTrials.gov
from January 2015 to September 2019. Two reviewers independently selected studies comparing PIS after failed MT in addition to usual care versus usual care only. A comparative meta-analysis was performed using random-effects models to estimate odds ratios of favorable clinical outcome at 90 days, defined as a modified Rankin scale 0–2, mortality and symptomatic intracranial hemorrhage (SICH).
Results
Four comparative studies were included for a total of 352 patients: 149 in the PIS group versus 203 in the control group. PIS was associated with significantly higher rates of 90-day favorable clinical outcome (odds ratio OR, 2.87 95% confidence interval (95% CI), 1.77–4.66;
p
< 0.001;
I
2
, 0%) and lower mortality (OR, 0.39 0.16–0.93;
p
= 0.03;
I
2
, 43%), whereas SICH rates did not significantly differ (OR, 0.68 0.37–1.27;
p
= 0.23;
I
2
, 0%).
Conclusion
From observational study results, attempting PIS after failed MT seems to improve clinical outcomes without increasing the risk of intracranial bleeding. Randomized trials are needed to confirm these results.
Purpose
Thromboembolic events represent the most common procedure-related complication associated with neurointerventions. Cangrelor is a potent, intravenous (IV), P2Y12-receptor antagonist with a ...rapid onset and offset presented as an alternative antiplatelet agent. We aim to evaluate the safety and effectiveness of IV cangrelor in neurovascular intervention.
Methods
This is a retrospective analysis of data from four cerebrovascular interventional centers. We identified patients who underwent acute neurovascular intervention and received cangrelor as part of their optimum care. Patients were divided into 2 groups: ischemic and aneurysm. Periprocedural thromboembolic events, hemorrhagic complications, and outcomes were analyzed.
Results
Sixty-six patients were included, 42 allocated into the ischemic group (IG), and 24 into aneurysm group (AG). The IG periprocedural symptomatic complication rate was 9.5%, represented by 3 postoperative intracranial hemorrhages and 1 retroperitoneal hematoma. At discharge, 47.6% had a favorable outcome and the mortality rate was 2.4%, related to clinical deterioration of a large infarct. In the AG, 4.2% had a periprocedural complication during or after cangrelor infusion, represented by an intracranial hemorrhage in an initially ruptured aneurysm. Favorable clinical outcome was seen in 56.2% and 87.7% of ruptured and unruptured aneurysms, respectively, upon discharge.
Conclusions
Cangrelor may be a feasible alternative for patients requiring immediate intervention with the use of endoluminal devices. It allows the possibility for a secure transition to long-term ticagrelor and progression to surgery in the setting of unexpected complications.
Objectives
Preoperative embolization of hypervascular spinal metastases (HSM) is efficient to reduce perioperative bleeding. However, intra-arterial digital subtraction angiography (IA-DSA) must ...confirm the hypervascular nature and rule out spinal cord arterial feeders. This study aimed to evaluate the reliability and accuracy of time-resolved contrast-enhanced magnetic resonance angiography (TR-CE-MRA) in assessing HSM prior to embolization.
Methods
All consecutive patients referred for preoperative embolization of an HSM were prospectively included. TR-CE-MRA sequences and selective IA-DSA were performed prior to embolization. Two readers independently reviewed imaging data to grade tumor vascularity (using a 3-grade and a dichotomized “yes vs no” scale) and identify the arterial supply of the spinal cord. Interobserver and intermodality agreements were estimated using kappa statistics.
Results
Thirty patients included between 2016 and 2019 were assessed for 55 levels. Interobserver agreement was moderate (κ = 0.52; 95% CI 0.09–0.81) for TR-CE-MRA. Intermodality agreement between TR-CE-MRA and IA-DSA was good (κ = 0.74; 95% CI 0.37–1.00). TR-CE-MRA had a sensitivity of 97.9%, a specificity of 71.4%, a positive predictive value of 95.9%, a negative predictive value of 83.3%, and an overall accuracy of 94.6%, for differentiating hypervascular from non-hypervascular SM. The arterial supply of the spine was assessable in 2/30 (6.7%) cases with no interobserver agreement (κ < 0).
Conclusions
TR-CE-MRA can reliably differentiate hypervascular from non-hypervascular SM and thereby avoid futile IA-DSAs. However, TR-CE-MRA was not able to evaluate the vascular supply of the spinal cord at the target levels, thus limiting its scope as a pretherapeutic assessment tool.
Key Points
• TR-CE-MRA aids in distinguishing hypervascular from non-hypervascular spinal metastases.
• TR-CE-MRA could avoid one-quarter of patients referred for HSM embolization to undergo futile conventional angiography.
• TR-CE-MRA’s spatial resolution is insufficient to replace IA-DSA in the pretherapeutic assessment of the spinal cord vascular anatomy.
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