Although intracranial aneurysms are rare in the paediatric population, the proportion of those involving posterior circulation is higher than that of adults (approximately 25% vs. 8%, respectively). ...Moreover, posterior circulation aneurysms in kids tend to be larger in size, many of them being giant dissecting types, and treatment of them is often challenging. Treatment of giant dissecting aneurysms, especially involving the Basilar artery is difficult due to strategic location and haemodynamic factors. Use of reconstructive techniques viz. flow-diverters and braided stents is difficult in children because of the lack of standard protocol for use of antiplatelet therapy and the need for prolonged use of the same. Continuous growth of parent vessel is also suggested as a pitfall for the use of a flow diverter/ braided stent which has a fixed caliber. Carefully planned endovascular parent or feeder branch artery occlusion (FAO) is a time-tested method to achieve flow reversal or favourable flow modifications in an arterial segment harbouring dissecting aneurysm. Here, in this case report, we describe a case of a ruptured distal giant basilar artery dissecting aneurysm in a 10-year-old boy treated with flow diversion by FAO. The dominant left vertebral artery was occluded, thereby diverting flow from the right vertebral artery towards the left posterior inferior cerebellar artery and decreasing flow through the aneurysm. On 1-year follow-up, the patient was asymptomatic and on check angiography, there was complete involution of the aneurysm with increased flow through bilateral posterior communicating arteries to distal posterior circulation which proved our hypothesis correct.
Objective: Resection of large Vestibular Schwannomas (VSs) can be associated with postoperative facial nerve injury. Diffusion-based tractography has emerged as a powerful tool for three-dimensional ...imaging and reconstruction of white matter fibers; however, tractography of the cranial nerves has not been well studied. In this prospective study, we aim to predict the position of facial nerve in large VSs (>3 cm) using Diffusion Tensor Imaging (DTI) tractography and correlate it with the intraoperative finding of the position of facial nerve.
Materials and Methods: Twenty patients with a large VS (>3 cm) undergoing surgery were subjected to preoperative DTI to predict the position of the facial nerve in relation to the tumor. The surgeon was blinded to the results of the preoperative DTI tractography. A comparative analysis was then made during operation. The location of the facial nerve in relation to the tumor was recorded during surgery using facial nerve stimulator.
Results: Of the 20 patients who underwent DTI tractography, it was not possible to preoperatively identify facial nerve in one patient. In another patient, although DTI tractography predicted the position of facial nerve, it was not identified intraoperatively. In the remaining 18 patients, DTI tractography accurately predicted the facial nerve position. The predicted position was in synchronization with the intraoperative facial nerve position in 16 patients (89% concordance). It was discordant in two patients (11%), but this was not found to be statistically significant (P = −0.3679).
Conclusion: This study validates the reliability of facial nerve DTI-based fiber tracking for prediction of the facial nerve position in patients with large VSs. The reliable preoperative visualization of facial nerve location in relation to the VS will allow surgeons to plan tumor removal accordingly and may increase the safety of surgery.
Background:
Moyamoya disease (MMD) is a chronic progressive cerebrovascular occlusive disease affecting commonly the anterior circle of Willis. Matushima grade inadequately reflects the angiographic ...changes postrevascularization procedure.
Aims:
To analyze the clinical and angiographic outcome of revascularization procedures (direct ST-middle cerebral artery (MCA) anastomosis and indirect encephalo-duro-arterio-myo-synangiosis (EDAMS)) in MMD and validate a new angiographic scoring system.
Materials and Methods:
Retrospective study included symptomatic patients of MMD who underwent revascularization; both indirect and combined methods between January 2002 and April 2012. Follow-up angiography was done after at least 3 months. We devised a novel scoring system the "angiographic outcome score" (AOS) including reformation of distal MCA and anterior cerebral artery, regression of basal moyamoya vessels, leptomeningeal collaterals and overall perfusion. AOS was applied to the angiograms independently by a neuroradiologist and a neurosurgeon that were blinded toward its preoperative or postoperative status.
Results:
Totally 33 patients underwent 36 EDAMS and 4 combined procedures (EDAMS + ST-MCA bypass). The mean follow-up was 20 months. None had recurrent transient ischemic attack or fresh infarct. Postoperative AOS was significantly higher than preoperative AOS. The Spearman rho showed positive correlation between Matushima grade and postoperative AOS. Significant regression of basal moyamoya vessels and increase in number of loci of transdural collaterals was seen.
Conclusions:
EDAMS is a simple yet effective method of revascularization in both pediatric as well as adult age groups. AOS is a simple, precise and easily reproducible scoring system, which reflects the favorable angiographic changes after revascularization.
The automatic segmentation of blood vessels in fundus images can help analyze the condition of retinal vasculature, which is crucial for identifying various systemic diseases like hypertension, ...diabetes, etc. Despite the success of Deep Learning-based models in this segmentation task, most of them are heavily parametrized and thus have limited use in practical applications. This paper proposes IterMiUnet, a new lightweight convolution-based segmentation model that requires significantly fewer parameters and yet delivers performance similar to existing models. The model makes use of the excellent segmentation capabilities of Iternet architecture but overcomes its heavily parametrized nature by incorporating the encoder-decoder structure of MiUnet model within it. Thus, the new model reduces parameters without any compromise with the network's depth, which is necessary to learn abstract hierarchical concepts in deep models. This lightweight segmentation model speeds up training and inference time and is potentially helpful in the medical domain where data is scarce and, therefore, heavily parametrized models tend to overfit. The proposed model was evaluated on three publicly available datasets: DRIVE, STARE, and CHASE-DB1. Further cross-training and inter-rater variability evaluations have also been performed. The proposed model has a lot of potential to be utilized as a tool for the early diagnosis of many diseases.
Background:
Laminoplasty can result in the loss of cervical lordosis (LOCL) or the development of kyphosis after surgery. Here, we evaluated the clinical and radiological parameters involved in ...predicting the postoperative LOCL following laminoplasty in patients with cervical spondylotic myelopathy (CSM) and ossification of the posterior longitudinal ligament (OPLL).
Methods:
For 50 patients with CSM and 35 with OPLL undergoing laminoplasty, preoperative and 1-year postoperative X-rays were obtained to determine the incidence and risk factors contributing to postoperative LOCL. The patients were divided into two groups depending on whether the preoperative T1 slope was above or below the median preoperative T1S (26°); Group A – high T1 slope group (
n
= 40) and Group B – low T1 slope group (
n
= 45).
Results:
Following laminoplasty, Group A patients had significantly higher preoperative lordosis (C2-C7 Cobb’s angle) (
P
= 0.001) and significantly higher LOCL (
P
= 0.02) versus Group B patients with low T1 slopes. The preoperative T1 slope was also found to be significantly correlated with the preoperative C2-C7 Cobb’s angles (
R
= 0.619,
P
= 0.001), LOCL (
R
= 0.487,
P
= 0.001), and preoperative C2-C7 sagittal vertical axis (
R
= 0.480,
P
= 0.001). Utilizing multivariate analysis and a generalized linear model, the preoperative T1 slope significantly impacted the Oswestry disability index (ODI) index (
P
= 0.002) and frequency of LOCL (
P
= 0.001) following laminoplasty.
Conclusion:
The preoperative T1 slope is a significant predictor of the LOCL and change in ODI following laminoplasty for CSM/OPLL utilizing a cutoff value of 29.5°.
Arterial pseudoaneurysms of the neck are rarely reported in the pediatric population and no dedicated large series are available. Trauma and infection are the most common causes for these aneurysms, ...with congenital and collagen vascular disorders being the less common causes. These lesions can be life threatening, especially when they present with bleeding or airway compromise.
We searched our radiology information system for all cases of pediatric neck aneurysm presented between June 2015 and May 2018. These cases were analyzed for clinicoepidemiologic variables, clinical presentation, imaging findings, management, and follow-up.
Six children were included in the study (male/female ratio, 5:1), with a mean age of 7.8 years (range, 2.5–15 years). Four presented acutely with either bleeding or rapidly enlarging neck swelling, whereas 2 presented with slowly increasing pulsatile swelling. One had a traumatic cause, 2 had infections, and 1 had infective cervical lymphadenitis complicated by iatrogenic injury whereas no definite causative mechanisms could be accounted for in 2 patients. Two of the children were managed by trapping of the aneurysm and 2 only by proximal parent vessel occlusion. The other 2 children were treated with stent graft deployment across the aneurysm neck to reconstruct the parent vessel. All the patients were doing well during the follow-up period (mean, 14.8 months).
Endovascular means of treatment for pediatric neck aneurysms is relatively simple and safe. Although parent vessel sacrifice is the gold-standard management, vessel-preserving strategies can be tried in select cases with favorable anatomy.
Abstract
Isolated brain involvement is rarely reported as isolated metachronous metastasis from osteosarcoma. Herein, we report a case of fibular osteosarcoma in a young female who presented with ...solitary hemorrhagic metachronous cerebral metastasis after years of disease-free interval. Imaging showed a large mass lesion in the right posterior temporal lobe with internal areas of bleed not associated with calcification or ossification mimicking high-grade glioma. No other sites of distant metastases were found on the workup. Two-dimensional echocardiography was done to rule out any cardiac anomaly, including the shunt defect, but no abnormality was detected. She was operated for the cerebral lesion, and histopathology of the resected specimen showed osteosarcoma. The patient was started on chemotherapy and is doing well so far. This case presents a unique scenario of osteosarcoma with an isolated lesion in the brain without any other site of distant metastasis.
Moyamoya disease (MMD) is a rare cerebrovascular disease characterized by progressive stenosis of the supraclinoid internal carotid artery. As a result of chronically decreased brain perfusion, ...eloquent areas of the brain become hypoperfused, leading to cognitive changes in patients. Repeated infarcts and bleeds produce clinically apparent neurologic deficits.
1) To study the functional and neuropsychological outcome in MMD after revascularization surgery. 2) To find postrevascularization correlation between functional and neuropsychological improvement and radiologic improvement.
A single-center prospective and analytic study was carried out including 21 patients with MMD during the study period from March 2021 to December 2022. Patients were evaluated and compared before and after revascularization for functional, neuropsychological, and radiologic status.
Postoperative functional outcome in terms of modified Rankin Scale score showed improvement in 33.33% of cases (P = 0.0769). An overall improving trend was observed in different neuropsychological domains in both adult and pediatric age groups. However, the trend of neuropsychological improvement was better in adults compared with pediatric patients. Radiologic outcome in the form of the Angiographic Outcome Score (AOS) significantly improved after revascularization (P = 0.0001). There was a trend toward improvement in magnetic resonance imaging (MRI) perfusion in the middle cerebral artery and anterior cerebral artery territories, 4.7% (P = 0.075) and 9.33% (P = 0.058) respectively, compared with preoperative MRI perfusion.
After revascularization, significant improvement occurred in functional and neuropsychological status. This result was also shown radiologically as evidenced by improvement in MRI perfusion and cerebral angiography.
Laminoplasty causes destruction of the posterior musculoligamentous complex, which may result in cervical kyphosis, or more commonly loss of cervical lordosis (LOCL). In this study, we evaluated the ...role of various preoperative radiologic parameters in predicting not only the LOCL/kyphosis but also the functional outcomes in the form of change in Oswestry Disability Index (ODI) score following laminoplasty.
Patients were evaluated both clinically and radiologically with dynamic cervical spine radiograph, noncontrast-enhanced computed tomography, and magnetic resonance imaging of the cervical spine preoperatively as well as at 1 year follow-up.
One hundred twenty-one patients who underwent laminoplasty for cervical spondylotic myelopathy/ossified posterior longitudinal ligament from 2011 to 2018 at our center were included in final analysis. In multivariate analysis, preoperative Cobb angle (P = 0.001), T1 slope (TIS; P = 0.001), and dynamic extension reserve (P < 0.001) were found to have an independent effect on LOCL. The receiver operating characteristic curve using the regression model significantly predicted LOCL >10° with an area under the curve of 88.3% (P < 0.001). Similarly, preoperative T1S (P = 0.036) and SVA (P < 0.001) were found to be independent predictors of significant improvement in ODI after laminoplasty. The receiver operating characteristic curve using the regression model significantly predicted change in ODI with an area under the curve of 83.7% (P < 0.001). Based on these findings, classification and scoring systems with good accuracy have been proposed for prediction of LOCL and improvement in ODI.
We have found that the chances of significant LOCL is determined by an interplay of preoperative Cobb angle, T1S, and dynamic extension reserve.
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