Diffusion-Weighted MR Imaging Findings of Cortical Vein Thrombosis at 3 T.

PURPOSE: Diagnosis of cortical vein thrombosis (CVT) on the basis of clot hyperintensity on diffusion-weighted imaging (DWI) has been reported as limited. Our aim was to evaluate different DWI findings of CVT either in isolated form or in combination with sinus thrombosis. METHODS: In this review-board-approved study, patients with the diagnosis of CVT on magnetic resonance venography (MRV) between 2004 and 2011 were evaluated, and 13 patients with 26 CVT (3 isolated and 23 combined CVT) sites were recruited. The evaluated DWI findings were as follows: (1) the hyperintense clot signal (CS) itself, and (2) clot susceptibility signal (CSS) that appears next to the CVT. Two blinded radiologists evaluated the data. Kappa (κ) statistics was applied for interobserver agreement. RESULTS: Both readers reported CS within the vascular clot itself in 6 of 26 (23%) CVT sites on DWI. CSS was reported in 16 of 26 (61.5%) CVT sites by reader 1, and in 14 of 26 (54%) of the CVT sites by reader 2. At four CVT sites with thrombosed veins on MRV, both readers reported no DWI findings. When both CS and CSS were evaluated together, reader 1 reported a positive DWI finding in 22 of 26 (84%) of the CVT sites, and reader 2 reported in 20 of 26 (79%) of the sites. κ Statistics showed a very good agreement (κ: 0.87). CONCLUSIONS: Besides the hyperintense CS, with additional evaluation of the presence of CSS, DWI can provide an additional clue in CVT patients and may suggest its diagnosis, which is important in clinically unsuspected patients.

Acute ischemic infarction defined by a region of multiple hypointense vessels on gradient-echo T2* MR imaging at 3T.

BACKGROUND AND PURPOSE: During the hyperacute phase of stroke, multiple hypointense vessels were identified specifically in the ischemic territory on gradient-echo T2*-weighted MR images (GRE-T2* WI) at 3T. The area was named a "region of multiple hypointense vessels (RMHV)." The aim of this study was to assess the usefulness of RMHV for the diagnosis of acute ischemic stroke (AIS) and to establish the relationship of this finding to other MR imaging studies. MATERIALS AND METHODS: Twenty patients with AIS underwent MR imaging at 3T consisting of GRE-T2*, diffusion-weighted images (DWI), and perfusion-weighted images (PWI) within 6 hours of symptom onset and follow-up images at 72 hours. RMHV was defined as an area containing multiple hypointense vessels strictly in the region of the ischemic territory on GRE-T2*. The RMHV volume on GRE-T2*, initial ischemic lesion volumes on DWI, PWI maps, and on follow-up images were measured and compared with the RMHV volume. RESULTS: RMHV on GRE-T2* was identified in 20 patients. There was no significant difference between the ischemic lesion volumes on mean transit time (247.3 +/- 88.1 mL), time-to-peak (228.6 +/- 88.8 mL), cerebral blood flow (200.6 +/- 89.7 mL), RMHV on GRE-T2* (214.4 +/- 86 mL), and the infarct volume at 72 hours (210.3 +/- 90.4 mL) (P = .975). CONCLUSIONS: RMHV on GRE-T2* can be used as a supportive imaging finding for the diagnosis of hyperacute ischemic stroke. RMHV volume provides information that is in accordance with the infarct volume at 72 hours and the data supplied by PWI.

Intraarterial Thrombolysis with r-tPA for Treatment of Anterior Circulation Acute Ischemic Stroke. Technical and Clinical Results.

SUMMARY: To investigate factors effecting the safety and recanalization efficacy of local intraarterial (IA) recombinant tissue plasminogen activator (r-tPA) delivery in patients with acute ischemic stroke. Eleven patients with anterior circulation acute ischemic stroke were treated. The neurological status of the patients were graded with the Glasgow Coma Scale (GCS) and National Institute of Health Stroke Scale (NIHSS). All patients underwent a computed tomography (CT) examination at admission. In addition four patients had diffusion-weighted and one patient had a perfusion magnetic resonance (MR) examinations. Patients were treated within six hours from stroke onset. Immediate, six hours, and 24 hours follow-up CT examinations were performed in order to evaluate the haemorrhagic complications and the extent of the ischemic area. The Rankin Scale (RS) was used as an outcome measure. Two of the 11 patients had carotid "T" occlusion (CTO), nine had middle cerebral artery (MCA) main trunk occlusion. Four patients had symptomatic haemorrhage with a large haematoma rupturing into the ventricles and subarachnoid space. Of these, three patients died within 24 hours. The remaining seven patients had asymptomatic haematomas that were smaller compared to symptomatic ones, and showed regression in size and density on follow-up CTs. At third month five patients had a good outcome and three patients had a poor outcome. In acute ischemic stroke, local IA thrombolysis is a feasible treatment when you select the right patient. Haemorrhage rate does not seem to exceed that occuring in the natural history of the disease and in other treatment modalities.

MR imaging, CT, and angiography features of endolymphatic sac tumors: report of two cases.

Low-grade adenocarcinoma of endolymphatic sac origin is a rare tumor of the temporal bone. There are some difficulties in its differential diagnosis from other vascular and non-vascular tumors of the temporal bone. However its radiological differentiation from other tumors of the temporal bone is important for surgical planning. We present a report on two endolymphatic sac tumors with some specific radiological findings which can support a correct diagnosis.

Determining optimal MRI follow-up after transsphenoidal surgery for pituitary adenoma: scan at 24 hours postsurgery provides reliable information.

There is no agreed-upon schedule for MRI follow-up after pituitary adenoma removal via the transsphenoidal approach. Our aim was to establish a plan for MRI follow-up after pituitary surgery. Eighty pituitary adenoma cases (25 microadenomas, 30 macroadenomas that did not infiltrate the cavernous sinus, and 25 macroadenomas with cavernous sinus infiltration) were prospectively studied with MRI following tumor resection via the transsphenoidal approach. Each patient was imaged at 24 hours, at 3, 6 and 9 months, and at 1 year or more postsurgery. The parameters studied were residual tumor, synthetic packing material (Gelfoam) versus fat graft, and normal pituitary, hypophyseal stalk and optic chiasma. The size of the pituitary structure as a whole was also measured. The latter was studied quantitatively, and the findings for the rest of the parameters were evaluated qualitatively, based on the examiners' confidence in their assessment. The final MRI study, done at least 1 year postsurgery in all cases, was considered the reference MRI for all scans. MRI performed 24 hours after surgery was diagnostically accurate for residual tumor and valuable for visualizing normal sellar structures. The findings also showed that fat packing takes longer to resorb than Gelfoam, but produces no potentially confounding contrast enhancement. An algorithm based on the results is presented for postsurgical MRI assessment of pituitary adenoma patients in which the scan at 24 hours postsurgery is the major factor that determines the timing of later rechecks.

Cervical neural foraminal widening caused by the tortuous vertebral artery.

A case of cervical neural foraminal widening due to tortuous vertebral artery is presented. This entity is rarely seen. Plain radiography, CT, 3-D CT angiography, MRI, and MRA findings of the case are presented and the importance of this vascular anomaly in the differential diagnosis of neural foraminal widening is discussed.

A rare cause of hyperprolactinemia: persistent trigeminal artery with stalk-section effect.

The primitive trigeminal, otic, hypoglossal, and proatlantal intersegmental arteries are fetal anastomoses between the carotid and vertebrobasilar systems. Persistent trigeminal artery (PTA) is the most frequent embryonic communication between the vertebrobasilar and carotid systems in adults. We report a case of PTA compressing the left side of the pituitary gland and stalk, in a patient with elevated blood prolactin level.

Middle cerebral artery duplication associated with multiple intracranial aneurysms. Case report.

We present a case of middle cerebral artery (MCA) duplication associated with ipsilateral distal MCA and contralateral MCA bifurcation aneurysms.

Value of transcranial Doppler ultrasonography in the diagnosis and follow-up of carotid-cavernous fistulae.

The introduction of transcranial Doppler ultrasonography (TCD) has made it possible to examine blood flow characteristics in carotid-cavernous sinus fistulae (CCSF) in a noninvasive, relatively simple, and reliable way. This study investigated the usefulness of TCD in the diagnosis and follow-up of various CCSF subtypes. We found characteristic TCD findings associated with high-flow CCSF, but perhaps more importantly, found this technique to be an excellent tool also for detecting and following treatment results in low-flow CCSF. The low-flow fistulae exhibit less specific clinical signs and are harder to distinguish using the noninvasive radiological methods of computed tomography (CT) and magnetic resonance imaging (MRI). The impact of our findings on future approaches to the diagnosis and follow-up of these different types of acquired vascular shunts is also discussed. The conclusions were as follows: a) TCD parameters (blood flow velocity and pulsatility index) for CCSF are specific, and are thus valuable in the hemodynamic assessment of these lesions. b) Since dural CCSF feature more subtle hemodynamic changes and CT and MRI findings may be normal, these cases pose diagnostic challenges. In these situations, TCD reveals specific diagnostic findings and allows the examiner to determine whether cerebral angiography is indicated.

Magnetic resonance imaging characteristics of benign macrocephaly in children.

Benign macrocephaly of infancy is a common problem in the child neurology practice. The radiologic features of this entity are not well defined. In most of the previous studies, macrocephalic patients were evaluated by computed tomography. To define the radiologic characteristics of this entity, 20 children with macrocephaly with normal neurologic examinations were enrolled in the study. All the patients were evaluated by magnetic resonance imaging studies. Sixty-five percent of patients had enlargement of the subarachnoid space and 35% of patients had megalencephaly. None of the patients had subdural collections. The mean age of patients with enlargement of the subarachnoid space was found to be younger than those with megalencephaly. The cases with parental histories of macrocephaly demonstrated both enlargement of the subarachnoid space and megalencephaly. Our results suggest that the radiologic finding of benign macrocephaly can be both enlargement of the subarachnoid space and megalencephaly.

Sagittal sinus thrombosis associated with thrombocytopenia: a report of two patients.

Reported are two patients presenting with both thrombocytopenia and sagittal sinus thrombosis. The first patient is a 42-month-old male with no identified thrombophilic risk factors who developed acute neurologic symptoms after an acute infection. The second patient is a 22-month-old female with no history of preceding infection but had a positive lupus anticoagulant test. She also developed deep venous thrombosis and was treated with intravenous heparin. Both patients are currently doing well without neurologic deficits. To the authors' knowledge the second patient is the youngest reported patient with cerebral vein thrombosis associated with thrombocytopenia and lupus anticoagulant. These observations call attention to the need for a thorough investigation of thrombophilic risk factors in pediatric patients with thrombotic complications.

Evaluation of parietal pleural invasion of lung cancers with breathhold inspiration and expiration MRI.

The goal of this study was to investigate the feasibility of detecting invasion of the parietal pleura by lung cancer with inspiratory-expiratory magnetic resonance imaging (MRI). Twenty-three patients with lung cancer in contact with pleura were studied with multisectional MRI during deep inspiration and expiration on the axial and coronal planes. Changes in the tumor's relation relative to the chest wall markers, vertebral bodies, or mediastinal structures were noted. Surgical correlation was available for each case. Twelve tumors were located at the right middle and lower lobes. Five patients who had a significant change in the position of the tumor were found not to have pleural invasion at surgery. The remaining seven tumors without change in their position with respiration were surgically found to invade the parietal pleura. Only 1 of the 11 upper lobe and apical segments of the lower lobe-located tumors showed a change in its position, which had no parietal pleural invasion at surgery. The remaining 10 tumors did not show any movement. Four of them had parietal pleural invasion that were surgically proven, and six tumors had no parietal pleural invasion at surgery. In conclusion, MRI performed during deep inspiration and expiration is a complementary method in detecting parietal pleural invasion for the tumors located in the lower and middle lobes.

Grading and hemodynamic follow-up study of arteriovenous malformations with transcranial Doppler ultrasonography.

This study presents and tests the clinical validity of a hemodynamic grading system that depends on noninvasive transcranial Doppler ultrasonographic parameters. The suggested transcranial Doppler-based grading system was compared with the Spetzler-Martin anatomic grading for prognosticative validity and clinical dependability. We concluded the following: (1) The pulsatility index was shown to be a more dependable transcranial Doppler parameter in the clinical evaluation of an arteriovenous malformation because of two reasons: preoperative pulsatility index findings inversely correlated with arteriovenous malformation volume, and the pulsatility index returned to normal values before the mean blood flow velocity did. Therefore, hemodynamic arteriovenous malformation grading can be based on the pulsatility index. (2) A transcranial Doppler-based hemodynamic arteriovenous malformation grading system correlated highly with the Spetzler-Martin grading in predicting postoperative neurologic deficits and adverse radiologic findings. (3) The presented grading system may contribute to the standardization and quantification of the hemodynamic changes during multidisciplinary management of arteriovenous malformations.

Cervical spondylotic myelopathy: surgical results and factors affecting prognosis.

OBJECTIVE: A variety of factors may affect surgical outcome in patients with cervical spondylotic myelopathy. The aim of this study is to determine these factors on the basis of preoperative radiological and clinical data. METHODS: To assess the factors affecting postoperative outcome after surgery for cervical spondylotic myelopathy, the clinical and radiological data of 27 patients with cervical spondylotic myelopathy were reviewed. Functional and neurological statuses were assessed using the Japanese Orthopaedic Association (JOA) scale modified by Benzel. In all patients, the effect of age, symptom duration, cervical curvature, presence or absence of preoperative high signal intensity within the spinal cord as revealed by T2-weighted magnetic resonance imaging, and diameters of the spinal canal and vertebral body on pre- and postoperative neurological statuses were investigated. Plain radiographs were obtained for all patients, magnetic resonance images for 21 patients (77.8%), computed tomographic scans for 13 patients (48.1%), myelograms for 6 patients (22.2%), and computed tomographic myelograms for 4 patients (14.8%). There were five patients with a JOA score of 10, six patients with a JOA score of 11, six patients with a JOA score of 12, four patients with a JOA score of 13, four patients with a JOA score of 14, one patient with a JOA score of 15, and one patient with a JOA score of 16. All patients underwent cervical laminectomies. The mean follow-up period was 54.1 months. The final neurological examinations revealed improvement in the JOA scores of 85.1 % of the patients. RESULTS: Statistical analysis of all patients revealed mean JOA scores of 12.185 +/- 1.618 and 14.370 +/- 2.15 before surgery and at final examination, respectively. The difference between the preoperative JOA score and the final JOA score was determined to be statistically significant (P < 0.0001). Statistical analyses also showed better neurological improvement in patients younger than 60 years and in patients with normal preoperative cervical lordosis. Although patients without preoperative high signal intensity of the spinal cord showed a better improvement rate than did patients with preoperative high signal intensity, the determined difference was statistically insignificant. CONCLUSION: It can be concluded that age and abnormal cervical curvature predict less postoperative neurological improvement. The presence of preoperative high signal intensity within the spinal cord may also reflect less neurological improvement.

A new, more dependable methodology for the use of transcranial Doppler ultrasonography in the management of subarachnoid haemorrhage.

The role of transcranial Doppler ultrasound (TCD) in clinical decision making about vasospasm due to subarachnoid haemorrhage (SAH), shows a great variation according to neurosurgical clinics. In this prospective study, a total of 143 patients, admitted to Marmara University Department of Neurosurgery between January 1991 to March 1995 and treated surgically with the diagnosis of aneurysmal SAH, were examined by TCD. Eighty of these patients fulfilled the requirements for inclusion. In order to increase clinical dependability of TCD, a new grading system is proposed and tested in comparison with the one previously used, which takes absolute flow velocities as the main parameter in grading. The new, individually based TCD grading system is proposed to minimize the pitfalls caused by proximal stenosis, wide range of normal Vm values and proximally evolving vasospasm. We concluded that: 1) The new, individually based TCD grading system has a high degree of clinical dependability. 2) Daily TCD examinations supply reliable predictive information about developing delayed ischaemic deficit (DID). If a TCD Gr II patient shows an increase of 35 cm/sec (in 24 hours) in Vm value, his probability of developing DID was found to be 60% (p < 0.05); if a TCD Gr B III patient shows the same rate of increase in Vm, his probability of developing DID was 80% (< 0.05). 3) TCD has an important clinical role in decision making about the management of SAH patients. 4) Surgical manipulation causes a reversible increase of one or two TCD-grades in the early postoperative days.

Multiple pineal cysts associated with an ependymal cyst presenting with infantile spasm.

We present a unique case of infantile spasm in a patient with multiple pineal cysts associated with an ependymal cyst. Such a morphological etiology, to our knowledge, has not been described for patients with infantile spasm. Although postoperative neuroradiological studies demonstrated satisfactory surgical results, the patient continued to have seizures.

Intradural rupture of cervical vertebral disc.

STUDY DESIGN: The authors discuss their experience with a patient who had cervical intradural disc herniation and relate the case to the relevant literature. OBJECTIVES: The patient was evaluated with direct radiographies, myelography, electromyography, and computerized tomography, as well as with neurologic examination. The follow-up period was 10 months post-operative. SUMMARY OF BACKGROUND DATA: Intradural disc herniation is a rare pathology nearly always confined to the lumbar region. In 1989, Katooka et al reviewed the existing literature and discovered 70 cases. Cervical intradural disc herniation, on the other hand, is much rarer, and there are only five cases in the literature. METHODS: The patient's neurologic, neuroradiologic, and operative findings were evaluated and compared with the cases reported in the literature. CONCLUSIONS: The five patients in the literature had signs of cord compression, but the present patient is the first with root compression.

Magnetic resonance imaging in the diagnosis of spinal hydatid cyst disease. Case report.

A very rare case of multiple spinal hydatid disease causing paraplegia is presented. The neuroradiological evaluation included an MRI study. The surgical approach and the medical treatment of the disease is discussed, with a review of the literature.

Subependymal giant cell astrocytomas in tuberous sclerosis.

Two cases of tuberous sclerosis with subependymal giant cell astrocytoma are presented. This rare autosomal dominant disorder was also detected in family members of the patients who had never had any symptoms of cerebral involvement. Both patients underwent surgery because of signs of increased intracranial pressure.

Pleomorphic xanthoastrocytoma associated with von Recklinghausen neurofibromatosis.

The authors present a case of pleomorphic xanthoastrocytoma that occurred in a 14-year-old boy with von Recklinghausen's neurofibromatosis. The circumscribed tumor with a cystic component was located in the medial right temporal lobe. The designation of pleomorphic xanthoastrocytoma has been suggested for this neoplasm on the basis of its unique histological features. These include positive glial fibrillary acidic protein staining.