Direct Aspiration versus Combined Technique for Distal Medium-Vessel Occlusions: Comparison on a Human Placenta Model.

BACKGROUND AND PURPOSE: Mechanical thrombectomy appears to be a promising option for distal medium-vessel occlusions, for which intravenous thrombolysis is effective but may be insufficient when used alone. This study aimed to determine the optimal technique for these distal mechanical thrombectomies using the human placenta model. MATERIALS AND METHODS: Twenty-four procedures were performed, allowing comparison of direct aspiration (n = 12) versus the combined technique (n = 12). Two positions of the aspiration catheter were tested for each of these techniques: in direct contact with the clot and at a distance from it (5-10 mm). Two types of clots were tested: red blood cell-rich clots and fibrin-rich clots. First-pass recanalization and induced arterial collapse and traction were assessed. RESULTS: The first-pass recanalization was less frequent for direct aspiration than for the combined technique, without reaching statistical significance (41.7% versus 75.0%, P = .098). Full collapse (P < .001) and extended arterial traction (P = .001) were significantly less frequent for direct aspiration. For direct aspiration with the aspiration catheter not in direct contact with the clot, there was not a single first-pass recanalization and there was systematic arterial collapse, resulting in a no-flow in the aspiration syringe. CONCLUSIONS: The combined technique appears to be more harmful, and although direct aspiration has a lower rate of first-pass recanalization, it seems appropriate to try direct aspiration as a first-line procedure. However, if the aspiration catheter cannot reach the clot, it is not useful or even risky to try aspiration alone. These results need to be confirmed by clinical studies.

Follow-up of Intracranial Aneurysms Treated by Flow Diverters: Evaluation of Parent Artery Patency Using 3D-T1 Gradient Recalled-Echo Imaging with 2-Point Dixon in Combination with 3D-TOF-MRA with Compressed Sensing.

BACKGROUND AND PURPOSE: MRA assessment of parent artery patency after flow-diverter placement is complicated by imaging artifacts produced by these devices. The purpose of this study was to assess the accuracy of liver acquisition with volume acceleration-flex technique (LAVA-Flex) MRA in combination with 3D-TOF with HyperSense MRA for the evaluation of parent vessel status after intracranial flow-diverter placement. MATERIALS AND METHODS: Fifty-six patients treated by flow diversion and followed with both DSA and 3T MRA between November 2020 and August 2021 were included. All patients were evaluated for parent artery patency using the same imaging protocol (DSA, noncontrast MRA including 3D-TOF with HyperSense and LAVA-Flex, and contrast-enhanced MRA, including time-resolved imaging of contrast kinetics MRA and delayed contrast-enhanced MRA). RESULTS: With DSA as a criterion standard to evaluate the patency of the parent vessel, noncontrast MRA had a good specificity (0.83) and positive predictive value (0.65), better than contrast-enhanced MRA (0.55 and 0.41, respectively). Both had excellent sensitivity and negative predictive value: noncontrast MRA, 0.93 and 0.97, respectively; contrast-enhanced MRA, 0.93 and 0.96, respectively. Specificity and positive predictive value tended to be lower for patients treated with additional devices than for those treated with flow diverters exclusively and for patients treated with a specific type of flow diverter. CONCLUSIONS: Noncontrast MRA can be used for noninvasive follow-up of intracranial aneurysms treated by flow diverters. The combined use of LAVA-Flex and 3D-TOF with HyperSense sequences allows monitoring the status of the parent artery and aneurysm occlusion.

Advanced multiparametric magnetic resonance imaging of multinodular and vacuolating neuronal tumor.

BACKGROUND AND PURPOSE: Multinodular and vacuolating neuronal tumor (MVNT) of the cerebrum is a rare brain lesion with suggestive imaging features. The aim of our study was to report the largest series of MVNTs so far and to evaluate the utility of advanced multiparametric magnetic resonance (MR) techniques. METHODS: This multicenter retrospective study was approved by our institutional research ethics board. From July 2014 to May 2019, two radiologists read in consensus the MR examinations of patients presenting with a lesion suggestive of an MVNT. They analyzed the lesions' MR characteristics on structural images and advanced multiparametric MR imaging. RESULTS: A total of 64 patients (29 women and 35 men, mean age 44.2 ± 15.1 years) from 25 centers were included. Lesions were all hyperintense on fluid-attenuated inversion recovery and T2-weighted imaging without post-contrast enhancement. The median relative apparent diffusion coefficient on diffusion-weighted imaging was 1.13 [interquartile range (IQR), 0.2]. Perfusion-weighted imaging showed no increase in perfusion, with a relative cerebral blood volume of 1.02 (IQR, 0.05) and a relative cerebral blood flow of 1.01 (IQR, 0.08). MR spectroscopy showed no abnormal peaks. Median follow-up was 2 (IQR, 1.2) years, without any changes in size. CONCLUSIONS: A comprehensive characterization protocol including advanced multiparametric magnetic resonance imaging sequences showed no imaging patterns suggestive of malignancy in MVNTs. It might be useful to better characterize MVNTs.

Practice of stereoelectroencephalography (sEEG) in drug-resistant epilepsy: Retrospective series with surgery and thermocoagulation outcomes.

OBJECTIVE: The aim of this study was to determine the success rate of sEEG in locating the epileptogenic zone (EZ) in patients with pharmaco-resistant epilepsy. Secondary objectives were to analyze sEEG-related morbidity and outcomes for post-sEEG thermocoagulation and cortical resection. METHODS: Data were collected on 49 sEEGs from 46 consecutive patients between 2010 and 2018. Following sEEG, either resective or palliative surgery with vagus nerve stimulation was performed. In 8 patients, EZ thermocoagulation was performed before EEG leads were withdrawn. Outcomes were collected based on the Engel and ILAE outcome scales. RESULTS: sEEG was contributive in 45 of 49 recordings, with a success rate of 92% in locating the EZ. Minor complications, such as transient neurologic deficit and electrode implantation failures, occurred in 6%. One major complication occurred, with death due to atypical late hematoma. Thermocoagulation was performed in 8 patients and stopped or significantly reduced seizure frequency in 7 (88%). Outcome of surgical resection (n=33) was good, with 20 (61%) seizure-free patients and 32 (97%) with definite improvement. CONCLUSIONS: Our findings suggest that sEEG is an effective technique for EZ location in patients with drug-resistant epilepsy. sEEG was contributive in up to 92% of patients, allowing thermocoagulation and/or surgical resection that resulted in seizure-freedom in two-thirds and seizure-reduction in one-third of cases. This study highlights the need for strict selection of implantation candidates, with strong initial hypothesis as to EZ location.

[Feedback on clinical oncology pharmacy]. / Retour d'expérience en pharmacie clinique oncologique.

The rising of oral anticancer therapies let more and more patients to be cared at home and improve their quality of life. However the toxicities of these drugs and the distance with health professionals imply that the patient needs to be more autonomous with respect to his treatment. Patients through therapeutic education programs allows them to manage side effects, to be more observant and then to subsequently benefit from the treatment. We report here, oncology clinical pharmacists experiences in some health facilities in France, presented at the 1st day of clinical oncology pharmacy (December 2017, Marseille).

Multinodular and Vacuolating Posterior Fossa Lesions of Unknown Significance.

Multinodular and vacuolating neuronal tumor of the cerebrum is a rare supratentorial brain tumor described for the first time in 2013. Here, we report 11 cases of infratentorial lesions showing similar striking imaging features consisting of a cluster of low T1-weighted imaging and high T2-FLAIR signal intensity nodules, which we referred to as multinodular and vacuolating posterior fossa lesions of unknown significance. No relationship was found between the location of the lesion and clinical symptoms. A T2-FLAIR hypointense central dot sign was present in images of 9/11 (82%) patients. Cortical involvement was present in 2/11 (18%) of patients. Only 1 nodule of 1 multinodular and vacuolating posterior fossa lesion of unknown significance showed enhancement on postcontrast T1WI. DWI, SWI, MRS, and PWI showed no malignant pattern. Lesions did not change in size or signal during a median follow-up of 3 years, suggesting that multinodular and vacuolating posterior fossa lesions of unknown significance are benign malformative lesions that do not require surgical intervention or removal.

Comparison of enhancement of the vestibular perilymph between gadoterate meglumine and gadobutrol at 3-Tesla in Meniere's disease.

PURPOSE: To compare the degree of enhancement of the perilymph between two macrocyclic gadolinium-based contrast agents (gadobutrol and gadoterate meglumine) in patients with Meniere's disease at 3-T magnetic resonance imaging (MRI). MATERIALS AND METHODS: The MRI examinations of 20 patients with Meniere's disease obtained 4hours after a single intravenous dose of macrocyclic gadolinium-based contrast agents were retrospectively compared. Ten patients (median age: 58.5 years; median body mass index [BMI]: 25) have received a single intravenous dose of gadoterate meglumine and 10 patients (median age: 45.5 years; median BMI: 25.4) have received a single-dose of gadobutrol. Two radiologists independently measured the signal intensity ratio (SIR) by using region of interest analysis and performed a visual assessment in order to evaluate the perilymph of each semicircular canal and of the vestibule. RESULTS: No differences in SIR of the symptomatic ear were found between gadobutrol (median SIR: 1.58) and gadoterate meglumine (median SIR: 1.3) (P=0.18). The SIR of the contralateral asymptomatic ear was significantly greater with gadobutrol (median: 1.62) than with gadoterate meglumine (median: 1.21) (P=0.009). No differences in endolymphatic structures visualization were found between gadobutrol and gadoterate meglumine in the symptomatic ears (P=0.27) but gadobutrol allowed a better assessment of endolymphatic structures and semicircular canals in the asymptomatic ear (P<0.001). CONCLUSION: Gadobutrol and gadoterate meglumine provide similar degrees of enhancement of the symptomatic ear in patients with Meniere's disease but gadobutrol provides better anatomical details regarding endolymphatic space and semicircular canals of asymptomatic, contralateral ear.

Management and outcome of cerebral venous thrombosis after head trauma: A case series.

Cerebral venous thrombosis (CVT) is an underdiagnosed complication of head trauma. To date, initiation of anticoagulation is still a matter of debate because of the risk of worsening traumatic hemorrhage. This report describes a case series of five patients admitted for head injury complicated by CVT. The main associated radiological signs were skull fractures crossing the venous sinus and adjacent traumatic hematoma. In four patients, anticoagulation was introduced within 48-72h of CVT diagnosis, with no subsequent hemorrhagic complications. The present report and data from the literature raise the question of systematic additional venoscans when confronted by associated radiological features of post-traumatic CVT. The safety of anticoagulation in selected patients is also discussed.

Usefulness of multidetector-row computerized tomographic angiography for the surgical planning in stereoelectroencephalography.

PURPOSE: Surgical planning of depth electrode implantation in stereo-electro-encephalography (SEEG) routinely uses magnetic resonance imaging (MRI) alone. Accurate visualization of arteries and veins in the vicinity of the electrode is essential to plan a safe trajectory to presumably reduce the risk of intracranial bleeding. The goal of this study was to compare multidetector row computerized tomographic angiography (MDCTA) with MRI for the visualization of vessels along each planned trajectory in patients who undergo SEEG. MATERIALS AND METHODS: Ten consecutive patients who were scheduled to undergo SEEG procedure were included. T1-weighted gadolinium-chelate enhanced MR sequence, stereotactic MDCT and MDCTA were performed after fixation of Leksell's frame. For each of the 106 planned stereotactic trajectories, the number of vessels in a 4.0mm diameter circle around the trajectory from the dura mater to the target that were visible on MDCTA were compared to that of visible vessels in the same areas on MRI. RESULTS: Ten vessels (10/106; 9.4%) were seen on MRI and 66 (66/106; 62.3%) on MDCTA (P<0.0001). All vessels visible on MRI were visible on MDCTA. The difference in number of visible vessels between the two techniques remained significant for the different lobes (i.e., frontal lobe, temporal lobe and parieto-occipital lobe). CONCLUSION: MDCTA enabled visualization of more vessels than MRI based SEEG. MDCTA may help neurosurgeons better define the trajectory of the electrode and reduce the risk of intracranial bleeding.

Imaging of giant cerebral aneurysms.

The aim of this study was to review the different imaging techniques for analysing giant intracranial aneurysms (digital subtraction angiography [DSA], magnetic resonance imaging [MRI], computed tomography [CT]) imaging and explain their respective contribution to the understanding of the characteristics of these complex aneurysms. Giant aneurysms have a complex pathology with multiple stages of evolution and consequences. Therefore, complex imaging is mandatory to enhance the understanding of these parameters and to plan an often complicated treatment strategy. DSA remains the gold standard for analysing aneurysms, but non-invasive sectional imaging (CT, MRI) also provides essential information in the specific case of giant aneurysms.

Endoscopic 3rd ventriculocisternostomy: procedural complications and long-term dysfunctions?

BACKGROUND AND PURPOSE: The endoscopic third ventriculostomy (ETV) has become the treatment of choice for managing non-communicating hydrocephalus. The aim of this study was to evaluate the efficacy and the morbi-mortality of this procedure and its long-term outcome. PATIENTS AND METHODS: This retrospective study involved 82 consecutive patients treated for non-communicating hydrocephalus by ETV, in a single centre, between June 1999 and November 2008. The main criterion of efficacy was clinical improvement with shunt independence. The secondary criteria were the ventricular size (third and lateral ventricles) outcome and the procedural morbidity and mortality. In order to determine the predictive factors of dysfunction, a uni- and multivariate analysis was conducted. RESULTS: Divided in two groups, the overall success rate was 65.4% in the paediatric group (n=26) and 83.9% in the adult group (n=56), after respectively a mean follow-up of 59.1±36.7 and 49.3±27.7 months. A procedural complication occurred in 5 patients (6.1%), with no procedure-related death. The predictive factors of ETV failure were an infectious aetiology and an age less than 16. Changes in ventricular size and success rate were independent. CONCLUSIONS: ETV is an effective procedure at long-term for the management of non-communicating hydrocephalus with low morbidity. Therefore, it should be considered as first-line treatment. Cerebrospinal meningitis infection and young age both expose patients to possible dysfunction.

Distal middle cerebral artery aneurysm: A proposition of microsurgical management.

OBJECTIVES: Based on a cohort of patients treated on distal middle cerebral artery (MCA) aneurysm by microsurgical approach, the objectives were to assess the following: the postoperative functional outcome, study the causes of early neurological deterioration and to determine the predictive factors of favourable outcome. PATIENTS AND METHODS: From a neurovascular prospective database, this retrospective longitudinal study included all the patients treated for cerebral aneurysm located on the distal segment of the MCA over two decades (January 1990-December 2011). The patients were all treated by microsurgical clipping exclusion. Any aneurysm was associated to infectious angiopathy. Data were retrieved from the patient's medical charts. The outcome was analysed twice: during the immediate postoperative period and at 6 months according to the modified Rankin scale. The relative risk was estimated for each variable and the prognostic factors were assessed using a multivariate logistic regression model (P<0.05). RESULTS: Twenty-eight patients, mean age 40±13.3 years (median: 43 years; range 6-70 years) were divided into the ruptured group (n=20) and unruptured group (n=8). In the ruptured group, the initial clinical status was good (WFNS I-III) in 12 patients (60%) and poor in eight (40%) with an intracerebral haematoma (ICH) in 11 (55%). For both groups, the aneurysm location on the distal MCA decreased at a rate from 64.8% of the insular segment to 25% of the opercular then 10.7% to the cortical. During the hospital stay, neurological deterioration occurred in 16 patients (57.2%). The diagnosed causes were cerebral ischaemia in 10 (35.6%), initial ICH in three (10.7%), hydrocephalus in two (7.1%) and epilepsy in one (7.1%). At 6 months, a favourable outcome (mRS 0-2) was observed in 19 patients (68.1%), a definitive morbidity in seven (24.9%) and death in two (7.2%). Based on the prognostic factors, only the absence of immediate postoperative neurological deterioration was identified as significant for a favourable outcome. CONCLUSION: These rare cerebral aneurysms resulted in a high proportion of poor initial status related to a frequent ICH. Cerebral ischaemia was a major cause of the immediate neurological deterioration and the absence of immediate neurological deterioration was the single identified prognostic factor.

[Post-traumatic syringomyelia: What should know the urologist?]. / Syringomyélie post-traumatique : ce que doit savoir l'urologue ?

The incidence of post-traumatic syringomyelia (PTS) is estimated according to recent studies at 25 to 30% of patients with traumatic spinal cord injuries in magnetic resonance imaging (MRI), which remains the gold standard exam for syringomyelia diagnosis and monitoring. Syringomyelia is translated by an increased cord signal (similar to CSF) with low-density T1-weighted image and high-density T2-weighted image, which extends beyond site of initial lesion at least to two vertebral segments. Two conditions are required for development of PTS: traumatic spinal cord injury and blocked the flow of CSF epidural. The mean interval from spinal cord injury to diagnosis SPT was 2.8years (range, 3months to 34years). The commonest symptoms are pain and sensory loss. PTS should be suspected if the patient has new neurological symptoms above level of injury, such as dissociated sensory injuries, reflexes abolition, and motor deficit, after the neural function becomes stable for certain time. In urologic practice, new neurological symptoms could be bladder and/or erectile dysfunction. The medical management based on prevention efforts with closed-glottis pushing, which could aggravate the syrinx cavity. In urology, extracorporeal shockwave lithotripsy, and laparoscopic or robotic surgery could extend the syrinx cavity for the same reason (increase abdominal pressure). The indications for surgical intervention and optimal surgical treatment technique for patients with PTS are not consensual. The literature demonstrated that surgery PTS is effective at arresting or improving motor deterioration, but not sensory dysfunction or pain syndromes.

Superior interhemispheric approach for midline meningioma from the anterior cranial base.

BACKGROUND: For suprasellar meningioma, the fronto-basal exposure is considered the standard approach. The superior interhemispheric (IH) approach is less described in the literature. OBJECTIVE: To assess the surgical complications, functional outcome (visual, olfaction), morbidity and mortality rates and late recurrence, after resection by superior IH approach of midline skull base meningioma. METHODS: Between 1998 and 2008, 52 consecutive patients with midline meningioma on the anterior portion of the skull base (mean age: 63.8 ± 13.1; sex ratio F/M: 3.7) were operated on via the superior IH approach. After a mean follow-up of 56.9 ± 32.9 months, an independent neurosurgeon proposed a prospective examination of functional outcome to each patient, as well as a visual and olfactory function assessment. RESULTS: Fifty-two patients were divided into a group with olfactory groove meningioma (n=34) and another with tuberculum sellae meningioma (n=18). The outcome was characterized by postoperative complications in 13 patients (25%), mortality rate in two (3.8%) and long-term morbidity at in 17 (37%) of 50 surviving patients. Based on multivariate analysis, no prognosis factor was significant as regards the favorable outcome. The mean postoperative KPS score (86.6 ± 9.4) was significantly improved. However, dysexecutive syndrome was observed in four patients (8%), hyposmia-anosmia in 34 (68%) and visual acuity deteriorated in one (2%). CONCLUSION: The superior IH approach could be considered a safe anteriorly orientated midline approach for removal OGM and TSM meningioma.

Usefulness of multislice computerized tomography angiography in preoperative diagnosis of ruptured cerebral aneurysms.

OBJECTIVE: Non-invasive imaging methods have become primordial in subarachnoid hemorrhage. The aim of our study was to evaluate the sensitivity and specificity of multislice computed tomographic angiography (MSCTA) for the diagnosis of cerebral aneurysm. METHODS: The 28 included consecutive patients with SAH underwent both MSCTA and digital subtraction angiography (DSA). The MSCTA studies were interpreted by two independent readers (A and B) for the presence, the location and size of the aneurysm comparatively to the DSA as reference examination. RESULTS: In 20 patients, 38 aneurysms were diagnosed and in eight no aneurysm was found. Per patient basis, the diagnostic sensitivity and specificity were excellent. Per aneurysm basis, the diagnostic sensitivity and specificity of MSCTA were, respectively, 97.4 and 100% for reader A, 100 and 100% for reader B. For aneurysms less than 3mm, sensitivity was 100% for both readers. Interobserver agreement was excellent for the detection of aneurysm (kappa=0.98, 95% CI [0.96-1]). Intertechnique and interobserver agreements were excellent for the measurement of aneurysms (slope=0.86, r=0.91 p=3.1x10(-7) and slope=1.04, r=0.99, p<10(-6), respectively). CONCLUSION: MSCTA was an accurate and reproducible non-invasive imaging technique for preoperative diagnosis of ruptured cerebral aneurysm. The MSCTA may be proposed in first intention after the diagnosis of SAH was established, with special care regarding injection procedure and a strict reading method using native images and thin MPR.