Initial experience with minimally invasive endoscopic evacuation of intracerebral hemorrhage in the setting of radiographic herniation.

BACKGROUND: Spontaneous intracerebral hemorrhage (ICH) can rapidly result in cerebral herniation, leading to poor neurologic outcomes or mortality. To date, neither decompressive hemicraniectomy (DH) nor hematoma evacuation have been conclusively shown to improve outcomes for comatose ICH patients presenting with cerebral herniation, with these patients largely excluded from clinical trials. Here we present the outcomes of a series of patients presenting with ICH and radiographic herniation who underwent emergent minimally invasive (MIS) ICH evacuation. METHODS: We reviewed our prospectively collected registry of patients undergoing MIS ICH evacuation at a single institution from 01/01/2017 to 10/01/2021. We selected all consecutive patients with Glasgow coma scale (GCS) ≤ 8 and radiographic herniation for this case series. Clinical and radiographic variables were collected, including admission GCS score, preoperative and postoperative hematoma volumes, National Institute of Health stroke scale (NIHSS) scores, and modified Rankin scale (mRS) scores at last follow-up. RESULTS: Of 176 patients with spontaneous supratentorial ICH who underwent minimally invasive endoscopic evacuation during the study time period, a total of 9 patients presented with GCS ≤ 8 and evidence of radiographic herniation. Among these patients, the mean age was 62 ± 12 years, the median GCS at presentation was 5 [IQR 4-6], the mean preoperative hematoma volume was 94 ± 44 mL, the mean time from ictus to evacuation was 12 ± 5 h, and the mean postoperative hematoma volume was 11 ± 16 mL, for a median evacuation percentage of 97% [83-99]. Three patients (33%) died, four (44%) survived with mRS 5 and two (22%) with mRS 4. Patients had a median NIHSS improvement of 5 compared to their initial NIHSS. Age was very strongly correlate to improvements in NIHSS (r2 = 0.90). CONCLUSION: Data from this initial experience suggest emergent MIS hematoma evacuation in the setting of ICH with radiographic herniation is feasible and technically effective. Further randomized studies are required to determine if such an intervention offers overall benefits to patients and their families.

Rare presentations of COVID-19: PRES-like leukoencephalopathy and carotid thrombosis.

Coronavirus disease 2019 (COVID-19) is a global pandemic, and it is increasingly important that physicians recognize and understand its atypical presentations. Neurological symptoms such as anosmia, altered mental status, headache, and myalgias may arise due to direct injury to the nervous system or by indirectly precipitating coagulopathies. We present the first COVID-19 related cases of carotid artery thrombosis and acute PRES-like leukoencephalopathy with multifocal hemorrhage.

Disc Degeneration in Unfused Caudal Motion Segments Ten Years Following Surgery for Adolescent Idiopathic Scoliosis.

HYPOTHESIS: The frequency of disc degeneration (DD) in the distal mobile segments will increase over time following surgery for adolescent idiopathic scoliosis (AIS). DESIGN: Retrospective review of a prospective AIS registry. INTRODUCTION: Durability of surgical outcomes is essential for maintenance of quality of life as well as for family decision making and for assessment of the value of a healthcare intervention. We assessed DD, its risk factors, and association with health-related quality of life 10 years after AIS surgery. METHODS: Five radiographic indicators of DD, previously validated, were evaluated preoperatively and 1 month, 2, 5, and 10 years postoperatively by a radiologist in operative AIS patients. A composite radiographic score (CRS; range 0-10) was calculated using the sum of each of the DD indicators. The severity of CRS in relation to the time point after surgery and various risk factors were assessed using linear regression or Pearson χ2 test. CRS ≥3 was chosen to indicate significant DD. Association of CRS with SRS-22 outcome was evaluated by linear regression. RESULTS: 193 consecutive patients (mean age at surgery 14.4 years; 86% female) were assessed. Surgical approach included 102 posterior and 91 anterior fusions. Contributors to maximum CRS at 10 years were Schmorl's nodes (7.3% of patients), osteophytes (40.4%), sclerosis (29%), and irregular endplate (8.3%). CRS ≥3 occurred in 1.6%, 0.54%, 3.7%, 6.8%, and 7.3% of patients at the various time points (r2=0.83, p=.0313), respectively. More than 50% of DD occurred at the second (35.5%) and third (20%) disc caudal to the LIV. LIV of L4 compared with more cephalad LIV had the highest risk of developing significant DD (27.3%; p=.0267). It was found that disc wedging subjacent to the LIV (≥5°) and LIV translation (≥2 cm) lead to a sixfold increase in significant DD (odds ratio=6.71 and 6.13, respectively). Severity of DD was not associated with the number of levels fused (p=.2131), the surgical approach (p=.8245), or the construct type (p=.2922). No significant association was established between 10-year CRS and SRS-22 scores. CONCLUSION: In the first study of its kind, we found that only 7.3% of patients had significant DD 10 years after surgical correction of AIS. Rates of DD increased over time. Our data provide evidence to support recommendations to save as many caudal motion segments as possible, to avoid fusing to L4, and maintain the LIV tilt angle below 5° and LIV translation less than 2 cm.

Transarterial embolization of vein of Galen malformations: the use of magnetic resonance imaging noninvasive optimal vessel analysis to quantify shunt reduction. Report of two cases.

In patients with vein of Galen malformations, high-flow shunting decreases cerebral perfusion. By reducing or eliminating these shunts, transarterial embolization can improve cerebral perfusion and clinical outcomes. Quantifying pre- and postembolization shunt blood flow may help determine the optimal timing and efficacy of embolization and may provide prognostic information. The authors used magnetic resonance imaging noninvasive optimal vessel analysis as a novel modality to measure volumetric blood flow through vein of Galen malformation shunts in a neonate and an infant before and after transarterial embolization.

Cumulative incidence of radiation-induced cavernomas in long-term survivors of medulloblastoma.

OBJECT: The goal of this study was to determine the incidence of radiation-induced cavernomas in children treated for medulloblastoma. METHODS: A retrospective chart and film review was performed for all patients treated for medulloblastoma at the Insitute for Neurology and Neurosurgery/Beth Israel Medical Center between August 1996 and the present. The clinical and radiographic histories of pediatric patients (ages 3-21 years at diagnosis) with a histologically confirmed diagnosis of medulloblastoma who received craniospinal radiation therapy were reviewed. Fifty-nine patients were identified, with a mean age at radiation treatment of 7.7 years and a mean follow-up time of 7.2 years. The dose to the craniospinal axis was 24 Gy (31 patients) or 36 Gy (28 patients). The radiation energy in the craniospinal axis was provided by photons in 55 patients and protons in four. All patients received a posterior fossa boost of 54 Gy (46 patients) or 72 Gy (13 patients). Twenty-six lesions developed in 18 patients (31%) during the observation period. The cumulative incidence of lesion development was 5.6, 14, and 43%, at 3, 5, and 10 years, respectively. The sites of occurrence were cerebral (20 cases) and cerebellar (six cases). There was no significant correlation between age at diagnosis, sex, craniospinal radiation dose or energy source, and lesion development. Only one patient required surgical intervention for a symptomatic hemorrhagic lesion in the frontal lobe. Histological analysis in this case was consistent with cavernoma. CONCLUSIONS: Cavernomas are common after cranial irradiation in children, and their incidence increases over time. Most of these lesions follow a benign course and do not require intervention.

Hemispheric revascularization in the setting of carotid occlusion and subclavian steal: a diagnostic and management role for quantitative magnetic resonance angiography?

OBJECTIVE: Advances in phase contrast magnetic resonance imaging have facilitated the noninvasive assessment of blood flow rates and flow direction in patients with complex cerebrovascular disorders. METHODS: We describe a case of right hemispheric hypoperfusion in which, on noninvasive assessment with quantitative magnetic resonance angiography, the patient was found to harbor an occult subclavian steal with flow reversal in the left vertebral artery. RESULTS: The presence of posterior communicating arteries noted on quantitative magnetic resonance angiography suggested that normalization of flow in the vertebral arteries by treating the subclavian occlusion could improve flow in the anterior circulation. Angiography confirmed the noninvasive findings, and the subclavian occlusion was treated with angioplasty and stenting. Postintervention quantitative magnetic resonance angiography documented quantitative improvement in right middle cerebral artery flow and restoration of antegrade flow in the left vertebral artery. CONCLUSION: This case illustrates the potential role of noninvasive assessment of blood flow rates and flow direction in the diagnosis, treatment planning, and follow-up of patients with complex cerebrovascular disease.

Optic neuritis: correlation of pain and magnetic resonance imaging.

PURPOSE: To demonstrate whether the magnetic resonance imaging (MRI) localization of the abnormal enhancement of the optic nerve can be related to the pain or pattern of visual field loss associated with acute optic neuritis. DESIGN: Retrospective observational series and MRI review from a referral neuro-ophthalmology service. PARTICIPANTS: Seventy-three women and 23 men with acute optic neuritis who had high resolution gadolinium-enhanced fat-suppressed MRI within twenty days of the onset of visual loss. METHODS: The presence of eye or other fifth cranial nerve (V(1)) pain, and pain with eye movement ipsilateral to the affected optic nerve or no eye pain was recorded. The neuroradiologist reviewed the MRI, masked to the affected eye, and recorded the length and segment (orbital, canalicular, intracranial, or combination of segments) of abnormal optic nerve enhancement. The presenting visual field defects were characterized as diffuse, central, arcuate, nasal or temporal. MAIN OUTCOME MEASURES: The types of pain and patterns of field loss were correlated with the segments of optic nerve enhancement in the affected eye. RESULTS: Five patients had nerves that did not enhance and were excluded from the outcome analysis. In the 91 patients with abnormal enhancement, 70 experienced eye/V(1) pain, 67 had pain with eye movement and 17 patients had no pain. Enhancement of the orbital optic nerve occurred in 66 patients, 93.9% who had eye/V(1) pain and 92.4% who had pain with eye movement. In the 25 patients with enhancement of the canalicular, intracranial or both segments, without orbital involvement, 32% had eye/V(1) pain and 24% had pain with eye movement. No pain occurred in 3% with enhancement of the orbital segment and in 60% with enhancement of the other optic nerve segments. The length of enhancement moderately correlated with eye/V(1) pain (r = 0.49, P = 0.01) and pain with eye movement (r = 0.37, P = 0.01). Patients with enhancement longer than 10 mm had pain five times (P = 0.004) more frequent than did those with enhancement

Acute occipital demyelinating lesion appearing as an infarct on diffusion magnetic resonance imaging.

PURPOSE: To report a case of a 27-year-old woman who presented with an acute right homonymous visual field deficit due to demyelination diagnosed by postprocessing analysis of the magnetic resonance imaging (MRI). DESIGN: Observational case report. METHODS: Magnetic resonance imaging analysis with an exponential diffusion-weighted imaging. RESULTS: On MRI, a left occipital lesion with mild enhancement after gadolinium infusion on the T1-weighted image, bright signal with some mass effect on the T2-weighted image, and the diffusion-weighted imaging suggested a diagnosis of an acute infarct. With the use of the exponential image technique, the T2 hyperintense signal present on the diffusion study was almost completely eliminated, changing the diagnosis and treatment plan. Subsequent examinations and MRI confirmed the diagnosis of demyelinating disease. CONCLUSIONS: In diseases such as cerebral ischemia and demyelination, MRI diffusion is often abnormal because such diseases modify the integrity of central nervous system structures. A technique that subtracts the T2 contribution to the diffusion-weighted imaging analysis supported a diagnosis of an acute demyelinating episode that was subsequently confirmed.

MR imaging characteristics of amyloid deposits in pituitary adenoma.

Although cases of pituitary adenomas containing amyloid deposits have been described in the literature, to our knowledge this is the first report to describe MR imaging characteristics of a pituitary adenoma containing almost entirely amyloid tissue.