Associations of diabetes status and glucose measures with outcomes after endovascular therapy in patients with acute ischemic stroke: an analysis of the nationwide TREAT-AIS registry.

Background: Hyperglycemia affects the outcomes of endovascular therapy (EVT) for acute ischemic stroke (AIS). This study compares the predictive ability of diabetes status and glucose measures on EVT outcomes using nationwide registry data. Methods: The study included 1,097 AIS patients who underwent EVT from the Taiwan Registry of Endovascular Thrombectomy for Acute Ischemic Stroke. The variables analyzed included diabetes status, admission glucose, glycated hemoglobin (HbA1c), admission glucose-to-HbA1c ratio (GAR), and outcomes such as 90-day poor functional outcome (modified Rankin Scale score ≥ 2) and symptomatic intracranial hemorrhage (SICH). Multivariable analyses investigated the independent effects of diabetes status and glucose measures on outcomes. A receiver operating characteristic (ROC) analysis was performed to compare their predictive abilities. Results: The multivariable analysis showed that individuals with known diabetes had a higher likelihood of poor functional outcomes (odds ratios [ORs] 2.10 to 2.58) and SICH (ORs 3.28 to 4.30) compared to those without diabetes. Higher quartiles of admission glucose and GAR were associated with poor functional outcomes and SICH. Higher quartiles of HbA1c were significantly associated with poor functional outcomes. However, patients in the second HbA1c quartile (5.6-5.8%) showed a non-significant tendency toward good functional outcomes compared to those in the lowest quartile (<5.6%). The ROC analysis indicated that diabetes status and admission glucose had higher predictive abilities for poor functional outcomes, while admission glucose and GAR were better predictors for SICH. Conclusion: In AIS patients undergoing EVT, diabetes status, admission glucose, and GAR were associated with 90-day poor functional outcomes and SICH. Admission glucose was likely the most suitable glucose measure for predicting outcomes after EVT.

Comparing Low- or Standard-Dose Alteplase in Endovascular Thrombectomy: Insights From a Nationwide Registry.

BACKGROUND: Timely intravenous thrombolysis and endovascular thrombectomy are the standard reperfusion treatments for large vessel occlusion stroke. Currently, it is unknown whether a low-dose thrombolytic agent (0.6 mg/kg alteplase) can offer similar efficacy to the standard dose (0.9 mg/kg alteplase). METHODS: We enrolled consecutive patients in the multicenter Taiwan Registry of Endovascular Thrombectomy for Acute Ischemic Stroke who had received combined thrombolysis (within 4.5 hours of onset) and thrombectomy treatment from January 2019 to April 2023. The choice of low- or standard-dose alteplase was based on the physician's discretion. The outcomes included successful reperfusion (modified Thrombolysis in Cerebral Infarction score, 2b-3), symptomatic intracerebral hemorrhage, 90-day modified Rankin Scale score, and 90-day mortality. The outcomes between the 2 groups were compared using multivariable logistic regression and inverse probability of treatment weighting-adjusted analysis. RESULTS: Among the 2242 patients in the Taiwan Registry of Endovascular Thrombectomy for Acute Ischemic Stroke, 734 (33%) received intravenous alteplase. Patients in the low-dose group (n=360) were older, had more women, more atrial fibrillation, and longer onset-to-needle time compared with the standard-dose group (n=374). In comparison to low-dose alteplase, standard-dose alteplase was associated with a lower rate of successful reperfusion (81% versus 87%; adjusted odds ratio, 0.63 [95% CI, 0.40-0.98]), a numerically higher incidence of symptomatic intracerebral hemorrhage (6.7% versus 3.9%; adjusted odds ratio, 1.81 [95% CI, 0.88-3.69]), but better 90-day modified Rankin Scale score (functional independence [modified Rankin Scale score, 0-2], 47% versus 31%; adjusted odds ratio, 1.91 [95% CI, 1.28-2.86]), and a numerically lower mortality rate (9% versus 15%; adjusted odds ratio, 0.73 [95% CI, 0.43-1.25]) after adjusting for covariates. Similar results were observed in the inverse probability of treatment weighting-adjusted models. The results were consistent across predefined subgroups and age strata. CONCLUSIONS: Despite the lower rate of successful reperfusion and higher risk of symptomatic intracerebral hemorrhage with standard-dose alteplase, standard-dose alteplase was associated with a better functional outcome in patients receiving combined thrombolysis and thrombectomy.

Development of a Machine Learning Algorithm to Correlate Lumbar Disc Height on X-rays with Disc Bulging or Herniation.

Lumbar disc bulging or herniation (LDBH) is one of the major causes of spinal stenosis and related nerve compression, and its severity is the major determinant for spine surgery. MRI of the spine is the most important diagnostic tool for evaluating the need for surgical intervention in patients with LDBH. However, MRI utilization is limited by its low accessibility. Spinal X-rays can rapidly provide information on the bony structure of the patient. Our study aimed to identify the factors associated with LDBH, including disc height, and establish a clinical diagnostic tool to support its diagnosis based on lumbar X-ray findings. In this study, a total of 458 patients were used for analysis and 13 clinical and imaging variables were collected. Five machine-learning (ML) methods, including LASSO regression, MARS, decision tree, random forest, and extreme gradient boosting, were applied and integrated to identify important variables for predicting LDBH from lumbar spine X-rays. The results showed L4-5 posterior disc height, age, and L1-2 anterior disc height to be the top predictors, and a decision tree algorithm was constructed to support clinical decision-making. Our study highlights the potential of ML-based decision tools for surgeons and emphasizes the importance of L1-2 disc height in relation to LDBH. Future research will expand on these findings to develop a more comprehensive decision-supporting model.

Prevalence and Characteristics of Intracranial Aneurysms in Hereditary Hemorrhagic Telangiectasia.

BACKGROUND AND PURPOSE: The association between hereditary hemorrhagic telangiectasia and intracranial aneurysms remains controversial. This study evaluated the prevalence and characteristics of intracranial aneurysms in patients with hereditary hemorrhagic telangiectasia with brain vascular malformations. MATERIALS AND METHODS: Between 2007 and 2021, patients enrolled in the Brain Vascular Malformation Consortium with definite hereditary hemorrhagic telangiectasia, the presence of brain vascular malformations, and available angiographic studies of the brain were retrospectively reviewed. Angiographic features of intracranial aneurysms and their relationship to coexisting brain vascular malformations were analyzed. We also examined the association between baseline clinical features and the presence of intracranial aneurysms. RESULTS: One hundred eighty patients were included. A total of 14 intracranial aneurysms were found in 9 (5%) patients, and 4 intracranial aneurysms were considered flow-related aneurysms. Patients with intracranial aneurysms were significantly older than patients without intracranial aneurysms (mean, 48.1 [SD, 18.2] years versus 33.5 [SD, 21.0] years; P = .042). If we excluded flow-related intracranial aneurysms, the prevalence of intracranial aneurysms was 3.3%. All intracranial aneurysms were in the anterior circulation, were unruptured, and had an average maximal diameter of 3.9 (SD, 1.5) mm. No intracranial aneurysms were found in pediatric patients with hereditary hemorrhagic telangiectasia. No statistically significant correlation was observed among other baseline demographics, hereditary hemorrhagic telangiectasia features, and the presence of intracranial aneurysms. CONCLUSIONS: The prevalence of intracranial aneurysms in this large cohort study is comparable with that in the general population and might be increased slightly due to hemodynamic factors associated with shunting brain vascular malformations.

Intravascular ultrasound guided vertebral artery stenting after basilar artery thrombectomy for acute brain stem stroke.

A 64-year-old lady presented as right vertebral artery occlusion and brain stem stroke (Figure 1A). Emergent thrombectomy opened the artery, but it re-occluded 10 minutes later (Figure 1B,C). Intravascular ultrasound showed heavy plaque burden and guided a balloon-expandable stenting successfully (Figure 1D-F).

Clinical outcomes of adjunct sinus stenting in dural arteriovenous fistulas : Role of flow restoration in steno-occlusion and cortical venous reflux.

PURPOSE: This study investigated the clinical outcomes and follow-up results of venous sinus stenting (VSS) for constrictive dural sinus restoration in patients with intracranial dural arteriovenous fistulas (DAVFs). We hypothesized that this treatment would have durable benefits in such patients. METHODS: Patients who underwent VSS for DAVFs with cortical venous reflux between January 2008 and June 2020 were identified after a retrospective review (n =18). Clinical and endovascular treatment data and follow-up information were reviewed. RESULTS: The mean age of the 18 patients was 59.9 years. Stents were implanted in 10 previously occluded sinuses and 9 stenotic sinuses in addition to endovascular embolization. One patient received bilateral VSS. Subdural hemorrhage occurred in one patient after recanalization for embolization, followed by uneventful stenting. In 17 patients with clinical follow-up, the median follow-up time was 59.5 months (interquartile range 18 to 84 months). Of these, sixteen patients had follow-up vascular imaging, revealing AVF obliteration in 6 patients (38%) and stent patency in 11 (69%). Retreatment was performed for 8 (50%) patients. The mean follow-up modified Rankin scale score was 1.28. All patients had longstanding symptomatic improvement. CONCLUSION: Restoration of sinus flow in DAVFs with cortical venous reflux through VSS has an acceptable complication rate and long-term symptomatic control; however, retreatment is often required, and stent occlusion is not uncommon.

Allometric scaling and growth: Evaluation and applications in subadult body mass estimation.

OBJECTIVES: Previously developed methods in subadult body mass estimation have not been tested in populations other than European-American or African-American. This study uses a contemporary Taiwanese sample to test these methods. Through evaluating their accuracy and bias, we addressed whether the allometric relationships between body mass and skeletal traits commonly used in subadult body mass estimation are conserved among different populations. MATERIALS AND METHODS: Computed tomography scans of lower limbs from individuals aged 0-17 years old of both sexes were collected from National Taiwan University Hospital along with documented body weight. Polar second moment of area, distal femoral metaphyseal breadth, and maximum superior/inferior femoral head diameter were collected either directly from the scans or from reconstructed 3D models. Estimated body mass was compared with documented body mass to assess the performance of the equations. RESULTS: Current methods provided good body mass estimates in Taiwanese individuals, with accuracy and bias similar to those reported in other validation studies. A tendency for increasing error with increasing age was observed for all methods. Reduced major axis regression showed the allometric relationships between different skeletal traits and body mass across different age categories can all be summarized using a common fitted line. A revised, maximum likelihood-based approach was proposed for all skeletal traits. DISCUSSION: The results suggested that the allometric relationships between body mass and different skeletal traits are largely conserved among populations. The revised method provided improved applicability with strong underlying theoretical justifications, and potential for future improvements.

Time to peak and full width at half maximum in MR perfusion: valuable indicators for monitoring moyamoya patients after revascularization.

Moyamoya disease (MMD) is a chronic, steno-occlusive cerebrovascular disorder of unknown etiology. Surgical treatment is the only known effective method to restore blood flow to affected areas of the brain. However, there are lack of generally accepted noninvasive tools for therapeutic outcome monitoring. As dynamic susceptibility contrast (DSC) magnetic resonance imaging (MRI) is the standard MR perfusion imaging technique in the clinical setting, we investigated a dataset of nineteen pediatric MMD patients with one preoperational and multiple periodic DSC MRI examinations for four to thirty-eight months after indirect revascularization. A rigid gamma variate model was used to derive two nondeconvolution-based perfusion parameters: time to peak (TTP) and full width at half maximum (FWHM) for monitoring transitional bolus delay and dispersion changes respectively. TTP and FWHM values were normalized to the cerebellum. Here, we report that 74% (14/19) of patients improve in both TTP and FWHM measurements, and whereof 57% (8/14) improve more noticeably on FWHM. TTP is in good agreement with Tmax in estimating bolus delay. Our study data also suggest bolus dispersion estimated by FWHM is an additional, informative indicator in pediatric MMD monitoring.

Prediction of mTICI 3 recanalization and clinical outcomes in endovascular thrombectomy for acute ischemic stroke: a retrospective study in the Taiwan registry.

PURPOSE: Early recanalization for acute ischemic stroke (AIS) due to large vessel occlusion (LVO) by endovascular thrombectomy (EVT) is strongly related to improved functional outcomes. With data obtained from the Taiwan registry, the factors associated with mTICI 3 recanalization and clinical outcomes in EVT are investigated. METHODS: From January 2014 to September 2016, 108 patients who underwent EVT for AIS due to LVO in 11 medical centers throughout Taiwan were included. Complete recanalization is defined as achieving modified thrombolysis in cerebral infarction (mTICI) grade 3. Good clinical outcomes are defined by the modified Rankin scale (mRS) 0-2 at 3 months after EVT. Clinical and imaging parameters for predicting mTICI 3 recanalization and good clinical outcomes are analyzed. RESULTS: Of the 108 patients who received EVT, 54 (50%) patients had mTICI 3 recanalization. Having received aspiration only and the use of IV-tPA are shown to be significant predictors for mTICI 3 recanalization with odds ratios of 2.61 and 2.53 respectively. Forty-six (42.6%) patients experienced good 3-month clinical outcomes (mRS 0-2). Pretreatment collateral statuses, NIHSS scores, time lapses between symptoms to needle, and the occurrence of hemorrhage at 24 h are all significant predictors for good outcomes with odds ratios of 2.88, 0.91, 0.99, and 0.31 respectively. CONCLUSIONS: Prediction of mTICI 3 recanalization and clinical outcomes offer valuable clinical information for treatment planning in EVT.

Multiphase Computed Tomographic Angiography with Bone Subtraction Using 3D Multichannel Convolution Neural Networks.

Multiphase computed tomographic angiography (CTA) have been demonstrated to be a reliable imaging tool for evaluating cerebral collateral circulation that can be used to select acute ischemic patients for recanalization therapy. We proposed using bone subtraction techniques to visualize multiphase CTA for clinicians to make fast and consistent decisions in the imaging triage of acute stroke patients. A total of 40 multiphase brain CTA datasets were collected and processed by two bone subtraction methods. The reference method used pre-contrast (phase 0) scans to create ground truth bone masks by thresholding. The tested method used only contrast enhanced (phases 1, 2, and 3) scans to extract bone masks with two versions (U-net and atrous) of 3D multichannel convolution neural networks (CNNs) in a supervised deep learning paradigm for semantic segmentation. Half (n = 20) of the datasets were used to train and half (n = 20) were used to test the conventional 3D U-net and a patch-based 3D multichannel atrous CNN. The tested U-net and atrous CNNs achieved a mean intersection over union (IoU) scores of 90.0% +/- 2.2 and 93.9% +/- 1.2 respectively.Clinical Relevance-This bone subtraction technique helps to visualize CTA volumetric datasets in the form of full brain angiogram-like images to assist the clinicians in the emergency department for evaluating acute ischemic stroke patients.

Update on cerebral hyperperfusion syndrome.

Cerebral hyperperfusion syndrome (CHS) is a clinical syndrome following a revascularization procedure. In the past decade, neurointerventional surgery has become a standard procedure to treat stenotic or occluded cerebral vessels in both acute and chronic settings, as well as endovascular thrombectomy in acute ischemic stroke. This review aims to summarize relevant recent studies regarding the epidemiology, diagnosis, and management of CHS as well as to highlight areas of uncertainty. Extracranial and intracranial cerebrovascular diseases in acute and chronic conditions are considered. The definition and diagnostic criteria of CHS are diverse. Although impaired cerebrovascular autoregulation plays a major role in the pathophysiology of CHS, the underlying mechanism is still not fully understood. Its clinical characteristics vary in different patients. The current findings on clinical and radiological presentation, pathophysiology, incidence, and risk factors are based predominantly on carotid angioplasty and stenting studies. Hemodynamic assessment using imaging modalities is the main form of diagnosis although the criteria are distinct, but it is helpful for patient selection before an elective revascularization procedure is conducted. After endovascular thrombectomy, a diagnosis of CHS is even more complex, and physicians should consider concomitant reperfusion injury. Management and preventative measures, including intensive blood pressure control before, during, and after revascularization procedures and staged angioplasty, are discussed in detail.

A Case of Occlusive Radiation Vasculopathy Presenting as Bilateral Internal Carotid Artery, Left Middle Cerebral Artery Occlusion and Literature Review.

Radiation vasculopathy is one of the rare causes of ischemic stroke. Carotid stenosis with large volume infarction may occur years after radiation therapy for head or neck cancer. We report a case of a patient with bilateral internal carotid artery occlusion presenting with left middle cerebral artery infarct 10 years after receiving treatment for tongue cancer. A literature review and discussion of treatment for such patients are presented.

Advances in cerebral amyloid angiopathy imaging.

Cerebral amyloid angiopathy (CAA) is a cerebral small vessel disease caused by ß -amyloid (Aß) deposition at the leptomeningeal vessel walls. It is a common cause of spontaneous intracerebral hemorrhage and a frequent comorbidity in Alzheimer's disease. The high recurrent hemorrhage rate in CAA makes it very important to recognize this disease to avoid potential harmful medication. Imaging studies play an important role in diagnosis and research of CAA. Conventional computed tomography and magnetic resonance imaging (MRI) methods reveal anatomical alterations, and remains as the most reliable tool in identifying CAA according to modified Boston criteria. The vascular injuries of CAA result in both hemorrhagic and ischemic manifestations and related structural changes on MRI, including cerebral microbleeds, cortical superficial siderosis, white matter hyperintensity, MRI-visible perivascular spaces, and cortical microinfarcts. As imaging techniques advance, not only does the resolution of conventional imaging improve, but novel skills in functional and molecular imaging studies also enable in vivo analysis of vessel physiological changes and underlying pathology. These modern tools help in early detection of CAA and may potentially serve as sensitive outcome markers in future clinical trials. In this article, we reviewed past studies of CAA focusing on utilization of various conventional and novel imaging techniques in both research and clinical aspects.

In vivo imaging of insulin-secreting human pancreatic ductal cells using MRI reporter gene technique: A feasibility study.

PURPOSE: The purpose of this study was to investigate the feasibility of in vivo imaging of human pancreatic ductal cells by OATP1B3 reporter gene under MRI. METHODS: A human cell line (PANC-1) derived from the pancreatic ductal epithelium was used in this study. After transduction of OATP1B3, the cellular physiological functions and the ability of intracellular uptake of the MRI contrast medium (Gd-EOB-DTPA) were examined. Induced differentiation of the PANC-1 cells into hormone-secreting cells were performed to simulate pancreatic ß-like cells. The hormone-secreting cells were implanted into rats and in vivo MRI was evaluated. RESULTS: The mRNA and proteins of OATP1B3 were highly expressed. No significant change of cellular physiological functions was found after the expression. After induced differentiation, the hormone secretion capacities of the OATP1B3-expressing PANC-1 cells were confirmed. Intra-cellular uptake of Gd-EOB-DTPA was determined in vitro by inductively coupled plasma mass spectrometry and MRI. In vivo MRI of the OATP1B3-expressing xenograft revealed an increased signal intensity after contrast enhancement. CONCLUSION: OATP1B3 can be used as a safe and feasible in vivo MRI gene reporter for human pancreatic ductal cells.

Sex as a Moderating Factor in the Relationship Between Hippocampal Volume and Sensory Gating in Patients With Schizophrenia.

Building on the knowledge of sex differences in auditory sensory gating in schizophrenia and hippocampal involvement in sensory gating, this study aimed to investigate sex as a potential moderator of the association between hippocampal volume and P50 in schizophrenia. Auditory P50 gating and hippocampal volume were measured in 16 male and 15 female patients with schizophrenia. The correlations between hippocampal volume and P50 were analyzed in males and females separately, corrected for potential confounders, including age, duration of illness, and antipsychotic medication. Different associative patterns of hippocampal volume with P50 gating ratio and with P50 difference were found by sex. The results suggest sex may play a role in the physiology of sensory gating.

Volume Visualization for Improving CT Lung Nodule Detection.

Inspired by the outstanding performance of deep convolutional neural networks (CNNs), nowadays modern computer-aided detection (CAD) systems for CT lung nodules generally delve into 2D or 3D CNNs directly without considering traditional image preprocessing techniques. However, detection of large pulmonary nodules and masses are computationally challenging, especially for 3D CNNs. In this paper, we examine the possibility of using volume visualized CT thin-slab images with 2D CNNs to reduce computation complexity and improve CAD performance. We tested 4 types of images: original 2D CT, 2D projection of thin slabs, mixture by arranging original and projection in different color channels, and mixture by the pixelwise maximum intensity of original CT and projection. We evaluated these images on a dataset of 30 CT scans with 30 different-sized nodules and masses on GoogLeNet via a transfer learning and cross validation paradigm. We found that projection visualization alone had a better or equal area-under curve score for all the different-sized nodules and masses. However, mixture by the maximum of CT and projection demonstrated a preferred performance with a true positive rate of 0.8 and a false positive rate of 0.046 in detecting large nodules and masses.

Greater ultrasonographic changes in pediatric moyamoya patients compared with adults after indirect revascularization surgeries.

OBJECTIVEPediatric and adult patients with moyamoya disease experience similar clinical benefits from indirect revascularization surgeries, but there are still debates about age-related angiographic differences of the collaterals established after surgery. The goal of this study was to assess age-related differences on ultrasonography before and after indirect revascularization surgeries in moyamoya patients, focusing on some ultrasonographic parameters known to be correlated with the collaterals supplied by the external carotid artery (ECA).METHODSThe authors prospectively included moyamoya patients (50 and 26 hemispheres in pediatric and adult patients, respectively) who would undergo indirect revascularization surgery. Before surgery and at 1, 3, and 6 months after surgery, the patients underwent ultrasonographic examinations. The ultrasonographic parameters included peak-systolic velocity (PSV), end-diastolic velocity (EDV), resistance index (RI), and flow volume (FV) measured in the ECA, superficial temporal artery (STA), and internal carotid artery on the operated side. The mean values, absolute changes, and percentage changes of these parameters were compared between the pediatric and adult patients. Logistic regression analysis was used to clarify the determinants affecting postoperative EDV changes in the STA.RESULTSBefore surgery, the adult patients had mean higher EDV and lower RI in the STA and ECA than the pediatric group (all p < 0.05). After surgery, the pediatric patients had greater changes (absolute and percentage changes) in the PSV, EDV, RI, and FV in the STA and ECA (all p < 0.05). The factors affecting postoperative EDV changes in the STA at 6 months were age (p = 0.006) and size of the revascularization area (i.e., revascularization in more than the temporal region vs within the temporal region; p = 0.009). Pediatric patients who received revascularization procedures in more than the temporal region had higher velocities (PSV and EDV) in the STA than those who received revascularization within the temporal region (p < 0.05 at 1-6 months), but such differences were not observed in the adult group.CONCLUSIONSThe greater changes of these parameters in the STA and ECA in pediatric patients than in adults after indirect revascularization surgeries indicated that pediatric patients might have a greater increase of collaterals postoperatively than adults. Pediatric patients who undergo revascularization in more than the temporal region might have more collaterals than those who undergo revascularization within the temporal region.

Association between mismatch negativity and voxel-based brain volume in schizophrenia.

OBJECTIVE: This study aimed to investigate the association between mismatch negativity (MMN) and volumes of several brain regions measured using a semi-automated method in patients with schizophrenia and healthy controls. METHODS: MMN in response to duration deviants and magnetic resonance imaging were acquired from 36 schizophrenia patients and 14 healthy controls. FreeSurfer was used for volumetric analysis. MMN amplitudes, brain volumes and their association were compared between schizophrenia and controls. Correlation analysis and multiple linear regression analysis were used to examine the correlated variables of MMN. RESULTS: MMN amplitude was significantly lower in the schizophrenia group. In schizophrenia, MMN was positively correlated with age and negatively correlated with left hippocampal and right pars opercularis volumes. The association between left hippocampal volume and MMN in schizophrenia remained significant after controlling for potential confounders. CONCLUSIONS: Smaller hippocampal volume may play a role in the abnormal manifestation of MMN in schizophrenia. SIGNIFICANCE: The significant association between MMN and left hippocampal volume may suggest unique neurobiological contribution of hippocampus in auditory processing in schizophrenia.

Improving Indirect Revascularization for Effective Treatment of Adult Moyamoya Disease: A Prospective Clinical, Cerebral Angiographic, and Perfusion Study.

BACKGROUND: Indirect revascularization is simple and safe, but it is not commonly used in adult moyamoya disease owing to its unreliable effect. This prospective study aimed to evaluate the effectiveness of indirect revascularization in treating adult moyamoya disease after refinement of the surgical technique and perioperative care. METHODS: Adult patients who underwent indirect revascularization as the primary treatment for moyamoya disease between November 2013 and January 2017 were studied. The indirect revascularization procedures included encephalo-duro-arterio-synangiosis and encephalo-myo-synangiosis in the temporal region and encephalo-pericranio-synangiosis in other hypoperfusion areas. The preoperative and postoperative clinical conditions, cerebral angiography findings, and time-to-peak prolongation areas on magnetic resonance perfusion studies were assessed to evaluate the revascularization effect. Refinements of the surgical technique included the selection of surgical area based on perfusion imaging, craniotomy size, and number of affected hemispheres, along with the inclusion of a dural flap in every procedure. RESULTS: Nineteen patients (17 females and 2 males), and a total of 31 cerebral hemispheres, were included. The mean patient age was 32.7 ± 11.4 years. After a mean follow-up of 38.6 ± 11.5 months, all patients showed clinical improvement or stabilization. Available postoperative angiography demonstrated Matsushima grade A or B in 19 of 21 hemispheres. The mean time-to-peak prolongation index of all 31 hemispheres improved from 24.09 ± 9.83% preoperatively to 12.82 ± 6.75% at 3-6 months after surgery (P < 0.001). The complication rate was 12.9%, and all complications were transient. CONCLUSIONS: With refinements of surgical techniques and perioperative care, indirect revascularization is more reliable and can be a viable alternative treatment for adult moyamoya disease. In our cohort, outcomes were satisfactory, with mean 38.6-month follow-up.

Engorged medullary vein on CT angiography in patients with dural arteriovenous fistula: prevalence, types, and comparison between regional and extensive types.

BACKGROUND AND PURPOSE: Engorged medullary vein (EMV) in patients with intracranial dural arteriovenous fistula (DAVF) suggests venous congestion. The aim of this study is to investigate its prevalence, pattern, and correlation with clinical findings. MATERIALS AND METHODS: CT angiography (CTA) raw data of DAVF were used for multiplanar reconstruction and then analyzed for the presence and pattern of EMV, which is defined as a dilated vein in the cerebral white matter. Patients with EMV were divided into two groups: regional and extensive. Regional type is defined as EMV limited to one cerebral hemisphere or cerebellum without evidence of subcortical calcification. Extensive type is defined as EMV involvement of more than one cerebral hemisphere or both the cerebrum and cerebellum. Descriptive analysis of clinical information, DAVF characteristics, and other imaging findings was conducted. Clinical information, including demographic data, clinical presentation, and hemorrhage, were correlated with both types of EMV. RESULTS: Among 192 eligible patients with DAVF, 71 (37%) had EMV. Patients with EMV were older (63 years vs 56 years, P=0.02), with DAVF more often at the transverse and sigmoid sinus (P<0.001), and more often presented with aggressive symptoms (59% vs 34%, P=0.02) than non-EMV patients, but there was no difference in the presentation of hemorrhage (15% vs 16%, P=0.99). Patients with regional EMV had a higher proportion of hemorrhage than those with the extensive type (24% vs 0%, P=0.006). CONCLUSIONS: EMV in patients with DAVF is associated with an aggressive manifestation. Regional type EMV is associated with a higher risk of a hemorrhagic presentation.