Intimate Partner Violence-Related Brain Injury: Unmasking and Addressing the Gaps.

Intimate partner violence (IPV) is a significant, global public health concern. Women, individuals with historically underrepresented identities, and disabilities are at high risk for IPV and tend to experience severe injuries. There has been growing concern about the risk of exposure to IPV-related head trauma, resulting in IPV-related brain injury (IPV-BI), and its health consequences. Past work suggests that a significant proportion of women exposed to IPV experience IPV-BI, likely representing a distinct phenotype compared with BI of other etiologies. An IPV-BI often co-occurs with psychological trauma and mental health complaints, leading to unique issues related to identifying, prognosticating, and managing IPV-BI outcomes. The goal of this review is to identify important gaps in research and clinical practice in IPV-BI and suggest potential solutions to address them. We summarize IPV research in five key priority areas: (1) unique considerations for IPV-BI study design; (2) understanding non-fatal strangulation as a form of BI; (3) identifying objective biomarkers of IPV-BI; (4) consideration of the chronicity, cumulative and late effects of IPV-BI; and (5) BI as a risk factor for IPV engagement. Our review concludes with a call to action to help investigators develop ecologically valid research studies addressing the identified clinical-research knowledge gaps and strategies to improve care in individuals exposed to IPV-BI. By reducing the current gaps and answering these calls to action, we will approach IPV-BI in a trauma-informed manner, ultimately improving outcomes and quality of life for those impacted by IPV-BI.

Carotid Plaque-RADS: A Novel Stroke Risk Classification System.

BACKGROUND: Carotid artery atherosclerosis is highly prevalent in the general population and is a well-established risk factor for acute ischemic stroke. Although the morphological characteristics of vulnerable plaques are well recognized, there is a lack of consensus in reporting and interpreting carotid plaque features. OBJECTIVES: The aim of this paper is to establish a consistent and comprehensive approach for imaging and reporting carotid plaque by introducing the Plaque-RADS (Reporting and Data System) score. METHODS: A panel of experts recognized the necessity to develop a classification system for carotid plaque and its defining characteristics. Using a multimodality analysis approach, the Plaque-RADS categories were established through consensus, drawing on existing published reports. RESULTS: The authors present a universal classification that is applicable to both researchers and clinicians. The Plaque-RADS score offers a morphological assessment in addition to the prevailing quantitative parameter of "stenosis." The Plaque-RADS score spans from grade 1 (indicating complete absence of plaque) to grade 4 (representing complicated plaque). Accompanying visual examples are included to facilitate a clear understanding of the Plaque-RADS categories. CONCLUSIONS: Plaque-RADS is a standardized and reliable system of reporting carotid plaque composition and morphology via different imaging modalities, such as ultrasound, computed tomography, and magnetic resonance imaging. This scoring system has the potential to help in the precise identification of patients who may benefit from exclusive medical intervention and those who require alternative treatments, thereby enhancing patient care. A standardized lexicon and structured reporting promise to enhance communication between radiologists, referring clinicians, and scientists.

Extracranial carotid artery atherosclerotic plaque and APOE polymorphisms: a systematic review and meta-analysis.

Introduction: Carotid atherosclerotic plaque is an important independent risk factor for stroke. Apolipoprotein E (APOE) influences cholesterol levels and certain isoforms are associated with increased carotid atherosclerosis, though the exact association between APOE and carotid plaque is uncertain. The study aimed to evaluate the association between APOE and carotid plaque. Methods: A systematic review was performed to retrieve all studies which examined the association between carotid plaque and APOE. This study was conducted in accordance with the PRISMA guidelines. Independent readers extracted the relevant data from each study including the type of imaging assessment, plaque definition, frequency of APOE E4 carrier status and type of genotyping. Meta-analyses with an assessment of study heterogeneity and publication bias were performed. Results were presented in a forest plot and summarized using a random-effects model. Results: After screening 838 studies, 17 studies were included for systematic review. A meta-analysis of 5 published studies showed a significant association between ε4 homozygosity and carotid plaque [odds ratio (OR), 1.53; 95% CI, 1.16, 2.02; p = .003]. Additionally, there was a significant association between patients possessing at least one ε4 allele, heterozygotes or homozygotes, and carotid plaque (OR, 1.25; 95% CI, 1.03, 1.52; p = .03). Lastly, there was no association between ε4 heterozygosity and carotid plaque (OR, 1.08; 95% CI, 0.93, 1.26; p = .30). Conclusion: APOE ε4 allele is significantly associated with extracranial carotid atherosclerotic plaque, especially for homozygous individuals.

Evaluation of methemoglobin as an intravascular contrast agent: T1 relaxation time effect in a rabbit model.

OBJECTIVE: Alternative contrast agents for MRI are needed for individuals who may respond adversely to gadolinium, and need an intravascular agent for specific indications. One potential contrast agent is intracellular methemoglobin, a paramagnetic molecule that is normally present in small amounts in red blood cells. An animal model was used to determine whether methemoglobin modulation with intravenous sodium nitrite transiently changes the T1 relaxation of blood. METHODS: Four adult New Zealand white rabbits were treated with 30 mg intravenous sodium nitrite. 3D TOF and 3D MPRAGE images were acquired before (baseline) and after methemoglobin modulation. T1 of blood was measured with 2D ss EPl acquisitions with inversion recovery preparation performed at two-minute intervals up to 30 min. T1 maps were calculated by fitting the signal recovery curve within major blood vessels. RESULTS: Baseline T1 was 1758 ± 53 ms in carotid arteries and 1716 ± 41 ms in jugular veins. Sodium nitrite significantly changed intravascular T1 relaxation. The mean minimum value of T1 was 1126 ± 28 ms in carotid arteries 8 to 10 min after the injection of sodium nitrite. The mean minimum value of T1 was 1171 ± 52 ms in jugular veins 10 to 14 min after the injection of sodium nitrite. Arterial and venous T1 recovered to baseline after a period of 30 min. CONCLUSION: Methemoglobin modulation produces intravascular contrast on T1-weighted MRI in vivo. Additional studies are needed to safely optimize methemoglobin modulation and sequence parameters for maximal tissue contrast.

A comparison of simultaneous multislice and conventional diffusion tensor imaging techniques for ischemic stroke evaluation at 1.5T.

OBJECTIVE: Diffusion tensor imaging (DTI) is a promising technique for ischemic stroke evaluation; however, acquisition time is longer than DWI. Simultaneous multislice (SMS) imaging acquires multiple slices together and reduces scan time. This study compared conventional and SMS DTI for ischemic stroke workup. METHODS: Following IRB approval, the departmental stroke protocol was supplemented with SMS DTI on a clinical 1.5T MRI. Cases suspicious for ischemic stroke outside the treatment window were included. Standard DTI (STD-DTI, 20-direction, b = 2000 s/mm2), was followed by SMS-2-DTI (two slices simultaneously imaged). Two blinded neuroradiologists independently assessed image quality and DTI-trace status (positive/negative = stroke/other). Average image quality, interrater reliability (κ), receiver operating characteristic area under the curve (AUC), signal-to-noise ratio (SNR = DTI-source min/max/average), coefficient of variation (CV), mean diffusivity (MD), and fractional anisotropy (FA, of DTI-trace) were compared using two-tailed t-tests and a p < .05. RESULTS: 41 patients were evaluated. SMS-2-DTI decreased DTI time by 132.17 ± 15.33 s, a 45% reduction. SMS-2-DTI reduced image quality (STD-DTI 4.7 ± 0.5 vs SMS-2-DTI 3.8 ± 0.6, p < .001). Diagnostic accuracy persisted, AUC was high for observer 1 (STD-DTI 0.95, 95%CI = 0.88-1.00 vs SMS-2-DTI 0.94, 95%CI = 0.87-1.00, p = .86) and observer 2 (STD-DTI 0.89, 95%CI = 0.79-0.99 vs SMS-2-DTI 0.86, 95%CI = 0.76-0.97, p = .66). Interrater reliability was high for STD-DTI (κ = 0.80, 95%CI = 0.61-0.98) and SMS-2-DTI (κ = 0.84, 95%CI = 0.67-1.00). SMS-2-DTI significantly decreased average SNR (STD-DTI 42.85 ± 4.44 vs SMS-2-DTI 32.58 ± 4.30, p < .001), and CV MD (STD-DTI 0.23 ± 0.03 vs 0.20 ± 0.04, p < .001). CV FA and CV DTI-trace were not statistically different. CONCLUSIONS: This study supports using SMS to accelerate DTI for ischemic stroke workup at 1.5T in the non-hyper-acute setting. ADVANCES IN KNOWLEDGE: This study highlights the feasibility of accelerated multislice DTI for faster diagnostic DTI-trace images capable of ischemic stroke detection.

Association between high-risk extracranial carotid plaque and covert brain infarctions and cerebral microbleeds.

PURPOSE: Covert brain infarctions (CBIs) and cerebral microbleeds (CMBs) represent subclinical sequelae of ischemic and hemorrhagic cerebral small vessel disease, respectively. In addition to thromboembolic stroke, carotid atherosclerosis has been associated with downstream vascular brain injury, including inflammation and small vessel disease. The specific plaque features responsible for this are unknown. We aimed to determine the association of specific vulnerable carotid plaque features to CBIs and CMBs to better understand the relation of large and small vessel disease in a single-center retrospective observational study. METHODS: Intraplaque hemorrhage (IPH) and plaque ulceration were recorded on carotid MRA and total, cortical, and lacunar CBIs and CMBs were recorded on brain MR in 349 patients (698 carotid arteries). Multivariable Poisson regression was performed to relate plaque features to CBIs and CMBs. Within-subject analysis in those with unilateral IPH and ulceration was performed with Poisson regression. RESULTS: Both IPH and plaque ulceration were associated with total CBI (prevalence ratios (PR) 3.33, 95% CI: 2.16-5.15 and 1.91, 95% CI: 1.21-3.00, respectively), after adjusting for stenosis, demographic, and vascular risk factors. In subjects with unilateral IPH, PR was 2.83, 95% CI: 1.76-4.55, for CBI in the ipsilateral hemisphere after adjusting for stenosis. Among those with unilateral ulceration, PR was 1.82, 95% CI: 1.18-2.81, for total CBI ipsilateral to ulceration after adjusting for stenosis. No statistically significant association was seen with CMBs. CONCLUSION: Both IPH and plaque ulceration are associated with total, cortical, and lacunar type CBIs but not CMBs suggesting that advanced atherosclerosis contributes predominantly to ischemic markers of subclinical vascular injury.

Emergent neurovascular imaging in patients with blunt traumatic injuries.

Blunt cerebrovascular injuries (BCVIs) are commonly encountered after blunt trauma. Given the increased risk of stroke incurred after BCVI, it is crucial that they are promptly identified, characterized, and treated appropriately. Current screening practices generally consist of computed tomography angiography (CTA), with escalation to digital subtraction angiography for higher-grade injuries. Although it is quick, cost-effective, and readily available, CTA suffers from poor sensitivity and positive predictive value. A review of the current literature was conducted to examine the current state of emergent imaging for BCVI. After excluding reviews, irrelevant articles, and articles exclusively available in non-English languages, 36 articles were reviewed and included in the analysis. In general, as CTA technology has advanced, so too has detection of BCVI. Magnetic resonance imaging (MRI) with sequences such as vessel wall imaging, double-inversion recovery with black blood imaging, and magnetization prepared rapid acquisition echo have notably improved the utility for MRI in characterizing BCVIs. Finally, transcranial Doppler with emboli detection has proven to be associated with strokes in anterior circulation injuries, further allowing for the identification of high-risk lesions. Overall, imaging for BCVI has benefited from a tremendous amount of innovation, resulting in better detection and characterization of this pathology.

Carotid Compliance and Parahippocampal and Hippocampal Volume over a 20-Year Period.

INTRODUCTION: We evaluated the association between carotid compliance, a measure of arterial stiffness, to parahippocampal volume (PHV) and hippocampal volume (HV) over 20 years later in the Atherosclerosis Risk in the Community study. METHODS: We included participants with common carotid compliance measurements at visit 1 (1987-1989) and volumetric brain MRI at visit 5 (2011-2013). The primary outcomes are pooled bilateral PHV and HV. We performed linear regression models adjusting for age, sex, vascular risk factors, and total brain volume. RESULTS: Of the 614 participants, higher compliance was correlated with higher PHV (R = 0.218[0.144-0.291], p < 0.001) and HV (R = 0.181 [0.105-0.255, p < 0.001]). The association was linear and significant after adjusting for confounders. At follow-up MRI, 30 patients with dementia had lower PHV and HV than patients without dementia (p < 0.001 and p < 0.001, respectively). CONCLUSION: Carotid compliance is associated with higher PHV and HV when measured 20 years later, further supporting the link between arterial stiffness and cognitive decline.

MR Angiography Series: Neurovascular MR Angiography.

Neurovascular MR angiography (MRA) is an evolving imaging technique and is crucial for the workup of numerous neurologic disorders. While CT angiography (CTA) provides a more rapid imaging assessment, in select patients it can impart a small risk of contrast material-induced nephrotoxicity or radiation-associated cancers. In addition, MRA offers some advantages over CTA for neurovascular evaluation, including higher temporal resolution and the capability for vessel wall imaging. This module is the third in a series created on behalf of the Society for Magnetic Resonance Angiography (SMRA), a group of researchers and clinicians who are passionate about the benefits of MRA but understand its challenges. The full digital presentation is available online. Work of the U.S. Government published under an exclusive license with the RSNA.

MR Perfusion in the Evaluation of Mechanical Thrombectomy Candidacy.

ABSTRACT: Stroke is a leading cause of disability and mortality, and the incidence of ischemic stroke is projected to continue to rise in coming decades. These projections emphasize the need for improved imaging techniques for accurate diagnosis allowing effective treatments for ischemic stroke. Ischemic stroke is commonly evaluated with computed tomography (CT) or magnetic resonance imaging (MRI). Noncontrast CT is typically used within 4.5 hours of symptom onset to identify candidates for thrombolysis. Beyond this time window, thrombolytic therapy may lead to poor outcomes if patients are not optimally selected using appropriate imaging. MRI provides an accurate method for the earliest identification of core infarct, and MR perfusion can identify salvageable hypoperfused penumbra. The prognostic value for a better outcome in these patients lies in the ability to distinguish between core infarct and salvageable brain at risk-the ischemic penumbra-which is a function of the degree of ischemia and time. Many centers underutilize MRI for acute evaluation of ischemic stroke. This review will illustrate how perfusion-diffusion mismatch calculated from diffusion-weighted MRI and MR perfusion is a reliable approach for patient selection for stroke therapy and can be performed in timeframes that are comparable to CT-based algorithms while providing potentially superior diagnostic information.

Differentiation of symptomatic and asymptomatic carotid intraplaque hemorrhage using 3D high-resolution diffusion-weighted stack of stars imaging.

Ischemic events related to carotid disease are far more strongly associated with plaque instability than stenosis. 3D high-resolution diffusion-weighted (DW) imaging can provide quantitative diffusion measurements on carotid atherosclerosis and may improve detection of vulnerable intraplaque hemorrhage (IPH). The 3D DW-stack of stars (SOS) sequence was implemented with 3D SOS acquisition combined with DW preparation. After simulation of signals created from 3D DW-SOS, phantom studies were performed. Three healthy subjects and 20 patients with carotid disease were recruited. Apparent diffusion coefficient (ADC) values were statistically analyzed on three subgroups by using a two-group comparison Wilcoxon-Mann-Whitney U test with p values less than 0.05: symptomatic versus asymptomatic; IPH-positive versus IPH-negative; and IPH-positive symptomatic versus asymptomatic plaques to determine the relationship with plaque vulnerability. ADC values calculated by 3D DW-SOS provided values similar to those calculated from other techniques. Mean ADC of symptomatic plaque was significantly lower than asymptomatic plaque (0.68 ± 0.18 vs. 0.98 ± 0.16 x 10-3  mm2 /s, p < 0.001). ADC was also significantly lower in IPH-positive versus IPH-negative plaque (0.68 ± 0.13 vs. 1.04 ± 0.11 x 10-3  mm2 /s, p < 0.001). Additionally, ADC was significantly lower in symptomatic versus asymptomatic IPH-positive plaque (0.57 ± 0.09 vs. 0.75 ± 0.11 x 10-3  mm2 /s, p < 0.001). Our results provide strong evidence that ADC measurements from 3D DW-SOS correlate with the symptomatic status of extracranial internal carotid artery plaque. Further, ADC improved discrimination of symptomatic plaque in IPH. These data suggest that diffusion characteristics may improve detection of destabilized plaque leading to elevated stroke risk.

Using Ultrasound and Inflammation to Improve Prediction of Ischemic Stroke: A Secondary Analysis of the Multi-Ethnic Study of Atherosclerosis.

INTRODUCTION: Current ischemic stroke risk prediction is primarily based on clinical factors, rather than imaging or laboratory markers. We examined the relationship between baseline ultrasound and inflammation measurements and subsequent primary ischemic stroke risk. METHODS: In this secondary analysis of the Multi-Ethnic Study of Atherosclerosis (MESA), the primary outcome is the incident ischemic stroke during follow-up. The predictor variables are 9 carotid ultrasound-derived measurements and 6 serum inflammation measurements from the baseline study visit. We fit Cox regression models to the outcome of ischemic stroke. The baseline model included patient age, hypertension, diabetes, total cholesterol, smoking, and systolic blood pressure. Goodness-of-fit statistics were assessed to compare the baseline model to a model with ultrasound and inflammation predictor variables that remained significant when added to the baseline model. RESULTS: We included 5,918 participants. The primary outcome of ischemic stroke was seen in 105 patients with a mean follow-up time of 7.7 years. In the Cox models, we found that carotid distensibility (CD), carotid stenosis (CS), and serum interleukin-6 (IL-6) were associated with incident stroke. Adding tertiles of CD, IL-6, and categories of CS to a baseline model that included traditional clinical vascular risk factors resulted in a better model fit than traditional risk factors alone as indicated by goodness-of-fit statistics. CONCLUSIONS: In a multiethnic cohort of patients without cerebrovascular disease at baseline, we found that CD, CS, and IL-6 helped predict the occurrence of primary ischemic stroke. Future research could evaluate if these basic ultrasound and serum measurements have implications for primary prevention efforts or clinical trial inclusion criteria.

Predicting neuroimaging eligibility for extended-window endovascular thrombectomy.

OBJECTIVE: Endovascular thrombectomy (EVT) and tissue plasminogen activator (tPA) are effective ischemic stroke treatments in the initial treatment window. In the extended treatment window, these treatments may offer benefit, but CT and MR perfusion may be necessary to determine patient eligibility. Many hospitals do not have access to advanced imaging tools or EVT capability, and further patient care would require transfer to a facility with these capabilities. To assist transfer decisions, the authors developed risk indices that could identify patients eligible for extended-window EVT or tPA. METHODS: The authors retrospectively identified stroke patients who had concurrent CTA and perfusion and evaluated three potential outcomes that would suggest a benefit from patient transfer. The first outcome was large-vessel occlusion (LVO) and target mismatch (TM) in patients 5-23 hours from last known normal (LKN). The second outcome was TM in patients 5-15 hours from LKN with known LVO. The third outcome was TM in patients 4.5-12 hours from LKN. The authors created multivariable models using backward stepping with an α-error criterion of 0.05 and assessed them using C statistics. RESULTS: The final predictors included the National Institutes of Health Stroke Scale (NIHSS), the Alberta Stroke Program Early CT Score (ASPECTS), and age. The prediction of the first outcome had a C statistic of 0.71 (n = 145), the second outcome had a C statistic of 0.85 (n = 56), and the third outcome had a C statistic of 0.86 (n = 54). With 1 point given for each predictor at different cutoffs, a score of 3 points had probabilities of true positive of 80%, 90%, and 94% for the first, second, and third outcomes, respectively. CONCLUSIONS: Despite the limited sample size, compared with perfusion-based examinations, the clinical variables identified in this study accurately predicted which stroke patients would have salvageable penumbra (C statistic 71%-86%) in a range of clinical scenarios and treatment cutoffs. This prediction improved (C statistic 85%-86%) when utilized in patients with confirmed LVO or a less stringent tissue mismatch (TM < 1.2) cutoff. Larger patient registries should be used to validate and improve the predictive ability of these models.

Rabbit models of intracranial atherosclerotic disease for pathological validation of vessel wall MRI.

INTRODUCTION: Vessel wall magnetic resonance imaging can improve the evaluation of intracranial atherosclerotic disease. However, pathological validation is needed to improve vessel wall magnetic resonance imaging techniques. Human pathology samples are not practical for such analysis, so an animal model is therefore needed. MATERIALS AND METHODS: Watanabe heritable hyperlipidemic rabbits and apolipoprotein E knockout rabbits were evaluated against New Zealand white wild-type rabbits. Evaluation of intracranial arteries was performed with vessel wall magnetic resonance imaging and pathological analysis, rating the presence and severity of disease in each segment. Two-tailed t-tests were performed to compare disease occurrence and severity prevalence among rabbit subtypes. Sensitivity and specificity were calculated to assess the diagnostic accuracy of vessel wall magnetic resonance imaging. RESULTS: Seventeen rabbits (five Watanabe heritable hyperlipidemic, four apolipoprotein E knockout and eight New Zealand white) were analysed for a total of 51 artery segments. Eleven segments (five Watanabe heritable hyperlipidemic and six apolipoprotein E knockout) demonstrated intracranial atherosclerotic disease on pathology. Disease model animals had lesions more frequently than New Zealand white animals (P<0.001). The sensitivity and specificity of vessel wall magnetic resonance imaging for the detection of intracranial atherosclerotic disease were 68.8% and 95.2%, respectively. When excluding mild cases to assess vessel wall magnetic resonance imaging accuracy for detecting moderate to severe intracranial atherosclerotic disease lesions, sensitivity improved to 100% with unchanged specificity. CONCLUSION: Intracranial atherosclerotic disease can be reliably produced and detected using 3T vessel wall magnetic resonance imaging-compatible Watanabe heritable hyperlipidemic and ApoE rabbit models. Further analysis is needed to characterize better the development and progression of the disease to correlate tissue-validated animal findings with those in human vessel wall magnetic resonance imaging studies.

Carotid artery plaque characteristics: current reporting practices on CT angiography.

PURPOSE: Extracranial ICA imaging has largely focused on the degree of luminal stenosis, but recent advances suggest specific plaque features are crucial in stroke risk assessment. We evaluated the current state of reporting carotid plaque features on neck CTAs at an academic institution. METHODS: In this retrospective observational study, we included neck CTAs performed on patients over age 50 with any reported carotid plaque. We evaluated reports for mention of the following: degree of luminal stenosis, soft plaque, calcified plaque, plaque thickness, quantification of soft and calcified plaque, plaque ulceration, and increased risk associated with specific features. We used Fisher's exact test to compare how often each feature was mentioned. RESULTS: We included a total of 651 reports from unique patients (mean age, 68.1 ± 13.3 years). A total of 639 reports (98.1%) explicitly mentioned degree of stenosis per NASCET criteria. Specific plaque features were less frequently characterized: soft plaque in 116 (17.8%); calcified plaque in 166 (25.5%); quantification of the amount of soft plaque and calcified plaque in 24 (3.7%) and 16 (2.5%) reports, respectively; plaque thickness in 12 (1.8%); plaque ulceration in 476 (73.1%); and increased risk associated with plaque in 2 (0.3%). Degree of stenosis was statistically more likely to be mentioned than any other plaque feature (p < 0.001). CONCLUSION: Currently, nearly all reports mention the degree of luminal stenosis on neck CTAs while a significant minority mention specific plaque features. Despite mounting evidence of the importance of carotid plaque features in stroke risk assessment, radiology reports do not routinely report these findings.

Neuroimmunogastroenterology: At the Interface of Neuroimmunology and Gastroenterology.

The central nervous system (CNS) is an important regulator of the gastrointestinal tract, and CNS dysfunction can result in significant and disabling gastrointestinal symptom manifestation. For patients with neuroimmunologic and neuroinflammatory conditions, the recognition of gastrointestinal symptoms is under-appreciated, yet the gastrointestinal manifestations have a dramatic impact on quality of life. The current treatment strategies, often employed independently by the neurologist and gastroenterologist, raise the question of whether such patients are being treated optimally when siloed in one specialty. Neuroimmunogastroenterology lies at the borderlands of medical specialties, and there are few resources to guide neurologists in this area. Here, we provide an overview highlighting the potential mechanisms of crosstalk between immune-mediated neurological disorders and gastrointestinal dysfunction.

Intravascular Lymphoma with Progressive CNS Hemorrhage and Multiple Dissections.

INTRODUCTION: Intravascular lymphoma (IVL) is an uncommon and often fatal disease characterized by intraluminal proliferation of lymphomatous cells within blood vessels. Because of a heterogeneous clinical presentation and lack of sensitive diagnostic protocols, diagnosis of IVL is most often made at autopsy. However, with early diagnosis and appropriate chemotherapy, the prognosis is greatly improved and complete remission is possible. In order to broaden the possible presentations of IVL, we present a patient with an atypical manifestation of biopsy-proven intravascular large B-cell lymphoma who suffered dissections of both intracranial and extracranial arteries in addition to progressive intracranial hemorrhages. Case Report. A 47-year-old woman presented with unilateral paresthesias. She developed progressive multifocal infarcts and hemorrhage with dissections of both intracranial and extracranial arteries, resulting in coma. Brain biopsy revealed IVL. She received aggressive chemotherapy and remains in complete remission with good neurologic recovery. CONCLUSION: IVL is known to exert its pathology on small arteries and capillaries, but is not known to cause dissections of large vessels. The diagnosis should be considered in cases with unexplained arterial dissections and progressive strokes. Early diagnosis with appropriate laboratory screening and tissue confirmation by biopsy can lead to greatly improved outcomes.

Analysis of retention of gadolinium by brain, bone, and blood following linear gadolinium-based contrast agent administration in rats with experimental sepsis.

PURPOSE: It is important to identify populations that may be vulnerable to the brain deposition of gadolinium (Gd) from MRI contrast agents. At intervals from 24 hours to 6 weeks following injection of a linear Gd contrast agent, the brain, blood and bone content of Gd were compared between control rats and those with experimental endotoxin-induced sepsis that results in neuroinflammation and blood-brain barrier disruption. METHODS: Male rats were injected intraperitoneally with 10 mg/kg lipopolysaccharide. Control animals received no injection. Twenty-four hours later, 0.2 mmol/kg of gadobenate dimeglumine was injected intravenously. Brain, blood, and bone Gd levels were measured at 24 hours, 1 week, 3 weeks, and 6 weeks by inductively coupled plasma mass spectroscopy. RESULTS: Blood Gd decreased rapidly between 24 hours and 1 week, and thereafter was undetectable, with no significant difference between lipopolysaccharide and control rats. Brain levels of Gd were significantly higher (4.29-2.36-fold) and bone levels slightly higher (1.35-1.11-fold) in lipopolysaccharide than control rats at all time points with significant retention at 6 weeks. CONCLUSION: Experimental sepsis results in significantly higher deposition of Gd in the brain and bone in rats. While blood Gd clears rapidly, brain and bone retained substantial Gd even at 6 weeks following contrast injection.

Subclinical Cerebrovascular Disease: Epidemiology and Treatment.

PURPOSE OF REVIEW: Subclinical cerebrovascular disease (sCVD) is highly prevalent in older adults. The main neuroimaging findings of sCVD include white matter hyperintensities and silent brain infarcts on T2-weighted MRI and cerebral microbleeds on gradient echo or susceptibility-weighted MRI. In this paper, we will review the epidemiology of sCVD, the current evidence for best medical management, and future directions for sCVD research. RECENT FINDINGS: Numerous epidemiologic studies show that sCVD, in particular WMH, is an important risk factor for the development of dementia, stroke, worse outcomes after stroke, gait instability, late-life depression, and death. Effective treatment of sCVD could have major consequences for the brain health of a substantial portion of older Americans. Despite the link between sCVD and many vascular risk factors, such as hypertension or hyperlipidemia, the optimal medical treatment of sCVD remains uncertain. Given the clinical equipoise about the risk versus benefit of aggressive medical management for sCVD, clinical trials to examine pragmatic, evidence-based approaches to management of sCVD are needed. Such a trial could provide much needed guidance on how to manage a common clinical scenario facing internists and neurologists in practice.

Blood pressure, glycemic control, and white matter hyperintensity progression in type 2 diabetics.

OBJECTIVE: To determine whether higher blood pressure mean (BPM) or hemoglobin A1c is associated with progression of white matter hyperintensity (WMH) on MRI in patients with type 2 diabetes, and whether intensive blood pressure or glycemic control can reduce that progression. METHODS: We performed a secondary analysis of the Action to Control Cardiovascular Risk in Diabetes Memory in Diabetes (ACCORD MIND) research materials. The primary outcome is change in WMH volume (ΔWMH) between a baseline and month-40 MRI, and the primary predictor is BPM and A1c between the MRIs. Additional analyses compared ΔWMH in the intensive vs standard glycemic control randomization arms (n = 502) and intensive vs standard blood pressure control randomization arms (n = 314). RESULTS: Higher systolic BPM, but not diastolic BPM or A1c, was associated with WMH progression. The ΔWMH in tertiles of increasing systolic BPM (115 ± 4, 127 ± 3, and 139 ± 6 mm Hg) was 0.7, 0.9, and 1.2 cm3 (p < 0.001). ΔWMH was lower in the intensive vs standard blood pressure control randomization arm (ΔWMH = 0.67 ± 0.95 vs 1.16 ± 1.13 cm3, p < 0.001), but there was no difference in the glycemic control arms (p = 0.917). CONCLUSION: In ACCORD MIND, higher systolic blood pressure was associated with WMH progression. The intensive blood pressure control intervention reduced this progression. Comorbid diabetes and hypertension has synergistic deleterious properties that increase the risk of micro- and macrovascular complications. These results provide further support for an aggressive approach to blood pressure control in type 2 diabetics.