Imaging for Predicting Hemorrhagic Transformation of Acute Ischemic Stroke-A Narrative Review.

Hemorrhagic transformation is caused by extravasation of blood products from vessels after acute ischemic stroke. It is an undesirable and potentially devastating complication, which occurs in 10%-40% of clinical cases. Hemorrhagic transformation is classified into four subtypes based on European cooperative acute stroke study II. Predicting hemorrhagic complications at presentation can be useful life saving/altering decisions for the patient. Also, understanding the mechanisms of hemorrhagic transformation can lead to new treatments and intervention measures. We highlighted various imaging techniques that have been used to predict hemorrhagic transformation. Specifically, we looked at the usefulness of perfusion and permeability imaging for hemorrhagic transformation. Use of imaging to predict hemorrhagic transformation could change patient management that may lead to the prevention of hemorrhagic transformation before it occurs. We concluded that the current evidence is not strong enough to rely on these imaging parameters for predicting hemorrhagic transformation and more studies are required.

Variation in CT perfusion protocol has implications on defining irreversibly damaged ischemic brain parenchyma.

KEY POINTS: • Computed tomographic perfusion (CTP) is increasingly being used in the characterization of brain ischemia.• Variations in post-processing protocols continue to be a challenge, resulting in a slight variation of CTP results.• We need to adopt a universal acquisition protocol to help optimize output of CTP.

Early diagnosis of mortality using admission CT perfusion in severe traumatic brain injury patients (ACT-TBI): protocol for a prospective cohort study.

INTRODUCTION: Severe traumatic brain injury (TBI) is a catastrophic neurological condition with significant economic burden. Early in-hospital mortality (<48 hours) with severe TBI is estimated at 50%. Several clinical examinations exist to determine brain death; however, most are difficult to elicit in the acute setting in patients with severe TBI. Having a definitive assessment tool would help predict early in-hospital mortality in this population. CT perfusion (CTP) has shown promise diagnosing early in-hospital mortality in patients with severe TBI and other populations. The purpose of this study is to validate admission CTP features of brain death relative to the clinical examination outcome for characterizing early in-hospital mortality in patients with severe TBI. METHODS AND ANALYSIS: The Early Diagnosis of Mortality using Admission CT Perfusion in Severe Traumatic Brain Injury Patients study, is a prospective cohort study in patients with severe TBI funded by a grant from the Canadian Institute of Health Research. Adults aged 18 or older, with evidence of a severe TBI (Glasgow Coma Scale score ≤8 before initial resuscitation) and, on mechanical ventilation at the time of imaging are eligible. Patients will undergo CTP at the time of first imaging on their hospital admission. Admission CTP compares with the reference standard of an accepted bedside clinical assessment for brainstem function. Deferred consent will be used. The primary outcome is a binary outcome of mortality (dead) or survival (not dead) in the first 48 hours of admission. The planned sample size for achieving a sensitivity of 75% and a specificity of 95% with a CI of ±5% is 200 patients. ETHICS AND DISSEMINATION: This study has been approved by the University of Manitoba Health Research Ethics Board. The findings from our study will be disseminated through peer-reviewed journals and presentations at local rounds, national and international conferences. The public will be informed through forums at the end of the study. TRIAL REGISTRATION NUMBER: NCT04318665.

Bleomycin for orbital and peri-orbital veno-lymphatic malformations - A systematic review.

BACKGROUND: Orbital and peri-orbital venolymphatic malformations (VLM) are low flow vascular malformations. Intralesional bleomycin is now commonly being used to treat such malformations. OBJECTIVE: The purpose of this systematic review is to synthesize evidence on the safety and efficacy of bleomycin/pingyangmycin sclerotherapy for the treatment of orbital and peri-orbital VLM. METHODS: We searched Medline, Embase, Scopus and Cochrane database for studies reporting outcomes of bleomycin/pingyangmycin sclerotherapy for orbital and peri-orbital VLM between 1974 to April 5th, 2019. Nine retrospective cohort studies enrolling 132 patients were included. Two reviewers independently screened and extracted data and assessed the risk of bias. Predefined outcome measures were subjective and objective reduction of the lesion and associated complications. RESULTS: Subjective reduction of the lesions was seen in 96.2% of the studies. Objective reduction of the lesion and symptomatic improvement were reported in 91.6 and 95% of the studies respectively. Non responders were 9.0%. Minor adverse events were reported in 18.1% of the studies. Major complications like pulmonary toxicity or pulmonary fibrosis was not encountered in any of the included studies. Quality of evidence was generally low. CONCLUSION: Bleomycin/pingyangmycin sclerotherapy is very effective and relatively safe for the treatment of orbital and periorbital VLM and is not associated with any major side effects including pulmonary fibrosis.Limitations: The systematic review is limited mainly due to low quality of the included studies with retrospective design.

Bleomycin for Head and Neck Venolymphatic Malformations: A Systematic Review.

BACKGROUND: Venolymphatic malformations are rare benign vascular lesions of the head and neck. Sclerotherapy has become the first-line therapy of these lesions with bleomycin being a sclerosing agent commonly used. PURPOSE: To perform a systematic review of the published literature to synthesize evidence on the safety and efficacy of bleomycin for the treatment of head and neck venolymphatic malformations. DATA SOURCES: A systematic review of the literature (January 1995-May 2019) was performed in PubMed, Embase, and Cochrane Library databases to identify studies on sclerotherapy of venolymphatic malformations of the head and neck. STUDY SELECTION: A total of 32 studies with participants met the inclusion criteria among which 1121 patients were included in the systematic review. DATA ANALYSIS: Two reviewers independently screened and extracted data and assessed the risk of bias. The primary outcome was the subjective or objective reduction of lesion size as well as minor and major complications. DATA SYNTHESIS: The bleomycin/pingyangmycin sclerotherapy achieved subjective or objective lesion size reduction in 96.3% (95% CI 94.1%-98.5%) of patients. Minor complications were observed in 16.2% and major complications in 1.1%. CONCLUSION: Bleomycin is a highly effective treatment of venolymphatic malformations of the head and neck with a low rate of major adverse events. This study represents an update on the "available" evidence, but only low-to-moderate quality studies were available. LIMITATIONS: This study reviewed 32 studies performed in different parts of the world, but there was heterogeneity of the study designs and interventions.

Diagnostic Yield of MRI for Sensorineural Hearing Loss - An Audit.

PURPOSE: Contrast-enhanced magnetic resonance imaging (CEMRI) of the head is frequently employed in investigations of sensorineural hearing loss (SNHL). The yield of these studies is perceptibly low and seemingly at odds with the aims of wise resource allocation and risk reduction within the Canadian healthcare system. The purpose of our study was to audit the use and diagnostic yield of CEMRI for the clinical indication of SNHL in our institution and to identify characteristics that may be leveraged to improve yield and optimize resource utilization. MATERIALS AND METHODS: The charts of 500 consecutive patients who underwent CEMRI of internal auditory canal for SNHL were categorized as cases with relevant positive findings on CEMRI and those without relevant findings. Demographics, presenting symptoms, interventions and responses, ordering physicians, and investigations performed prior to CEMRI testing were recorded. Chi-squared test and t-test were used to compare proportions and means, respectively. RESULTS: CEMRI studies revealed relevant findings in 20 (6.2%) of 324 subjects meeting the inclusion criteria. Pre-CEMRI testing beyond audiometry was conducted in 35% of those with relevant positive findings compared to 7.3% of those without (p < 0.001). Auditory brainstem response/vestibular-evoked myogenic potentials were abnormal in 35% of those with relevant CEMRI findings compared to 6.3% of those without (p < 0.001). CONCLUSION: CEMRI is a valuable tool for assessing potential causes of SNHL, but small diagnostic yield at present needs justification for contrast injection for this indication. Our findings suggest preferred referral from otolaryngologists exclusively, and implementation of a non-contrast MRI for SNHL may be a better diagnostic tool.

Endovascular Thrombectomy for Stroke Effectiveness Study-An Audit From a Small Tertiary Care Center.

PURPOSE: Endovascular thrombectomy (EVT) treatment for acute ischemic stroke is now recommended as a standard of care. However, implementing EVT in routine clinical practice poses many challenges, even in countries with advanced health-care systems. The aim of the current study is to delineate if EVT at our institution is an effective treatment for acute ischemic stroke. METHODS: All patients who underwent EVT at our institution between December 2011 and July 2017 were retrospectively assessed from our prospective registry. Clinical and imaging (including the Alberta Stroke Program Early CT [ASPECT] score, single-phase computed tomography angiography, and computed tomography perfusion) criteria were utilized to determine EVT suitability. Primary outcomes included modified Rankin score (mRS) at 90 days and recanalization determined by the modified Treatment in Cerebral Infarction score. Effectiveness was assessed by comparing our cohort with patients receiving EVT in the ESCAPE (Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke) trial. RESULTS: Eighty-eight patients presented to our hospital after a median of 87 minutes last seen normal. Of these, median ASPECT score was 9. A majority (72%) also received intravenous alteplase. Successful recanalization (≥TICI 2b) was achieved in 79%. At 90 days, 48% (36/75) were functionally independent (mRS score of 0-2) and 28% (21/75) were disabled (mRS score of 3-5); 24% (18/75) died (mRS of 6) within 90 days. CONCLUSIONS: An audit of our initial experience with EVT for the treatment of acute ischemic stroke in a small tertiary care center yielded similar results compared to the ESCAPE trial, which is encouraging for implementing this treatment in routine clinical practice.

Admission Perfusion CT for Classifying Early In-Hospital Mortality of Patients With Severe Traumatic Brain Injury: A Pilot Study.

OBJECTIVE. The purposes of this study were to assess the feasibility and safety of perfusion CT of patients with severe traumatic brain injury (TBI) at hospital admission and to examine whether early in-hospital mortality could be characterized with perfusion CT (PCT). The hypothesis was that PCT can be used to characterize brain death, when present, in patients with severe TBI at hospital admission. SUBJECTS AND METHODS. In this prospective cohort pilot study, PCT was performed on patients with severe TBI at first imaging workup at hospital admission. PCT images were processed at the end of the study and assessed for features of brain death. The PCT features were then compared with the clinical outcome of in-hospital mortality. RESULTS. A total of 19 patients (13 men [68.4%]; six women [31.6%]; mean age, 36.4 years; median, 27.5 years) had a mean hospital stay longer than 1 month. No complications of PCT were found. In the first 48 hours after admission, four patients (21%) died. Admission PCT changes suggesting brainstem death were sensitive (75%) and specific (100%) and had high positive (100%) and negative (93.75%) predictive value for correct classification early in-hospital mortality. CONCLUSION. Admission PCT of patients with severe TBI was feasible and safe. Admission PCT findings helped in correctly classifying early in-hospital mortality in the first 48 hours of hospital admission.

Clinico-radiological correlation of magnetic resonance imaging findings in patients with idiopathic intracranial hypertension.

PURPOSE: Although several studies have reported imaging findings associated with idiopathic intracranial hypertension (IIH), less is known about the correlation between imaging findings and IIH-related symptoms or signs. Our study aimed to determine if clinical features of IIH are correlated with magnetic resonance imaging (MRI) features. METHODS: A retrospective chart review was conducted on consecutive patients presenting at the neuro-ophthalmology department over the last 15 years. All patients diagnosed with IIH were identified and those with available MRI were included in the final analysis. All MRI images were reviewed by a neuroradiologist blinded to the presenting symptoms and signs. Statistical analysis was performed to determine the correlation between the MRI findings with each clinical symptom or sign. RESULTS: Thirty-one out of 88 patients with the initial diagnosis of IIH had MRI available and were included in the study. Significant correlations were observed between colour vision and amount of perineural fluid around the optic nerve on MRI (r = - 0.382; p = 0.004), disc assessment and intraocular optic nerve protrusion (r = 0.364; p = 0.004), disc assessment and perineural fluid around the optic nerve (r = 0.276; p = 0.033) and disc assessment and venous sinus stenosis (r = 0.351; p = 0.009). CONCLUSION: Our study highlights correlations between imaging and clinical findings of IIH. MRI findings in IIH may be useful in ruling out ominous causes of intracranial pressure and risk stratifying ophthalmologic intervention and management of patients with headaches possibly due to IIH.

T2 Hypointensity Aids in the Diagnosis of Intracranial Metastatic Adenocarcinoma.

BACKGROUND: The T2 hypointensity has been suggested to be associated with intracranial metastatic adenocarcinomas (IMA). The purpose of our study was to determine the association of T2 hypointensity with IMA. METHODS: All patients with pathologically confirmed metastatic brain tumors who had a magnetic resonance imaging (MRI) at our institution in the last 10 years were retrospectively assessed. Qualitative assessment of the lesions on MRI was done by two separate readers who were blinded to the pathological diagnosis. For qualitative assessment, the T2 hypointensity in the lesion was compared with the contralateral normal appearing white matter. Odds ratio, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. RESULTS: Of 107 patients with intracranial metastasis, only 73 (40 females; 33 males; mean age 61 years) had MRI available for review. Of these, only 46 (25 females; 21 males; mean age 61 years) had pathologically proven IMA. T2 hypointensity was seen in 20% of IMA. The odds ratio of T2 hypointensity in IMA was 3 compared to nonadenocarcinomas but was not statistically significant (p = 0.16). Intralesional hemorrhage was seen in 20. When controlled for hemorrhage, the odds ratio for T2 hypointensity in IMA was 4.7. The specificity, sensitivity, PPV, and NPV for T2 hypointensity to diagnose IMA were 92%, 19%, 81%, and 40%, respectively. CONCLUSION: T2 hypointensity was seen only in 20% of IMA with an odds ratio of 4.7. T2 hypointensity showed a high specificity and PPV for diagnosis of IMA.

Imaging Improves Efficacy of Vertebroplasty - A Systematic Review and Meta-Analysis.

BACKGROUND: Clinical trials with percutaneous vertebral augmentation (PVA) for intractable pain from vertebral compression fractures (VCF) have shown variable results. Variation in the outcomes may be related to poor patient selection on imaging. OBJECTIVE: To assess if PVA augmentation for osteoporotic VCF results in better improvement in pain when patients were selected based on clinical examination plus imaging vs clinical examination only. RESULTS: A systematic review and meta-analysis were performed. PubMed, Embase and Cochrane Library databases were searched from 2000 to May 2018. Two reviewers independently screened and extracted data to identify randomised control trials (RCTs) on PVA for osteoporotic VCF and assessed the risk of bias. Standard systematic review and meta-analysis methods were advocated by the Cochrane Collaboration and PRISMA Statement. A total of 12 RCTs with 1110 participants met the inclusion criteria. Eight of the 10 studies (938 participants) that used imaging to confirm oedema in the target vertebral bodies showed PVA (compared to nonsurgical treatment) was effective in reducing pain (immediate term: mean difference (MD) of -1.89; 95% confidence interval -1.93 to -1.85, p < 0.001; short term: MD of -1.68; 95% CI -1.82 to -1.54, p < 0.001; intermediate term: MD of -2.04; 95% CI -2.15 to -1.94, p < 0.001 and long term: MD of -1.88; 95% CI -1.95 to -1.80, p < 0.001). CONCLUSIONS: RCTs using imaging to confirm marrow oedema in the index vertebra showed an improved size effect compared to RCTs using no imaging. This benefit was observed in the immediate, short, intermediate and long term.

Améliorer l'efficacité de la vertébroplastie au moyen de l'imagerie médicale : une revue systématique et une méta-analyse.Contexte: Des essais cliniques au cours desquels on a fait appel aux techniques percutanées de la vertébroplastie (vertebral augmentation) pour soulager des douleurs réfractaires produites par des fractures vertébrales par compression (FVC) ont donné à voir des résultats variables. Cette variabilité pourrait être liée à une mauvaise sélection des participants au moyen d'examens d'IRM. Objectif: Évaluer dans quelle mesure la vertébroplastie entraîne un soulagement accru de la douleur dans le cas de patients aux prises avec des FVC d'origine ostéoporotique. On a ainsi voulu comparer des patients choisis en fonction d'un examen clinique et d'un examen d'IRM avec d'autres patients choisis en fonction d'un seul examen clinique. Résultats: Nous avons mené une revue systématique ainsi qu'une méta-analyse. Pour ce faire, nous avons effectué des recherches dans les bases de données suivantes : PubMed, Embase et Cochrane, et ce, de l'année 2000 au mois de mai 2018. Deux examinateurs indépendants ont ensuite extrait et passé au crible des données afin d'identifier les essais cliniques randomisés (ECR) portant sur la vertébroplastie dans le cas de FVC d'origine ostéoporotique et d'évaluer les risques de biais. À noter que notre revue systématique et notre méta-analyse ont été effectuées en tenant compte des méthodes recommandées par Cochrane et PRISMA. Au total, douze ECR incluant 1110 participants ont satisfait à nos critères de sélection. Sur 10 ECR (938 participants) dans lesquels on a recouru à un examen d'IRM pour confirmer la présence d'un œdème dans les corps vertébraux ciblés, 8 d'entre eux ont révélé que le recours à la vertébroplastie était plus efficace qu'un traitement non-chirurgical dans le soulagement de la douleur (sur le champ : écart moyen de -1,89 ; IC 95 % -1,93 à -1,85 ; p < 0,001 ; à court terme : écart moyen de -1,68 ; IC 95 % -1,82 à -1,54 ; p < 0,001 ; à moyen terme : écart moyen de -2,04 ; IC 95 % -2,15 à -1,94 ; p < 0,001 ; et à long terme : écart moyen de -1,88 ; IC 95% -1,95 à -1,80 ; p < 0,001). Conclusions: En somme, les ECR utilisant des examens d'IRM pour confirmer la présence d'œdèmes de la moelle épinière dans une vertèbre de référence (index vertebra) ont révélé une taille d'effet améliorée si on les compare à des ECR n'utilisant pas ces examens. Cet avantage a été observé sur le champ mais aussi à court, moyen et long terme.

Are Anterior Communicating Aneurysms Truly Anterior Communicating Aneurysms? An Observational Study.

OBJECTIVE: The term anterior communicating (ACom) aneurysm is often broadly used to classify any aneurysm formed on the A1-A2 junction, A1, A2, or ACom arteries. Aneurysm location has been associated with rupture risk, so whether an aneurysm is truly formed on the ACom artery can critically affect treatment decisions. The aim of this study was to reclassify broadly termed ACom aneurysms into 4 subgroups (A1, A2, true ACom, and A1-A2 junction) based on their location. METHODS: A retrospective, pilot study was conducted to identify all consecutive patients with ACom aneurysm managed over the past 4 years in a single center. Using computed tomography angiography, aneurysms were classified into 1 of the 4 subgroups. Additional information was collected on patient demographics, subarachnoid hemorrhages, projections of aneurysm dome, and aneurysm diameter. RESULTS: A total of 48 aneurysms with available computed tomography angiography imaging were included in the final analysis. The reclassification of ACom aneurysms into subgroups resulted in 40 A1-A2 junction, 6 true ACom, 2 A2, and zero A1 aneurysms. A total of 100% versus 80% of true ACom and A1-A2 junction aneurysms ruptured, respectively. All elective coiling procedures were performed on unruptured A1-A2 junction aneurysms. CONCLUSIONS: We found only 13% of the aneurysms initially referred to as ACom to be true ACom aneurysms. A more nuanced approach to ACom aneurysm classification may better guide management strategies.

Diagnosing Neoplastic Hematoma: Role of MR Perfusion.

BACKGROUND: The imaging appearance of neoplastic hematoma can be complicated by the presence of a large hematoma, even on magnetic resonance imaging (MRI). We describe the role of MR perfusion (MRP) in detecting neoplastic hematomas in patients with intraparenchymal hematoma (IPH). MATERIAL AND METHODS: A retrospective review was performed for consecutive patients with IPH, where MRP was performed. Routine, post-gadolinium MRI and MRP were analyzed. All patients were either operated on for evacuation of IPH or followed up on imaging. The MRP parameters of cerebral blood volume (CBV) and cerebral blood flow (CBF) and pattern of enhancement (peripheral linear vs. nodular) were recorded. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) were calculated for these parameters for diagnosing neoplastic hematoma. RESULTS: Of 116 patients with MRP, 16 patients (male 8; mean age-65.5 years) had IPH on their initial MRI. For diagnosing neoplastic hematoma, the sensitivity, specificity, PPV and NPV for increased CBF and CBV were 100%, 88.9%, 87.5%, and 100%; for peripheral linear enhancement were 100%, 28.6%, 50%, 100% and for nodular enhancement were 85.7%, 77.8%, 75% and 12.5%, respectively. The combination of peripheral linear enhancement and increased CBF and CBV showed 100% sensitivity, specificity, PPV and NPV. CONCLUSION: In our small series, the combination of peripheral linear enhancement and increased CBF and CBV showed 100% sensitivity, specificity, PPV and NPV for diagnosing a neoplastic hematoma. These findings need to be validated in a larger study.

Diffusion weighted imaging may help differentiate intracranial hemangiopericytoma from meningioma.

BACKGROUND AND PURPOSE: Hemangiopericytoma and meningioma appear similar on routine diagnostic imaging and hence are difficult to distinguish. The purpose of our study was to examine the diffusion weighted imaging (DWI) characteristics of these two types of tumours. METHODS: In a retrospective study, each patient with hemangiopericytoma was matched with two meningioma patients based on tumour location and size. Minimum and mean apparent diffusion coefficients (ADC) were measured in the tumour and the contralateral normal-appearing white matter (NAWM). A normalized ADC was calculated. The two tumour types were subjectively assessed for heterogeneity on ADC maps. RESULTS: Of the 14 patients with histopathological proven hemangiopericytoma, only 7 had available DWI for analysis. These 7 patients were matched based on tumour location and size with 14 patients out of the 209 meningioma patients screened. Hemangiopericytomas were more heterogeneous on ADC maps (P < 0.001) and had a higher mean ADC compared to that of meningiomas (P < 0.001). CONCLUSION: Hemangiopericytomas showed heterogeneity on DWI and significantly higher ADC compared to that of meningiomas in our small study. These observations need to be confirmed in future studies with larger sample sizes.

The Role of Neuroimaging in the Determination of Brain Death.

BACKGROUND AND PURPOSE: Brain death determination (BDD) is primarily a clinical diagnosis, where death is defined as the permanent loss of brainstem function. In scenarios where clinical examinations are inaccurate, ancillary imaging tests are required. The choice of ancillary imaging test is variable, but the common denominator for all of them is to establish a lack of cerebral blood flow. The purpose of this study was to compare the diagnostic accuracy and interrater reliability of different ancillary imaging tests used for BDD. METHODS: Archival data were retrospectively analyzed for all patients who underwent any ancillary imaging test for BDD at our institution. The results of ancillary imaging tests were compared with, the reference standard, the clinical checklist for declaration of brain death. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of different ancillary imaging tests for BDD were performed. Interobserver agreement between two observers was measured using kappa statistics for each of the imaging modalities. RESULTS: A total of 74 patients underwent 41 computer tomography perfusion (CTP), 54 CT angiogram, 15 radionuclide scans, 1 cerebral angiogram, 3 magnetic resonance imaging, and 71 nonenhanced CT (NECT) head for BDD. All ancillary tests (except NECT head) showed 100% specificity and PPV. CTP had the highest sensitivity and NPV. All ancillary imaging tests demonstrated very high interrater reliability. CONCLUSIONS: The uses of ancillary imaging tests for BDD are increasing. Within this study's limitations, CTP followed by radionuclide scan were found to be the most accurate and reliable ancillary imaging test for BDD.

Computed Tomography Perfusion Aids in the Prognostication of Comatose Postcardiac Arrest Patients.

Early assessment of the potential for neurologic recovery in comatose cardiac arrest patients (CCAP) has been a challenge despite significant evolution in management and imaging techniques. The purpose of study was to determine if the use of computed tomography perfusion (CTP) in CCAPs is feasible and if this technique can predict the likelihood that CCAPs will have a devastating outcome at hospital discharge. We prospectively enrolled 10 newly admitted comatose adults who had an out-of-hospital cardiac arrest and were treated with standard therapeutic hypothermia protocols. Patients underwent CTP of the head within 6 hours after finishing therapeutic hypothermia treatment. The imaging findings were compared with the results of a clinical assessment, as well as the modified Rankin Scale (mRS) score at hospital discharge. Sensitivity, specificity, and positive and negative predictive values for CTP were calculated to predict clinical outcome. Eight patients had an mRS score of ≥5, and 2 patients had an mRS score of ≤2 at hospital discharge. CTP predicted a good clinical outcome in both patients with an mRS score of ≤2. The area under the curve (AUC) for plain computed tomography of the head, computerized tomography angiogram 4-point scale, computerized tomography angiogram 7-point scale, CTP of the whole brain, and CTP of the brainstem for predicting the results of the immediate clinical assessment were 0.76, 0.83, 0.67, 0.83, and 1.0, respectively. The AUCs for predicting outcome at discharge were 0.69, 0.63, 0.56, 0.63, 0.63, and 0.69, respectively. In conclusion, our pilot study showed that CTP is feasible and had a very high AUC for predicting the results of immediate clinical assessment in CCAP.

Digital Subtraction Angiography-Dynavision in Pretreatment Planning for Embolization of Dural Arterio-Venous Fistulas.

BACKGROUND AND PURPOSE: We have found DSA-Dynavision with multiplanar reconstruction very helpful in understanding the complex anatomy and planning of treatment of carotico-cavernous fistulas. The purpose of our study was to examine whether using DSA-Dynavision in pretreatment planning results in better outcome after endovascular treatment of dural arterio-venous fistulas (dAVFs). METHODS: Patients with dAVF treated with endovascular embolization were retrospectively identified from our interventional neuroradiology database. Patients were assessed and divided into those with DSA-Dynavision and those without. They were compared for procedural time, angiographic evidence of cure, rates of resolution of cortical venous reflux (CVR), complications, and need for postembolization surgery. RESULTS: Eighty-six percent of 28 patients (mean age 57 years, range 1.67-84 years) had Borden type 3 DAVF; 7% had Borden type 2; and 7% had Borden type 1. DSA-Dynavision was used in 14 of 28 (50%) patients. Fewer patients with DSA-Dynavision required postendovascular embolization surgery (7% vs. 50%, P = .01) and fewer DSA-Dynavision patients had CVR postprocedure (29% vs. 71%, P = .023). Mean procedural time (207 vs. 249 minutes; P = .40); permanent neurological complication rates (7% vs. 7%, P = 1.0); rate of immediate angiographic occlusion (64% vs. 29%, P = .061), and reported resolution of symptoms (79% vs. 53%, P = .18) were not significantly different. There was no significant difference in follow-up (mean: 75 vs 120 weeks, P = .47). CONCLUSION: The use of DSA-Dynavision in planning of endovascular treatment of dAVF is associated with higher rates of elimination of CVR and less need for postembolization surgery.