Valsalva sinus aneurysms: findings at CT and MR imaging.

Aneurysms of the Valsalva sinus (aortic sinus) can be congenital or acquired and are rare. They are more common among men than women and among Asians than other ethnic groups. Nonruptured aneurysms may be asymptomatic and incidentally discovered, or they may be symptomatic and manifest acutely with mass effect on adjacent cardiac structures. Ruptured Valsalva sinus aneurysms result in an aortocardiac shunt and may manifest as insidiously progressive congestive heart failure, severe acute chest pain with dyspnea, or, in extreme cases, cardiac arrest. Although both ruptured and nonruptured Valsalva sinus aneurysms may have potentially fatal complications, after treatment the prognosis is excellent. Thus, prompt and accurate diagnosis is critical. Most Valsalva sinus aneurysms are diagnosed on the basis of echocardiography, with or without angiography. However, both electrocardiographically gated computed tomography and magnetic resonance (MR) imaging can provide excellent anatomic depiction, and MR imaging can provide valuable functional information.

Vertebral osteomyelitis following vertebroplasty: is acne a potential contraindication and are prophylactic antibiotics mandatory prior to vertebroplasty?

We present a case of vertebral osteomyelitis following vertebroplasty in a patient with acne of the back. Vertebral biopsy revealed Corynebacterium species and blood cultures were positive for Propionibacterium species. The patient did not respond to long-term intravenous antibiotics and required vertebral corpectomy and debridement with instrumentation. Interventionalists should be able to recognize acne of the back and consider this as a potential contraindication to vertebroplasty. Prophylactic antibiotics should be considered in all patients prior to vertebroplasty since subepidermal organisms are not eliminated with the standard skin prep.

The added value of concurrently administered temozolomide versus adjuvant temozolomide alone in newly diagnosed glioblastoma.

PURPOSE: Temozolomide (TMZ), given concurrently with radiotherapy (RT) and as adjuvant monotherapy afterwards, has led to improved survival in glioblastoma multiforme (GBM). However, it is unclear whether its primary mechanism of action is through enhancement of radiation response, independent cytotoxicity, or both. We sought to determine the relative contribution of concomitant temozolomide in patients treated by concurrent and adjuvant TMZ versus adjuvant TMZ alone in the setting of newly diagnosed GBM. METHODS AND MATERIALS: We identified patients diagnosed with GBM and treated with surgery, involved-field radiotherapy, and chemotherapy at MGH between 2002 and 2004. Eligible patients received either adjuvant temozolomide alone (group 1) or temozolomide concurrently with RT followed by adjuvant TMZ (group 2). The primary endpoint of this retrospective analysis was overall survival (OS). RESULTS: Forty-three patients (group 1, n = 21; group 2, n = 22) were included in this study. The median follow-up was 33.7 months for surviving patients. There were no significant differences in baseline characteristics between these two groups. On univariate analysis, patients who received concurrent and adjuvant temozolomide experienced a 2-year OS of 51% and median survival of 25.5 months, compared with a 2-year OS of 36% and median survival of 15.6 months for group 1 patients (P < 0.05). On multivariable analysis, the hazard ratio (HR) favoring concurrent TMZ trended towards significance (HR = 0.51, P = 0.08) despite modest patient numbers. CONCLUSIONS: Concurrent and adjuvant TMZ was associated with improved survival compared to adjuvant TMZ alone, highlighting the potentiation of radiation effect by temozolomide in the clinical setting.

Size matters: hemorrhage volume as an objective measure to define significant intracranial hemorrhage associated with thrombolysis.

BACKGROUND AND PURPOSE: This study defines significant thrombolysis associated intracranial hemorrhage (ICH) by identifying an objective threshold volume that predicts clinical deterioration attributable to ICH. METHODS: Prospectively collected clinical and radiographic information, from 103 consecutive patients who underwent intraarterial thrombolysis for acute ischemic stroke, was reviewed. Multiple paired comparisons between stratified hematoma volume and change in National Institutes of Health Stroke Scale (NIHSS) score by 24 to 36 hours and by time of hospital discharge was used to identify significant differences. Associations between hemorrhage volume and infarct volume in relation to clinical outcomes were examined. Rates of hemorrhagic transformation (HT), symptomatic hemorrhage, and parenchymal hematoma involving over 30% of the infarct were compared with hemorrhage volume. Multivariate regression analysis was used to determine the relationship between change in discharge NIHSS score and hemorrhage volume adjusting for known predictors of clinical outcomes. RESULTS: Multiple paired comparisons indicate that hemorrhage greater than 25 mL (HV25) had a more distinct impact on NIHSS score by time of hospital discharge than at 24 to 36 hours. Twenty-seven (26.2%) patients had HT and 12 (11.7%) had HV25. Among symptomatic hemorrhage, parenchymal hematoma involving over 30% of the infarct, and HV25, HV25 appeared more reflective of clinical deterioration from ICH. Hemorrhage volume increased with infarct volume but they were independently associated with change in NIHSS score on regression analysis. CONCLUSIONS: Clinical deterioration from ICH and ischemic injury are more effectively distinguished at time of hospital discharge. The authors propose to define significant hemorrhage associated with thrombolysis as hemorrhage volume greater than 25 mL.

Angiographic assessment of pial collaterals as a prognostic indicator following intra-arterial thrombolysis for acute ischemic stroke.

BACKGROUND AND PURPOSE: This study examines whether anatomic extent of pial collateral formation documented on angiography during acute thromboembolic stroke predicts clinical outcome and infarct volume following intra-arterial thrombolysis, compared with other predictive factors. METHODS: Angiograms, CT scans, and clinical information were retrospectively reviewed in 65 consecutive patients who underwent thrombolysis for acute ischemic stroke. Clinical data included age, sex, time to treatment, National Institutes of Health Stroke Scale (NIHSS) score on presentation of symptoms, NIHSS score at the time of hospital discharge, and modified Rankin scale score at time of hospital discharge. Site of occlusion, scoring of anatomic extent of pial collaterals before thrombolysis, and recanalization (complete, partial, or no recanalization) were determined on angiography. Infarct volume was measured on CT scans performed 24-48 hours after treatment. RESULTS: Fifty-three patients (82%) qualified for review. Both infarct volume and discharge modified Rankin scale scores were significantly lower for patients with better pial collateral scores than those with worse pial collateral scores, regardless of whether they had complete (P < .0001) or partial (P = .0095) recanalization. Adjusting for other factors, regression analysis models indicate that the infarct volume was significantly larger (P < .0001) and modified discharge Rankin scale score and discharge NIHSS score significantly higher for patients with worse pial collateral scores. Similarly, adjusting for other factors, the infarct volume was significantly lower (P = .0006) for patients with complete recanalization than patients with partial or no recanalization. CONCLUSIONS: Evaluation of pial collateral formation before thrombolytic treatment can predict infarct volume and clinical outcome for patients with acute stroke undergoing thrombolysis independent of other predictive factors. Thrombolytic treatment appears to have a greater clinical impact in those patients with better pial collateral formation.