Effects of Intensive Versus Standard Ambulatory Blood Pressure Control on Cerebrovascular Outcomes in Older People (INFINITY).

BACKGROUND: Subcortical microvascular disease represented by brain white matter hyperintensity on magnetic resonance imaging is associated with functional decline in older people with hypertension. The effects of 2 levels of 24-hour average systolic blood pressure (BP) on mobility, white matter disease progression, and cognitive function over 3 years were studied. METHODS: This trial was a prospective, randomized, blinded end-points study in patients ≥75 years of age with systolic hypertension and magnetic resonance imaging evidence of white matter hyperintensity lesions. Patients were randomized to a 24-hour mean systolic BP of ≤130 mm Hg (intensive treatment) versus ≤145 mm Hg (standard treatment) with antihypertensive therapies. Primary study outcomes were changes in mobility (gait speed) and accrual of white matter hyperintensity volume after 3 years. Changes in cognitive function (executive processing) and adverse events were also evaluated. RESULTS: In 199 randomized patients, the mean age of the cohort was 80.5 years, and 54% were women; the average 24-hour systolic BP was 149 mm Hg. Goal BPs were achieved after a median treatment period of 3 to 4 months; at that time, the mean 24-hour systolic BP was 127.7 mm Hg in the intensive treatment group and 144.0 mm Hg in the standard treatment group for an average difference of 16.3 mm Hg. Changes in gait speed were not different between treatment groups (0.40±2.0 versus 0.42±2.7 s in the intensive treatment and standard treatment groups, respectively; P=0.91), whereas changes from baseline in white matter hyperintensity volumes were smaller (0.29%) in the intensive treatment group compared with the standard treatment group (0.48%; P=0.03). Cognitive outcomes also were not different between the treatment groups. Major adverse cardiovascular events were higher in the standard treatment group compared with the intensive treatment group (17 versus 4 patients; P=0.01). Falls, with or without injury, and syncope were comparable in the treatment groups. CONCLUSIONS: Intensive lowering of ambulatory BP reduction in older patients with hypertension did not result in differences in mobility outcomes but was associated with a reduction in accrual of subcortical white matter disease. Over periods >3 years, a reduction in the accumulation of white matter disease may be a factor in conserving function. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01650402.

Relationships among clinic, home, and ambulatory blood pressures with small vessel disease of the brain and functional status in older people with hypertension.

BACKGROUND: Subcortical small vessel disease, represented as white matter hyperintensity (WMH) on magnetic resonance images (MRI) is associated with functional decline in older people with hypertension. We evaluated the relationships of clinic and out-of-office blood pressures (BP) with WMH and functional status in older persons. METHODS: Using cross-sectional data from 199 older study participants enrolled in the INFINITY trial, we analyzed the clinic, 24-hour ambulatory, and home BPs and their relationships with WMH burden and mobility and cognitive outcomes. RESULTS: Volume of WMH was associated with clinic and 24-hour ambulatory systolic BP but not home systolic BP. The mobility measure, supine-to-sit time, had a significant association with 24-hour systolic BP and pulse pressure but not with diastolic BP or values obtained by home BP. Cognitive measures of processing speed (Trails Making Test Part A and the Stroop Word Test) were significantly associated with 24-hour systolic BP, but not clinic and home BPs. CONCLUSION: These data demonstrate that ambulatory BP measurements in older people are more strongly associated with WMH and certain measures of functional status compared to home BP measurements. Hence, home BP may not be a useful substitute for ambulatory BP for assessing subcortical small vessel disease and its consequences. Further longitudinal analyses comparing clinic and various types of out-of-office BP measures with small vessel brain disease are needed. Clinicaltrials.gov identifier: NCT01650402.

Case Report: What is Your Differential Diagnosis for Bilateral Cerebellar Infarct?

Neurovascular variants are not frequently described outside of specialty literature. Infarction involving these atypical neurovascular structures present with unusual clinical findings and radiologic imaging. A 63-year-old man with hypertension, diabetes, and former tobacco use presented from the Department of Corrections with global headache, nausea, vomiting, and double vision. He was found to be hypertensive to 240/120. CT imaging noted acute ischemic changes in the bilateral posterior inferior cerebellar artery distribution. Follow up 3-D time-of-flight (TOF) magnetic resonance angiography (MRA) of the cranial region demonstrated abrupt cut off of an azygous right posterior inferior cerebellar artery (PICA) and presumed absence of the left PICA. The patient underwent occipital craniotomy for evolving ischemic stroke and development of hydrocephalus, and ultimately recovered without neurologic deficits.

Clival lesion incidentally discovered on cone-beam computed tomography: A case report and review of the literature.

An osteolytic lesion with a small central area of mineralization and sclerotic borders was discovered incidentally in the clivus on the cone-beam computed tomography (CBCT) of a 27-year-old male patient. This benign appearance indicated a primary differential diagnosis of non-aggressive lesions such as fibro-osseous lesions and arrested pneumatization. Further, on magnetic resonance imaging (MRI), the lesion showed a homogenously low T1 signal intensity with mild internal enhancement after post-gadolinium and a heterogeneous T2 signal intensity. These signal characteristics might be attributed to the fibrous tissues, chondroid matrix, calcific material, or cystic component of the lesion; thus, chondroblastoma and chondromyxoid fibroma were added to the differential diagnosis. Although this report was limited by the lack of final diagnosis and the patient lost to follow-up, the incidental skull base finding would be important for interpreting the entire volume of CBCT by a qualified oral and maxillofacial radiologist.

Classification and volumetric analysis of temporal bone pneumatization using cone beam computed tomography.

OBJECTIVE: This study performed volumetric analysis and classified different repeated patterns of temporal bone pneumatization in adults using cone beam computed tomography (CBCT) scans. STUDY DESIGN: A total of 155 temporal bones were retrospectively evaluated from 78 patients with no radiographic evidence of pathology. Two reference structures were used to classify temporal bone pneumatization into 3 groups. Volumetric analysis of the pneumatization was performed using a window thresholding procedure on multiplanar CBCT images. Correlation between direct communication of peritubal cells with the eustachian tube and the degree of pneumatization was also assessed. RESULTS: Using 2 reference structures, pneumatization pattern in the temporal bone can be classified into 3 groups. Statistically significant differences were present in their mean volumes between 3 groups. Statistically significant correlation was found between degree of pneumatization and presence of peritubal cells associated with ET. CONCLUSIONS: This study showed that CBCT can be effectively used for imaging temporal bone air cavities and for volumetric assessment.

Novel application of 3-dimensional rotational C-arm conebeam computed tomography angiography for metastatic hypervascular tumor mass in the spine.

STUDY DESIGN: This is a case report. OBJECTIVE: To report a 3-dimensional (3D) rotational C-arm conebeam computed tomography (CT) (DynaCT) angiography generating computed tomographic data concurrently with spinal angiographic datasets. This technology allowed 3D modeling of the anterior spinal arterial supply in juxtaposition to a hypervascular tumor mass, thus affording unprecedented guidance in presurgical planning. SUMMARY OF BACKGROUND DATA: An enhanced demonstration of spatial relationships between the vascular elements and their adjacent soft-tissue structures is needed to visualize the minute anterior spinal artery optimally. METHODS: A 76-year-old male with a history of renal cell carcinoma metastasis to the T6 vertebra 1 year prior, presented with worsening myelopathy caused by severe spinal cord compression at T6 level, and a plan for surgical decompression was established. Because of the hypervascular nature of this renal cell carcinoma metastasis, preoperative embolization was requested to minimize blood loss during the operation. A digital subtraction angiogram identified the major arterial contribution to the tumor to also supply the radiculomedullary branch to the anterior spinal artery. To further characterize this blood supply, a rotational DynaCT angiography was performed. RESULTS: The rotationally acquired data were processed generating volumetric CT datasets demonstrating the 3D relationships of the anterior spinal artery, the blood supply to the tumor and the adjacent soft-tissue and bony structures. A shared blood supply to both the tumor mass and the anterior spinal artery from the left T6 segmental artery was confirmed. The dual nature of this blood supply presented increased risk of ischemic spinal cord injury by possible nontarget embolization. Therefore, the embolization was deferred. CONCLUSION: The DynaCT angiography precisely characterized the complex blood supply of a hypervascular vertebral tumor mass in relation to a shared arterial supply to the thoracic spinal cord. The optimal visualization properly aided presurgical planning. LEVEL OF EVIDENCE: N/A.

Ventriculomegaly associated with ependymal gliosis and declines in barrier integrity in the aging human and mouse brain.

Age-associated ventriculomegaly is typically attributed to neurodegeneration; however, additional factors might initiate or contribute to progressive ventricular expansion. By directly linking postmortem human MRI sequences with histological features of periventricular tissue, we show that substantial lateral ventricle surface gliosis is associated with ventriculomegaly. To examine whether loss of ependymal cell coverage resulting in ventricle surface glial scarring can lead directly to ventricle enlargement independent of any other injury or degenerative loss, we modeled in mice the glial scarring found along the lateral ventricle surface in aged humans. Neuraminidase, which cleaves glycosidic linkages of apical adherens junction proteins, was administered intracerebroventricularly to denude areas of ependymal cells. Substantial ependymal cell loss resulted in reactive gliosis rather than stem cell-mediated regenerative repair of the ventricle lining, and the gliotic regions showed morphologic and phenotypic characteristics similar to those found in aged humans. Increased levels of aquaporin-4, indicative of edema, observed in regions of periventricular gliosis in human tissue were also replicated in our mouse model. 3D modeling together with volume measurements revealed that mice with ventricle surface scarring developed expanded ventricles, independent of neurodegeneration. Through a comprehensive, comparative analysis of the lateral ventricles and associated periventricular tissue in aged humans and mouse, followed by modeling of surface gliosis in mice, we have demonstrated a direct link between lateral ventricle surface gliosis and ventricle enlargement. These studies highlight the importance of maintaining an intact ependymal cell lining throughout aging.

INtensive versus standard ambulatory blood pressure lowering to prevent functional DeclINe in the ElderlY (INFINITY).

Reductions in mobility and cognitive function linked to accrual of brain microvascular disease related white matter hyperintensities (WMHs) on magnetic resonance imaging can occur in older hypertensive patients in as little as 2 years. We have designed a trial evaluating 2 levels of ambulatory blood pressure (ABP) control in individuals with normal or mildly impaired mobility and cognition who have detectable cerebrovascular disease (>0.5% WMH fraction of intracranial volume) on functional outcomes. The study is a prospective randomized, open-label trial with blinded end points, in patients ages ≥75 years with elevated 24-hour systolic blood pressure (BP) (145 mm Hg in the untreated state) who do not have unstable cardiovascular disease, heart failure, or stroke. The primary and key secondary outcomes in the trial are change from baseline in mobility and cognitive function and damage to brain white matter as demonstrated by accrual of WMH volume and changes in diffusion tensor imaging. Approximately 300 patients will be enrolled, and 200 randomized to 1 of 2 levels of ABP control (intensive to achieve a goal 24-hour systolic BP of ≤130 mm Hg or standard to achieve a goal 24-hour systolic BP of ≤145 mm Hg) for a total of 36 months using similar antihypertensive regimens. The analytical approach provides 85% power to show a clinically meaningful effect in differences in mobility accompanied by quantitative differences in WMH between treatment groups. The INFINITY trial is the first to guide antihypertensive therapy using ABP monitoring rather than clinic BP to reduce cerebrovascular disease.

Cluster headache associated with moyamoya.

A 34-year-old man with right-sided cluster headache presented with a stroke from right-sided moyamoya. Following surgery on the right, both moyamoya and cluster headache remitted, but eighteen months later a cluster attack and symptoms of cerebral ischemia from moyamoya recurred on the left. Again, following surgery on the left, both moyamoya symptoms and cluster attacks disappeared. Cluster headache secondary to moyamoya has not previously been described.

Clinical diagnostic accuracy and magnetic resonance imaging of patients referred by physical therapists, orthopaedic surgeons, and nonorthopaedic providers.

STUDY DESIGN: Nonexperimental, retrospective design. OBJECTIVES: This study was designed to compare clinical diagnostic accuracy (CDA) between physical therapists (PTs), orthopaedic surgeons (OSs), and nonorthopaedic providers (NOPs) at Keller Army Community Hospital on patients with musculoskeletal injuries (MSI) referred for magnetic resonance imaging (MRI). BACKGROUND: US Army PTs are frequently the first credentialed providers privileged to examine and diagnose patients with musculoskeletal injuries. Physical therapists assigned at Keller Army Community Hospital have also been credentialed with privileges to order MRI studies for several years. METHODS AND MEASURES: To reduce provider bias, a retrospective analysis was performed on 560 patients referred for MRI over an 18-month period. An electronic review of each patient's radiological profile was performed to assess agreement between clinical diagnosis and MRI findings. Data analyses were performed through descriptive statistics and contingency tables. RESULTS: Analysis on agreement between clinical diagnosis and MRI findings produced a CDA of 74.5% (108/145) for PTs, 80.8% (139/172) for OSs, and 35.4% (86/243) for NOPs. There was a significant difference in CDA between PTs and NOPs (P<.001), and between OSs and NOPs (P<.001). There was no difference in CDA between PTs and OSs (P>.05). CONCLUSIONS: Clinical diagnostic accuracy by PTs and OSs on patients with musculoskeletal injuries was significantly greater than for NOPs, with no difference noted between PTs and OSs.