Flow diverter devices in the treatment of complex middle cerebral artery aneurysms when surgical and endovascular treatments are challenging.

OBJECTIVE: In this study, the authors retrospectively evaluated the effectiveness and the safety of non-surgical middle cerebral artery (MCA) aneurysms treated via the implantation of a flow diverter device (FDD). METHODS: Clinical, procedural and follow-up data were analyzed in order to evaluate the safety and effectiveness of the treatment with the FDD in complex MCA aneurysms. Safety was assessed recording (intra-procedural, peri-procedural and delayed) complications in order to determine the morbidity and mortality rates. Functional outcome was evaluated with modified Rankin Scale (mRS) prior and after the endovascular procedure. To assess the efficacy, midterm and long-term clinical, angiographic and cross-sectional imaging follow-ups were recorded. RESULTS: 47 patients (21 males; 26 females) with MCA aneurysms were treated with FDD. 7 were ruptured. 21 aneurysms were saccular, 19 dissecting, 3 fusiform, 2 blood blister-like and 2 were pseudo-aneurysms. 14 aneurysms were small, 23 large and 10 giant, with a mean size of 15.3 mm. 8 aneurysms were recurrent (Raymond-Roy class III): 2 patients had an aneurysmal sac recanalization after being treated with simple coiling and 6 after being treated with microsurgical clipping. In 4 cases (8.5%), more than one FDD was telescopically positioned in order to treat the aneurysm, for a total of 54 FDDs used. The overall mortality rate was 2.1% (1/47) and the overall morbidity rate was 8.6% (4/47). Midterm neuroimaging follow-ups showed the complete occlusion of the aneurysm in 63% cases, which became 91% at the end of the follow-up. CONCLUSIONS: FDD is a safe and effective tool that can be used in the treatment of complex MCA aneurysms, where conventional neurosurgical treatments can be challenging or ineffective.

Understanding Language Reorganization With Neuroimaging: How Language Adapts to Different Focal Lesions and Insights Into Clinical Applications.

When the language-dominant hemisphere is damaged by a focal lesion, the brain may reorganize the language network through functional and structural changes known as adaptive plasticity. Adaptive plasticity is documented for triggers including ischemic, tumoral, and epileptic focal lesions, with effects in clinical practice. Many questions remain regarding language plasticity. Different lesions may induce different patterns of reorganization depending on pathologic features, location in the brain, and timing of onset. Neuroimaging provides insights into language plasticity due to its non-invasiveness, ability to image the whole brain, and large-scale implementation. This review provides an overview of language plasticity on MRI with insights for patient care. First, we describe the structural and functional language network as depicted by neuroimaging. Second, we explore language reorganization triggered by stroke, brain tumors, and epileptic lesions and analyze applications in clinical diagnosis and treatment planning. By comparing different focal lesions, we investigate determinants of language plasticity including lesion location and timing of onset, longitudinal evolution of reorganization, and the relationship between structural and functional changes.

In Vivo Brain GSH: MRS Methods and Clinical Applications.

Glutathione (GSH) is an important antioxidant implicated in several physiological functions, including the oxidation-reduction reaction balance and brain antioxidant defense against endogenous and exogenous toxic agents. Altered brain GSH levels may reflect inflammatory processes associated with several neurologic disorders. An accurate and reliable estimation of cerebral GSH concentrations could give a clear and thorough understanding of its metabolism within the brain, thus providing a valuable benchmark for clinical applications. In this context, we aimed to provide an overview of the different magnetic resonance spectroscopy (MRS) technologies introduced for in vivo human brain GSH quantification both in healthy control (HC) volunteers and in subjects affected by different neurological disorders (e.g., brain tumors, and psychiatric and degenerative disorders). Additionally, we aimed to provide an exhaustive list of normal GSH concentrations within different brain areas. The definition of standard reference values for different brain areas could lead to a better interpretation of the altered GSH levels recorded in subjects with neurological disorders, with insights into the possible role of GSH as a biomarker and therapeutic target.

Chest CT Scan for the Diagnosis of Pediatric Pulmonary TB: Radiological Findings and Its Diagnostic Significance.

Diagnosing active TB in children remains a clinical challenge, due to difficulties in achieving a definite microbiological confirmation, aspecific clinical manifestation, low sensitivity of chest radiography (CXR). For this reason, the use of chest computed tomography (CT) scan to evaluate suspected TB pediatric cases is increasing. We retrospectively reviewed records of patients aged <16 years diagnosed with active TB at the Pediatric Infectious Disease Unit of the Catholic University of the Sacred Heart to describe CT findings and to evaluate the need for its execution for diagnosis. In 41 cases, 7 CXR were normal (17.1%) while no CT scan was evaluated as negative. In 19 cases (46.3%), CXR was considered non-probable TB pulmonary, compared with 11 of 37 cases (29.7%) of CT. In 15 cases (36.6%) CXR was described as probable for TB pulmonary, instead 26 of the 37 cases evaluated by CT (70.3%) were classified as probable TB. We describe CT findings in patients with pediatric TB. We confirmed that CT can improve the diagnostic accuracy. In particular, the comparison between the CT and CXR ability in detecting cases of pulmonary TB in accordance with the proposed radiological probability criteria, showed a superiority of CT in detecting probable TB pictures (70.3%) compared with 36.6% of the x-Ray.

The low-profile Neuroform Atlas stent in the treatment of wide-necked intracranial aneurysms - immediate and midterm results: An Italian multicenter registry.

BACKGROUND AND PURPOSE: Wide-necked brain aneurysms therapy remains a challenge for neurointerventionalists, mainly for the high recurrence rate. Low-profile stents make feasible the treatment of these aneurysms. In our multicenter series we analyzed clinical and angiographic results of Neuroform Atlas stent-assisted coiling. MATERIALS AND METHODS: From January 2016 to March 2017, 113 wide-necked aneurysms were discovered with CTA, MRA and DSA. The Atlas stent-assisted coiling procedures were performed under general anesthesia with sequential or jailing techniques. Six months follow-up DSA was performed to assess the recurrence rate through the modified Raymond-Roy occlusion scale (RROC). Moreover, patients were evaluated clinically to analyse the degree of disability according to the mRS. MRI was performed at 12 months evaluating both the cerebral tissue and the vessels. RESULTS: In all the procedures it was feasible to navigate the Neuroform Atlas to the goal vessel and deploy the stent across the aneurysmal neck. Intra-procedural complications account for the 6.2% (7/113). The immediate occlusion rate was RROC 1 in 88%, 2 in 9% and 3 in 3% of cases. The 6 months clinical data showed mRS Score 0-1 in 96.5% of patients; 3 patients died of complications related to SAH. The 12 months follow-up showed RROC of 1 in 82%, 2 in 13% and 3 in 5% of cases. No aneurysm has been retreated. CONCLUSIONS: In our multicenter experience the Neuroform Atlas stent assisted-coiling has shown to be a safe and effective technique for the treatment of wide-necked intracranial aneurysms with encouraging clinical and angiographic results.

ADAPT with New Catalyst 5 Reperfusion Catheter for Distal M2 Ischemic Stroke: Preliminary Experience.

OBJECTIVE: We sought to assess preliminary technical and clinical outcomes of Catalyst 5 (CAT 5) as front-line aspiration treatment for M2-M3 occlusion in acute ischemic stroke. METHODS: Patients with symptomatic stroke and distal M2 or M3 occlusions were enrolled retrospectively. A direct aspiration first-pass technique was used as the first treatment option for absolute contraindication to intravenous fibrinolytic therapy. Time to recanalization, first attempt recanalization, and number of attempts were recorded. Successful recanalization was defined as a modified thrombolysis in cerebral infarction score ≥2b; incidence of procedure-related complications was recorded. National Institutes of Health Stroke Scale at discharge and modified Rankin Scale score at 90 days were evaluated by a dedicated neurologist. RESULTS: A total of 11 acute occlusions of distal M2-M3 segment were treated with a direct aspiration first-pass technique using CAT 5 (mean age 69.3 years). Tandem occlusion was present in 2 cases. Intracranial preocclusive mean vessel diameter was 1.9 mm. Overall modified thrombolysis in cerebral infarction score ≥2b was obtained in 72.7% of patients with mean time to recanalization of 36.4 minutes and a mean of 1.9 attempts. First-attempt recanalization with CAT 5 was obtained in 54% of patients with a mean time to recanalization of 29.2 minutes. A stent retriever with proximal aspiration was incorporated as a rescue device in 2 cases. Embolization of new territories was reported after CAT 5 aspiration in 1 patient. No intracranial hemorrhage was detected on follow-up computed tomography. The median National Institutes of Health Stroke Scale score at discharge was 3. At 90 days, a modified Rankin Scale score of 0-2 was achieved in 90.9% of patients. CONCLUSIONS: Preliminary experience using CAT 5 in distal occlusions demonstrates that it may be safe and effective in acute stroke treatment.

Correction to: Gadolinium-Based Contrast Agent-Related Toxicities.

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Gadolinium-Based Contrast Agent-Related Toxicities.

In recent years, gadolinium-based contrast agents have been associated with different types of toxicity. In particular, nephrogenic systemic fibrosis, a progressive sclerotic-myxedematous systemic disease of unknown etiology, is related to gadolinium-based contrast agent administration in patients with kidney dysfunction. More recently, evidence of magnetic resonance signal intensity changes on pre-contrast T1-weighted images after multiple gadolinium-based contrast agent administrations resulted in the hypothesis of gadolinium brain accumulation in patients with normal renal function, subsequently confirmed in pathological samples. However, there is limited current data and further investigations are necessary before drawing definite conclusions on the clinical consequences of gadolinium-based contrast agent accumulation in human tissues and particularly in the brain. Gadolinium-based contrast agent-related toxicity appears connected to molecular stability, which varies together with the pharmacokinetic properties of the compound and depends on the individual characteristics of the subject. During a lifetime, the physiological changes occurring in the human body may influence its interaction with gadolinium-based contrast agents: the integrity and developmental stage of the organs has an effect on the dynamics of gadolinium-based contrast agent distribution and excretion, thus leading to different possible mechanisms of deposition and toxicity. Therefore, the aim of this work is to discuss the pharmacokinetics and pharmacodynamics of gadolinium-based contrast agents, with a special focus on the brain, and to explore potential predominant gadolinium-based contrast agent-related toxicity in two cornerstone periods of the human life cycle: fetal/neonatal and adulthood/aged.

Dentate nucleus T1 hyperintensity: is it always gadolinium all that glitters?

In the last few years, several scientific papers and reports have demonstrated magnetic resonance (MR) signal intensity (SI) changes on pre-contrast T1-weighted images following multiple gadolinium-based contrast agents (GBCA) administrations, particularly following the exposure to linear GBCAs. Pathological animal and human post-mortem studies have confirmed the relationship between this radiological finding and the presence of gadolinium accumulation in vulnerable brain regions in patients with normal renal function. In this short communication, we report the case of a 15-year-old patient affected by b-cell acute lymphoblastic leukemia (bALL) who developed a hyperintense signal in the dentate nuclei following multiple administrations of a macrocyclic GBCA. The purpose of this report is to discuss possible differential diagnoses of this radiological finding with special focus on the differentiation between iron or manganese accumulation, post-irradiation changes and GBCA-related Gd deposition, highlighting the importance of the acquisition of accurate clinical data to improve our scientific knowledge.

Flow diverter devices in ruptured intracranial aneurysms: a single-center experience.

OBJECTIVE In this single-center series, the authors retrospectively evaluated the effectiveness, safety, and midterm follow-up results of ruptured aneurysms treated by implantation of a flow diverter device (FDD). METHODS The records of 17 patients (12 females, 5 males, average World Federation of Neurosurgical Societies score = 2.9) who presented with subarachnoid hemorrhage (SAH) due to the rupture of an intracranial aneurysm treated with an FDD were retrospectively reviewed. Of 17 ruptured aneurysms, 8 were blood blister-like aneurysms and the remaining 9 were dissecting aneurysms. The mean delay between SAH and treatment was 4.2 days. Intraprocedural and periprocedural morbidity and mortality were recorded. Clinical and angiographic follow-up evaluations were conducted between 6 and 12 months after the procedure. RESULTS None of the ruptured aneurysms re-bled after endovascular treatment. The overall mortality rate was 12% (2/17), involving 2 patients who died after a few days because of complications of SAH. The overall morbidity rate was 12%: 1 patient experienced intraparenchymal bleeding during the repositioning of external ventricular drainage, and 1 patient with a posterior inferior cerebellar artery aneurysm developed paraplegia due to a spinal cord infarction after 2 weeks. The angiographic follow-up evaluations showed a complete occlusion of the aneurysm in 12 of 15 surviving patients; of the 3 remaining cases, 1 patient showed a remnant of the aneurysm, 1 patient was retreated due to an enlargement of the aneurysm, and 1 patient was lost at the angiographic follow-up. CONCLUSIONS FDDs can be used in patients with ruptured aneurysms, where conventional neurosurgical or endovascular treatments can be challenging.

Embolization of Dural Arteriovenous Fistula of the Cavernous Sinus Through Percutaneous Ultrasound-Guided Puncture of the Facial Vein.

BACKGROUND: The goal of dural arteriovenous fistula of the cavernous sinus treated with coils through ultrasound-guided access to the facial vein is to interrupt the fistulous communications and decrease the pressure in the cavernous sinus and consequently in the ophthalmic veins. The traditional approach in the treatment of these fistulae is transvenous endovascular occlusion of the cavernous sinus. Transvenous embolization has been proven to be safe and can provide complete and permanent occlusion of the fistula in a single session. The most commonly used venous pathway is the inferior petrosal sinus, but, if it is inaccessible, then, the superior ophthalmic vein is considered; nonetheless, it can require a surgical exposure. Other pathways include the transfemoral transfacial vein. An arterial approach is considered usually when venous approach pathways fail. Arterial occlusion of feeders supplying the fistula is associated with a greater risk of embolic complications. CASE DESCRIPTION: We report a case of dural arteriovenous fistula of the cavernous sinus treated with coils through ultrasound-guided access to the facial vein. CONCLUSIONS: We propose an alternative pathway when the conventional transvenous approach through the inferior petrosal sinus is excluded. An ultrasound-guided facial vein approach can be considered as a direct and safe alternative to reach the cavernous sinus and obtain exclusion of the fistula.

MR imaging of brain pilocytic astrocytoma: beyond the stereotype of benign astrocytoma.

BACKGROUND: Pilocytic astrocytoma (PA) is the most common pediatric brain glioma and is considered the prototype of benign circumscribed astrocytoma. Despite its low malignancy, the CT and MRI features of brain PA may resemble those of much more aggressive brain tumors. Misdiagnosis of PA is particularly easy when it demonstrates MR morphological and non-morphological findings that are inconsistent with its non-aggressive nature and that overlap with the features of more aggressive brain tumors. METHOD: Basing on the evidence that the variation in the histological, genetic, and metabolic "fingerprint" for brain PA is dependent on tumor location, and the hypothesis that tumor location is related to the broad spectrum of morphological and non-morphological MR imaging findings, the authors discuss the MR imaging appearance of brain PA using a location-based approach to underline the typical and less typical imaging features and the main differential diagnosis of brain PA. A brief summary of the main pathological and clinical features, the natural history, and the treatment of brain PA is also provided. RESULT: A combination of morphological and non-morphological MR imaging features and a site-based approach to differential diagnosis are required for a pre-operative diagnosis. The new "cutting-edge" MR imaging sequences have the potential to impact the ease and confidence of pediatric brain tumor interpretation and offer a more efficient diagnostic work-up. CONCLUSIONS: Although the typical imaging features of brain pilocytic astrocytoma make radiological diagnosis relatively easy, an atypical and more aggressive appearance can lead to misdiagnosis. Knowing the broad spectrum of imaging characteristics on conventional and advanced MR imaging is important for accurate pre-operative radiological diagnosis and correctly interpreting changes during follow-up.

Bilateral Internal Carotid Artery Segmental Agenesis: Embryology, Common Collateral Pathways, Clinical Presentation, and Clinical Importance of a Rare Condition.

BACKGROUND: Bilateral segmental agenesis of the internal carotid artery is a rare congenital anomaly. We present a case of bilateral internal carotid artery segmental agenesis in an asymptomatic 18-year-old man. Embryology, common collateral pathways, clinical presentation, and clinical importance of this condition are discussed. According to our review of the literature, this report is the first to describe bilateral internal carotid artery segmental agenesis in a patient studied with magnetic resonance imaging, computed tomography, Doppler ultrasonography, and digital subtraction angiography. CASE DESCRIPTION: An 18-year-old man presented to our hospital complaining of occasional mild headaches. Neurologic examination was unremarkable. Imaging findings consisted of bilateral segmental agenesis of the internal carotid arteries. CONCLUSION: Bilateral segmental agenesis of internal carotid artery may be completely asymptomatic and harmless, but associated conditions, such as cerebral aneurysms or abnormal collateral circulation, should alert clinicians to the possibilities of subarachnoid hemorrhage or cerebral ischemia.

Quantitative analysis of craniofacial dysmorphology in infants with anterior synostotic plagiocephaly.

PURPOSE: The study aimed to identify premature synostosis of "major" and "minor" sutures of the coronal sutural arch and splanchnocranium sutures to evaluate the relationship between craniofacial dysmorphology and the sutural pattern in children with anterior plagiocephaly. METHODS: A quantitative analysis of the skull base and facial changes was performed on preoperative high-resolution CT images in 18 children with anterior synostotic plagiocephaly and compared with imaging findings in 18 age-matched healthy subjects. RESULTS: All patients had patent splanchnocranium sutures. Fifteen out of 18 children showed early and isolated synostosis of the unicoronal suture (the major suture of the coronal ring) and were classified in groups II and III according to the classification scheme of anterior synostotic plagiocephaly based on the severity of craniofacial dysmorphology. Premature fusion of the unilateral coronal suture in groups II and III caused a marked asymmetry and reduced growth of the anterior and middle fossae on the synostotic side and a secondary varying severity in terms of asymmetric growth of the facial complex. Although both groups showed anterior displacement of the mandibular articulation on the synostotic side, group II showed only maxillary asymmetry, while group III showed maxillary and mandibular asymmetry. CONCLUSIONS: In anterior synostotic plagiocephaly, the severity of skull base changes and asymmetric growth of the facial complex is not caused by skull base sutural synostotic involvement but is probably related to the different timing of unilateral coronal suture closure.

Anatomy of anteromedial thigh perforators: CT-angiography study.

The anatomy of perforator for anteromedial thigh (AMT) flap is a very much-debated issue. In this article, we report AMT perforator vascular anatomy by CT-Angiography (CTA) evaluation of 68 consecutive healthy thighs. Perforators emergence, caliber, length, course, and source vessel in the central three fifth of the thigh were studied by a virtual coordinate system. A mean 4.94 ± 1.75 perforators per thigh (average length, 2.6 ± 0.99 cm) from superficial femoral artery (SFA) were found, emerging medial and lateral to sartorius muscle. A mean 0.4 ± 0.74 perforators per thigh (average length, 2.45 ± 0.97 cm) branched from rectus femoris artery, of which 80% were emerging lateral to sartorius muscle. A mean 0.62 ± 0.91 perforators per thigh (average length, 3.1 ± 1.23 cm) branched from an unnamed branch of SFA, of which 88% were emerging lateral to the sartorius muscle. Perforators' calibre was inferior to 1-5 mm in 177 perforators (51.6%), between 1.5 and 2 mm in 159 (46.7%), and over 2 mm in 7 (2%). The findings from this study show that AMT region is plenty of reliable perforators with overlapping fascial emergence but branching from three different source arteries.

A systematic approach to vertebral hemangioma.

Vertebral hemangiomas (VHs) are a frequent and often incidental finding on computed tomography (CT) and magnetic resonance (MR) imaging of the spine. When their imaging appearance is "typical" (coarsened vertical trabeculae on radiographic and CT images, hyperintensity on T1- and T2-weighted MR images), the radiological diagnosis is straightforward. Nonetheless, VHs might also display an "atypical" appearance on MR imaging because of their histological features (amount of fat, vessels, and interstitial edema). Although the majority of VHs are asymptomatic and quiescent lesions, they can exhibit active behaviors, including growing quickly, extending beyond the vertebral body, and invading the paravertebral and/or epidural space with possible compression of the spinal cord and/or nerve roots ("aggressive" VHs). These "atypical" and "aggressive" VHs are a radiological challenge since they can mimic primary bony malignancies or metastases. CT plays a central role in the workup of atypical VHs, being the most appropriate imaging modality to highlight the polka-dot appearance that is representative of them. When aggressive VHs are suspected, both CT and MR are needed. MR is the best imaging modality to characterize the epidural and/or soft-tissue component, helping in the differential diagnosis. Angiography is a useful imaging adjunct for evaluating and even treating aggressive VHs. The primary objectives of this review article are to summarize the clinical, pathological, and imaging features of VHs, as well as the treatment options, and to provide a practical guide for the differential diagnosis, focusing on the rationale assessment of the findings from radiography, CT, and MR imaging.

Concepts in Navel Aesthetic: A Comprehensive Surface Anatomy Analysis.

INTRODUCTION: The navel contributes to abdominal surface identity and beauty. In Western societies, the display of the navel in women's fashion has grown and, nowadays, women are much more concerned about its shape and position. Despite this, few studies are available on navel surface anatomy and there is no standardization regarding its proper placement in cosmetic abdominoplasty. MATERIALS AND METHODS: In this observational study, we analyzed navel shape and position on 81 high quality pictures, having been chosen as top 2013 bikini models by editors of mass media. An on-line survey on navel shape and position has been made via facebook.com, involving 1,682 people. RESULTS: The analysis revealed that navel position is quite variable based on the proportions analyzed with an acceptable narrow data spread of the xiphoid-umbilicus:umbilicus-abdominal mean crease ratio of 1.62 ± 0.16. The data dispersion for the other three ratios was wider, making them less reliable as references. The most appreciated navel shape was the vertical oval with superior hooding (82 %), and the less appreciated ones were the horizontal oval (29 %) and the protruding shape (47 %). When comparing navel position on the same body, the majority of participants choose the one with the navel relocated according to the golden ratio (i.e., 1.618) CONCLUSION: The most attractive navel position is located at the xiphoid-umbilicus:umbilicus-abdominal crease golden ratio. Bony landmarks seem to be not reliable as references for proper navel positioning. The use of the Fibonacci (golden mean) caliper intraoperatively might aid in proper positioning of the navel in abdominoplasty.