Bruno Law-Ye

Successful endovascular treatment of three fusiform cerebral aneurysms with the Pipeline Embolization Device in a patient with dilating HIV vasculopathy

Dilating HIV vasculopathy can be a cause of ischemic and hemorrhagic stroke in patients with HIV. Although first identified in children, this condition is increasingly being recognized in adults and has a dismal natural history under medical or expectant management. Vessel wall invasion by varicella zoster virus, HIV or Mycobacterium avium intracellulare complex (MAI) has been postulated as a possible etiology. We present a case of an adult patient with HIV and chronic disseminated MAI infection who presented with ischemic stroke and three fusiform cerebral aneurysms that were successfully treated with the pipeline embolization device (PED). Flow diversion may be a viable treatment option for patients presenting with this serious neurovascular condition when aneurysm location precludes parent vessel sacrifice or surgical bypass. In addition, platelet function testing with VerifyNow may be valuable in selecting the appropriate P2Y12 receptor antagonist to be used in order to prevent PED thrombosis, since some of the antiretroviral drugs may inhibit clopidogrel or prasugrel metabolism.

The Degenerative Spine

Degenerative disease of the spine is a leading cause of back pain and radiculopathy, and is a frequent indication for spine MR imaging. Disc degeneration, disc protrusion/herniation, discarhtrosis, spinal canal stenosis, and facet joint arthrosis, as well as interspinous processes arthrosis, may require an MR imaging workup. This review presents the MR imaging patterns of these diseases and describes the benefit of the MR imaging in these indications compared with the other imaging modalities like plain radiographs or computed tomography scan.

First Depiction of Flow Voids to Differentiate Pituicytomas from Giant Adenomas

Pituicytomas are rare low-grade glial lesions of neurohypophysis or adenohypophysis. They are often misdiagnosed as adenomas due to their similar morphology. Previous reports have underlined their nonspecific aspect. In our experience, presence of flow voids on magnetic resonance, which usually indicate hypervascularized tumors with strong arterial supply, may be a useful sign to identify pituicytomas. Unlike adenomas, pituicytomas are highly vascularized tumors. Second, we emphasize the strong enhancement of these tumors when compared with normal hypophysis, which may be another sign of their hypervascularization. Indeed, adenomas, on the opposite side, present less enhancement than normal hypophysis. This observation is corroborated by previous histologic studies that showed adenomas present less vascular density than normal pituitary glands. However, in large tumors, the normal hypophysis can sometimes not be individualized and thus the enhancement gradient between the tumor and normal tissue cannot be properly assessed. Due to their rarity, no previous reports had ever emphasized the specific signs that could allow us to differentiate pituicytomas from adenomas; however, it seems crucial due to the potential hemorrhagic complications of pituicytoma surgery.

Post-surgery pCASL perfusion MRI of endolymphatic sac tumor

A 21-year-old patient presented with a large right-sided ELST. RI investigation performed after preoperative partial embolizaion, demonstrated large residual enhancement of the internal umor portion. The pCASL sequence was acquired on a 3 T MRI canner (HDxT, GE Healthcare, Milwaukee, WI) with the followng parameters: TR/TE 4733/9.8 ms, NEX 3, receiver bandwidth 2.5 kHz, post-label delay 2025 ms, FOV 24 cm3, spiral acquisiion with 8 arms and 512 points per arm, in-plane resolution .49*3.49*4 mm, scan time 4′41 min. The cerebral blood flow (CBF) ap showed hyperperfusion, suggesting high tumor blood flow ithin the lesion (Fig. 1A, B). These findings were concordant with he post-embolization arteriography results. The patient underent supposedly complete tumor resection. The postoperative ontrast-enhanced T1-weighted sequence demonstrated minimal nhancement, which could result from postoperative inflammaion. However, the pCASL sequence was indicative of a strongly yper-perfused lesion, corresponding to a residual tumor in the nternal part of the lesion (Fig. 1C, D). The anatomopathological nalysis of resection margins confirmed the residual tumor, which as treated by radiosurgery.

Pre-surgical CT-assessment of neurogenic myositis ossificans of the hip and risk factors of recurrence: a series of 101 consecutive patients

BackgroundNeurogenic Myositis Ossificans (NMO) is a rare disabling pathology characterized by peri-articular heterotopic ossifications following severe peripheral or central nervous system injuries. It results in ankylosis and vessels or nerves compressions. Our study aimed to describe the pre-operative findings of patients with NMO of the hip using biphasic computerized tomography (CT).MethodsBetween 2006 and 2012, we retrospectively analyzed 101 consecutive patients with hip NMO. We analyzed all CTs and surgical reports following a standardized grid depicting the osteoma and its relations with joint capsule, vessels and nerves and bone mineralization. We studied surgical complications and recurrence during follow-up. Chi2-test and Fischer’s test were performed to compare qualitative values with respectively normal and non-normal distribution. Quantitative values were analyzed with a one factor analysis of variance (ANOVA) test. Agreement between pre-surgical CT and surgical observations was evaluated with Cohen’s kappa test.ResultsCorrelation between pre-operative CT and surgical findings was excellent regarding relationships with vessels (0,82) and was good concerning relationships with sciatic nerves (0.62) and with joint capsule (0.68). Close contact or disruption of joint capsule (p = 0.005), joint space narrowing (p = 0.007) and bone demineralization (p < 0.001) were correlated with NMO recurrence.ConclusionsBiphasic enhanced-CT allows pre-operative assessment of NMO with good correlation to surgical observations and helps prevent surgical complications.

Combined Angio-Seal™ and stenting rescue treatment in a case of iatrogenic common carotid artery dissection during direct puncture for ruptured intracranial aneurysm embolization: A technical note

BACKGROUND AND IMPORTANCE Direct puncture may offer an alternative access for embolization of intracranial aneurysms in patients presenting with tortuous vessels. Nevertheless, major complications such as compressive hematoma and arterial dissection can occur with this technique. CLINICAL PRESENTATION A tight common carotid artery (CCA) dissection was seen secondary to direct puncture in a 72-year-old patient who presented with a ruptured anterior communicating artery (ACom) aneurysm. After regular coiling of the aneurysm and using a femoral approach, an Angio-Seal™ device (St Jude Medical, Saint Paul, MN, USA) was placed and a carotid wallstent (Stryker Neurovascular, Fremont, CA, USA) successfully deployed at the dissected CCA, which was followed by good clinical and angiographic outcomes. CONCLUSION A combined rescue technique combining Angio-Seal insertion and stent deployment was safe and effective for managing iatrogenic carotid artery dissection.

Malignant transformation of epidermoid cyst with diffuse leptomeningeal carcinomatosis on skull base and trigeminal perineural spread

Intracranial epidermoid cysts (EC) are common congenital lesions accounting for approximately 1% of all intracranial tumors (1). Malignant transformation of EC is a rare but severe complication associated with poor prognosis (2). Our letter aims to depict a rare case of diffuse leptomeningeal carcinomatosis on skull base and trigeminal perineural spread of a squamous cell carcinoma (SCC) complicating an EC.

Muscular MRI-based algorithm to differentiate inherited myopathies presenting with spinal rigidity

ObjectivesInherited myopathies are major causes of muscle atrophy and are often characterized by rigid spine syndrome, a clinical feature designating patients with early spinal contractures. We aim to present a decision algorithm based on muscular whole body magnetic resonance imaging (mWB-MRI) as a unique tool to orientate the diagnosis of each inherited myopathy long before the genetically confirmed diagnosis.MethodsThis multicentre retrospective study enrolled 79 patients from referral centres in France, Brazil and Chile. The patients underwent 1.5-T or 3-T mWB-MRI. The protocol comprised STIR and T1 sequences in axial and coronal planes, from head to toe. All images were analyzed manually by multiple raters. Fatty muscle replacement was evaluated on mWB-MRI using both the Mercuri scale and statistical comparison based on the percentage of affected muscle.ResultsBetween February 2005 and December 2015, 76 patients with genetically confirmed inherited myopathy were included. They were affected by Pompe disease or harbored mutations in RYR1, Collagen VI, LMNA, SEPN1, LAMA2 and MYH7 genes. Each myopathy had a specific pattern of affected muscles recognizable on mWB-MRI. This allowed us to create a novel decision algorithm for patients with rigid spine syndrome by segregating these signs. This algorithm was validated by five external evaluators on a cohort of seven patients with a diagnostic accuracy of 94.3% compared with the genetic diagnosis.ConclusionWe provide a novel decision algorithm based on muscle fat replacement graded on mWB-MRI that allows diagnosis and differentiation of inherited myopathies presenting with spinal rigidity.Key Points• Inherited myopathies are rare, diagnosis is challenging and genetic tests require specialized centres and often take years.• Inherited myopathies are often characterized by spinal rigidity.• Whole body magnetic resonance imaging is a unique tool to orientate the diagnosis of each inherited myopathy presenting with spinal rigidity.• Each inherited myopathy in this study has a specific pattern of affected muscles that orientate diagnosis.• A novel MRI-based algorithm, usable by every radiologist, can help the early diagnosis of these myopathies.

Neuronal injuries evidenced by transient cortical magnetic resonance enhancement in hemiplegic migraine: A case report

Background Magnetic resonance imaging abnormalities in hemiplegic migraine have been described previously but were limited to a cortical thickening and biphasic alternation of hypoperfusion and hyperperfusion. Our report reveals possible blood-brain barrier disruption during migraine. Case We present the first demonstrated case of regressive diffuse hemispheric cortical enhancement in sporadic hemiplegic migraine, with histological correlation revealing neuronal lesions similar to ischemic lesions. This is probably due to the severity of the attack as indicated by the left hemiplegia and transient altered consciousness in our 43-year-old male patient. Conclusion Cortical contrast enhancement on 3D T1 images may suggest migraine severity and be predictive of neuronal loss.

Needle aspiration as an alternative treatment for glio-ependymal cysts

Dear editor, We have been very interested to read Robles et al.’s review about intracranial glio-ependymal/neuroglial cysts [7]. In this article, the authors reviewed different treatment alternatives for symptomatic cysts: shunting, fenestration, or resection. They suggested that the ideal procedure will depend on the location of the cyst, aiming to relieve the mass effect with minimal damage to the surrounding parenchyma. Based on our experience, we suggest that first-line stereotactic needle aspiration can be an effective option. To the best of our knowledge, we are the first to report this minimally invasive procedure. We treated two patients with needle aspiration for glioependymal cysts, the diagnosis being based on MRI findings and pathological analysis of aspirated liquid. The first patient was a 54-yo female who presented with cerebellar syndrome and gait instability. She had a general work-up to rule out an infectious or tumoral lesion. The MRI showed a 22-mm cyst without an enhanced wall in the left cerebellar peduncle with CSF signal (Fig. 1A). After multidisciplinary discussion, the patient was treated with a stereotactic puncture. We collected 3 ml of normal CSF on biochemical, bacteriological, and cytological study. The post-operative course was uneventful. Follow-up showed a significant and durable reduction of the cyst, even after 7 years (Fig. 1B), and the patient remains asymptomatic until this day. The second patient is a 50-yo woman with a past history of left thalamic infarct complaining of progressing left hemiparesis, vertigo, dysarthria, and mild memory impairment. Clinical examination confirmed weakness of the left limbs, hypoesthesia, and left hemispatial neglect. Brain MRI showed a right pre-rolandic cyst with mass effect on sulci, measuring 38 × 36 × 30mm. The patient was treated with a stereotactic puncture, aspirating 15 ml of clear CSF. In this case, the symptoms reappeared after 2 months and the cyst increased back to 22 × 21 × 18mm, prompting to place a cysto-peritoneal shunt. It provoked the collapse of the cyst on post-surgical CT-scan and the symptoms resolved. The patient was still asymptomatic after 18-month follow-up. We suggest that stereotactic needle aspiration should be considered as a first-line minimally invasive alternative, as it has shown effective to durably relieve mass effect in one of our patients. It is realized under local anesthesia, according to the classical stereotactic procedure with a Leksell frame. The needle avascular trajectory is calculated using Brainlab stereotactic planning software (Brainlab, Germany). A 1.5-mm core Sedan needle is used to aspirate the liquid. There is no guideline about glio-ependymal cysts treatment because of their rarity. Therefore, surgeons usually use guidelines that derive from arachnoid cysts experience. In those cases, needle aspiration is not appropriate, since the cysts are lined with CSF-producing cells, with a short-term 50% recurrence [1, 2]. However, aspirationmay bemore adapted for glioependymal cysts, lined with glial and ependymal cells which do not systematically secrete CSF. Offering this procedure as a therapeutic option induces less trauma to the adjacent parenchyma than resection or fenestration and is not associated with shunting specific complications (infection, dysfunction ...). If the symptoms recur and the cyst increases, it is possible and necessary to offer an invasive procedure, like in our second case. Moreover, Robles et al.’s review showed that recurrence also occurs after fenestration [7], even though most cases have follow-up periods of no more than 6 months [3, 4, 6, 8]. To consider a minimally invasive procedure, differential diagnosesmust be ruled out pre-operativelywith exhaustive workup, including infectious cysts (hydatidosis or cysticercosis [5]), porencephalic cavities, arachnoid, colloid, dermoid or epidermoid, neurenteric cysts, low-grade tumors (hemangioblastomas, This article is part of the Topical Collection on CSF Circulation