Christophe Portefaix

Follow-Up of Coiled Intracranial Aneurysms: Comparison of 3D Time-of-Flight MR Angiography at 3T and 1.5T in a Large Prospective Series

BACKGROUND AND PURPOSE: Our aim was to compare 3D TOF-MRA sequences at 3T and 1.5T in the follow-up of coiled aneurysms. The follow-up of coiled intracranial aneurysms is mandatory to depict potential recanalization. 3D-TOF MRA is an appropriate tool for this purpose. MATERIALS AND METHODS: DSA and 3D TOF-MRA at 1.5T and 3T were performed in a prospective series of 126 aneurysms in 96 patients (58 women, 38 men; age, 25–75 years; mean, 51.3 ± 11.3 years). DSA was the reference standard to which the accuracy of 3D TOF-MRA was compared. The quality of aneurysm occlusion was assessed independently and anonymously by a core lab by using a 3-grade scale (total occlusion, neck remnant, and aneurysm remnant). Adequate occlusion was defined as total occlusion or neck remnant and used in a 2-grade scale: adequate occlusion/aneurysm remnant. RESULTS: With DSA, total occlusion was depicted in 58 aneurysms (46.0%); neck remnant, in 33 aneurysms (26.2%); and aneurysm remnant, in 35 aneurysms (27.8%). Adequate occlusion was seen in 91 cases (72.2%). A remnant (aneurysm or neck) was depicted in 68 cases (54.0%). For the 3 imaging techniques and regardless of scale used, the interobserver agreement was always greater at 3T than at 1.5T. SE and NPV for the prediction of aneurysm remnant versus adequate occlusion were higher at 3T than at 1.5T (SE 3T, 0.74; SE 1.5T, 0.54; NPV 3T, 0.90; NPV 1.5T, 0.85). CONCLUSIONS: In this large prospective series of patients, 3D TOF-MRA was superior at 3T to 1.5T for the evaluation of coiled intracranial aneurysms.

Follow-up of intracranial aneurysms treated by flow diverter: comparison of three-dimensional time-of-flight MR angiography (3D-TOF-MRA) and contrast-enhanced MR angiography (CE-MRA) sequences with digital subtraction angiography as the gold standard

Background and purpose Follow-up of intracranial aneurysms treated by flow diverter with MRI is complicated by imaging artifacts produced by these devices. This study compares the diagnostic accuracy of three-dimensional time-of-flight MR angiography (3D-TOF-MRA) and contrast-enhanced MRA (CE-MRA) at 3 T for the evaluation of aneurysm occlusion and parent artery patency after flow diversion treatment, with digital subtraction angiography (DSA) as the gold standard. Materials and methods Patients treated with flow diverters between January 2009 and January 2013 followed by MRA at 3 T (3D-TOF-MRA and CE-MRA) and DSA within a 48 h period were included in a prospective single-center study. Aneurysm occlusion was assessed with full and simplified Montreal scales and parent artery patency with three-grade and two-grade scales. Results Twenty-two patients harboring 23 treated aneurysms were included. Interobserver agreement using simplified scales for occlusion (Montreal) and parent artery patency were higher for DSA (0.88 and 0.61) and CE-MRA (0.74 and 0.55) than for 3D-TOF-MRA (0.51 and 0.02). Intermodality agreement was higher for CE-MRA (0.88 and 0.32) than for 3D-TOF-MRA (0.59 and 0.11). CE-MRA yielded better accuracy than 3D-TOF-MRA for aneurysm remnant detection (sensitivity 83% vs 50%; specificity 100% vs 100%) and for the status of the parent artery (specificity 63% vs 32%; sensitivity 100% vs 100%). Conclusions At 3 T, CE-MRA is superior to 3D-TOF-MRA for the evaluation of aneurysm occlusion and parent artery patency after flow diversion treatment. However, intraluminal evaluation remains difficult with MRA regardless of the sequence used.

Value of 4D MR Angiography at 3T Compared with DSA for the Follow-Up of Treated Brain Arteriovenous Malformation

BACKGROUND AND PURPOSE: Four-dimensional, contrast-enhanced MRA is a useful technique for the diagnosis and classification of brain AVM. The purpose of this study was to evaluate its usefulness in the follow-up of treated brain AVM. MATERIALS AND METHODS: Patients with treated brain AVM (embolization, radiosurgery, and/or surgery) were investigated with both DSA (the “gold standard”) and 4D MRA. Four-dimensional MRA was performed at 3T using a 4D sequence, combining contrast-enhanced timing-robust angiography, keyhole, and sensitivity encoding techniques. Examinations were evaluated by 2 independent readers and disagreements were resolved by a third reader. Interobserver and intermodality agreement with respect to residual nidus, residual venous drainage, and brain AVM patency were determined. RESULTS: Between May 2008 and February 2013, 37 patients with a median age of 45 years (interquartile range = 26–55) were prospectively included. Examinations were acquired 36 months (IQR = 10–45.5) after the last treatment. Interobserver agreement for brain AVM patency was very good for both 4D MRA (κ 0.82, 95% CI .67–.98) and DSA (κ 0.84, 95% CI .69–.98). After consensus reading, intermodality agreement for the evaluation of brain AVM patency was good (κ 0.73, 95% CI .55–.90). Diagnostic accuracy of 4D MRA for residual brain AVM compared with DSA, reached a sensitivity of 73.7%, specificity 100%, positive predictive value 100%, and negative predictive value 78.3%. Agreements by technique of treatment are also detailed. CONCLUSIONS: Four-dimensional MRA is a useful radiation-free technique for the follow-up of patients with treated brain AVM, especially patients treated by radiosurgery. However, given its actual limitations it is not sufficient to assert the cure; DSA remains mandatory for this purpose.

Surgical treatment by electrical stimulation of the auditory cortex for intractable tinnitus

Tinnitus is a public health issue in France. Around 1% of the population is affected and 30,000 people are handicapped in their daily life. The treatments available for disabling tinnitus have until now been disappointing. We are reporting on the surgical treatment by electrical stimulation of the auditory cortex of a female patient affected by disabling tinnitus that resisted classical treatments. The tinnitus appeared suddenly 10 years ago after a left ear tympanoplasty. The acouphenometry measures revealed a bilateral tinnitus, predominant on the right side, constant, with high frequency (6000 Hz). Transcranial magnetic stimulation (TMS) was performed at first with several supraliminal and infraliminal protocols. This showed promising results. Anatomic and functional magnetic resonance imaging (fMRI) of the auditory cortex before and after repetitive TMS (rTMS) demonstrated a modification of the cortical activity and where the ideal location for a cortical electrode might be, to straddle primary and secondary auditory cortex. After these investigations, two quadra polar electrodes (Resume, Medtronic Ltd, Hertfordshire, UK), connected to a stimulating device implanted under the skin (Synergy, Medtronic Ltd), were extradurally implanted. The surgical procedure was similar to the one performed for analgesic cortical stimulation. No surgical complications were reported. The activation of the stimulator provided a reduction of 65% of the tinnitus impact, with a persistent effect on the right side. The feasibility of the cortical stimulation in symptomatic treatment of tinnitus was proven by this preparatory work. The middle- and long-term therapeutic effects remain to be evaluated.

Role of MRA in the detection of intracranial aneurysm in the acute phase of subarachnoid hemorrhage

BACKGROUND Magnetic resonance angiography (MRA) has been evaluated for the detection of unruptured intracranial aneurysms with favorable results at 3 Tesla (3T) and with similar diagnostic accuracy as both 3D time-of-flight (3D-TOF) and contrast-enhanced (CE-MRA) MRA. However, the diagnostic value and place of MRA in the detection of ruptured aneurysms has been little evaluated. Thus, the goal of this prospective single-center series was to assess the feasibility and diagnostic value of 3T 3D-TOF MRA and CE-MRA for aneurysm detection in acute non-traumatic subarachnoid hemorrhage (SAH). METHODS From March 2006 to December 2007, all consecutive patients admitted to our hospital with acute non-traumatic SAH (≤10 days) were prospectively included in this study evaluating MRA in the diagnostic workup of SAH. Feasibility of MRA and sensitivity/specificity of 3D-TOF and CE-MRA were assessed compared with gold standard DSA. RESULTS In all, 84 consecutive patients (45 women, 39 men; age 23-86 years) were included. The feasibility of MRA was low (43/84, 51.2%). The reasons given for patients not undergoing magnetic resonance imaging (MRI) examination were clinical status (27 patients), potential delay in aneurysm treatment (11 patients) and contraindications to MRI (three patients). In patients explored by MRA, the sensitivity of CE-MRA (95%) was higher compared with 3D-TOF (86%) with similar specificity (80%). Also, 3D-TOF missed five aneurysms while CE-MRA missed two. CONCLUSION The value of MRA in the diagnostic workup of ruptured aneurysms is limited due to its low feasibility during the acute phase of bleeding. Sensitivity for aneurysm detection was good for both MRA techniques, but tended to be better with CE-MRA.

Linear association between social anxiety symptoms and neural activations to angry faces: from subclinical to clinical levels

Social anxiety disorder (SAD), which is characterized by the fear of being rejected and negatively evaluated, involves altered brain activation during the processing of negative emotions in a social context. Although associated temperament traits, such as shyness or behavioral inhibition, have been studied, there is still insufficient knowledge to support the dimensional approach, which assumes a continuum from subclinical to clinical levels of social anxiety symptoms. This study used functional magnetic resonance imaging (fMRI) to examine the neural bases of individual differences in social anxiety. Our sample included participants with both healthy/subclinical as well as clinical levels of social anxiety. Forty-six participants with a wide range of social anxiety levels performed a gender decision task with emotional facial expressions during fMRI scanning. Activation in the left anterior insula and right lateral prefrontal cortex in response to angry faces was positively correlated with the level of social anxiety in a regression analysis. The results substantiate, with a dimensional approach, those obtained in previous studies that involved SAD patients or healthy and subclinical participants. It may help to refine further therapeutic strategies based on markers of social anxiety.

Differential bilateral involvement of the parietal gyrus during predicative metaphor processing: an auditory fMRI study.

Despite the growing literature on figurative language processing, there is still debate as to which cognitive processes and neural bases are involved. Furthermore, most studies have focused on nominal metaphor processing without any context, and very few have used auditory presentation. We therefore investigated the neural bases of the comprehension of predicative metaphors presented in a brief context, in an auditory, ecological way. The comprehension of their literal counterparts served as a control condition. We also investigated the link between working memory and verbal skills and regional activation. Comparisons of metaphorical and literal conditions revealed bilateral activation of parietal areas including the left angular (lAG) and right inferior parietal gyri (rIPG) and right precuneus. Only verbal skills were associated with lAG (but not rIPG) activation. These results indicated that predicative metaphor comprehension share common activations with other metaphors. Furthermore, individual verbal skills could have an impact on figurative language processing.

Contrast-Enhanced and Time-of-Flight MRA at 3T Compared with DSA for the Follow-Up of Intracranial Aneurysms Treated with the WEB Device

BACKGROUND AND PURPOSE: Imaging follow-up at 3T of intracranial aneurysms treated with the WEB Device has not been evaluated yet. Our aim was to assess the diagnostic accuracy of 3D–time-of-flight MRA and contrast-enhanced MRA at 3T against DSA, as the criterion standard, for the follow-up of aneurysms treated with the Woven EndoBridge (WEB) system. MATERIALS AND METHODS: From June 2011 to December 2014, patients treated with the WEB in our institution, then followed for ≥6 months after treatment by MRA at 3T (3D-TOF-MRA and contrast-enhanced MRA) and DSA within 48 hours were included. Aneurysm occlusion was assessed with a simplified 2-grade scale (adequate occlusion [total occlusion + neck remnant] versus aneurysm remnant). Interobserver and intermodality agreement was evaluated by calculating the linear weighted κ. MRA test characteristics and predictive values were calculated from a 2 × 2 contingency table, by using DSA data as the standard of reference. RESULTS: Twenty-six patients with 26 WEB-treated aneurysms were included. The interobserver reproducibility was good with DSA (κ = 0.71) and contrast-enhanced-MRA (κ = 0.65) compared with moderate with 3D-TOF-MRA (κ = 0.47). Intermodality agreement with DSA was fair with both contrast-enhanced MRA (κ = 0.36) and 3D-TOF-MRA (κ = 0.36) for the evaluation of total occlusion. For aneurysm remnant detection, the prevalence was low (15%), on the basis of DSA, and both MRA techniques showed low sensitivity (25%), high specificity (100%), very good positive predictive value (100%), and very good negative predictive value (88%). CONCLUSIONS: Despite acceptable interobserver reproducibility and predictive values, the low sensitivity of contrast-enhanced MRA and 3D-TOF-MRA for aneurysm remnant detection suggests that MRA is a useful screening procedure for WEB-treated aneurysms, but similar to stents and flow diverters, DSA remains the criterion standard for follow-up.

Neural Correlates of Contrast and Humor: Processing Common Features of Verbal Irony

Irony is a kind of figurative language used by a speaker to say something that contrasts with the context and, to some extent, lends humor to a situation. However, little is known about the brain regions that specifically support the processing of these two common features of irony. The present study had two main aims: (i) investigate the neural basis of irony processing, by delivering short ironic spoken sentences (and their literal counterparts) to participants undergoing fMRI; and (ii) assess the neural effect of two irony parameters, obtained from normative studies: degree of contrast and humor appreciation. Results revealed activation of the bilateral inferior frontal gyrus (IFG), posterior part of the left superior temporal gyrus, medial frontal cortex, and left caudate during irony processing, suggesting the involvement of both semantic and theory-of-mind networks. Parametric models showed that contrast was specifically associated with the activation of bilateral frontal and subcortical areas, and that these regions were also sensitive to humor, as shown by a conjunction analysis. Activation of the bilateral IFG is consistent with the literature on humor processing, and reflects incongruity detection/resolution processes. Moreover, the activation of subcortical structures can be related to the reward processing of social events.

Mental healthcare in older adults with schizophrenia: results from 118 French public psychiatric departments.

The increased life expectancy in people with severe and persistent psychiatric illness, such as schizophrenia or bipolar disorder, has been predicted to substantially affect mental healthcare system (Bartels et al., 2002) that must adapt to meet the needs of older adults (Jeste et al., 1999). Development of specialized geriatric psychiatry services is thus needed. In France, public mental health departments are organized into “sectors,” i.e. catchment areas defining mutually independent geographical areas, each of them comprising a mean population of 72,000 inhabitants. Catchment area healthcare teams cover all levels of service provision, i.e. primary, secondary, and tertiary care, and are responsible for the provision of healthcare services for all the inhabitants of the areas concerned. Apart from the planning and budgeting advantages of this method of organizing service, this approach leads to enhanced likelihood of providing continuity of care. However, it also implies that each sector healthcare team have the knowledge and the means required to adequately manage all mental disorders, limiting thus the development of services specialized in the care of specific disorders and in geriatric psychiatry (Verdoux and Tignol, 2003). In this report, we sought to give an overview on the global provision of psychiatric care for older adults in France and examine the proportion of older patients with schizophrenia among psychiatric patients followed up in France between 2008 and 2009. Data were collected in 118 public-sector psychiatric departments between 2008 and 2009. Each department was questioned about the total number of patients aged over 18 years old they had followed up during this period, their age, and the number of patients with an International Classification of Diseases, 10th Revision (ICD10) diagnosis of schizophrenia or schizoaffective disorder (F20–F25). Lastly, all departments were asked whether they offer specialized services for elderly patients. Study results indicate that one out of five (n = 376±303; 21%) patients was aged 60 years or older. Patients with a diagnosis of schizophrenia represented nearly 13% (n = 236±147) of the total number of patients, while the percentage of patients with schizophrenia aged 60 years and older was 1.5% (n = 26±15) of the total number of patients. More than one out of ten patients with schizophrenia was aged 60 years and older (11.1%). Less than four out of ten mental health departments (39.8%) provided specialized services for elderly patients. In these departments, 76% reported ambulatory care services, 42% consultation-liaison, 36% full-time hospitalization with an average of five beds dedicated to the elderly, and 19% day hospitalization. Mental health in older people has become a major issue in the European Union (EU) (Jané-Llopis and Gabilondo, 2008). The EU stresses the importance of promoting autonomy and independence for older people with mental health diseases by privileging community-based care and maintaining elderly subjects in their own environment. However, our results, in line with those of a recent study (Tucker et al., 2007), suggest that despite substantial improvements during the last decades, the development of mental health departments offering specialized services for older patients is insufficient to meet the impending crisis in geriatric mental health. Mental healthcare for older adults with mental illness, and particularly those with schizophrenia, needs to be accessible, affordable, culturally appropriate, and integrated into a comprehensive system of mental health services that ensures continuity and coordination of care. Despite evidence for the efficacy of a variety of interventions for mental disorders in the elderly, implementation of these interventions in usual care settings remains limited (Bartels et al., 2002). The main objectives for the next few years are to ensure equitable access to appropriate assessment and treatment of mental disorders in older individuals, develop the interface between specialist mental health services and generic services caring for older people, and provide adequate training to young psychiatrists and mental health staff. In France, the National Health Strategy plan recently presented by the government seeks to diminish care provision disparities, with a particular focus on the older population. In conclusion, although elderly patients represent one out of five psychiatric patients in France, only one-third of French public mental health departments provide services specialized in geriatric psychiatry. Given the rapid growth of