Guillaume Saliou

Diagnosis and treatment of dural carotid–cavernous fistulas: a consecutive series of 27 patients

Objectives: To report clinical characteristics, angiographical findings and results of endovascular treatment of patients presenting with dural carotid–cavernous fistulas (DCCFs). Method: Retrospective analysis of 27 consecutive patients with DCCF referred to a specialised interventional neuroradiology department. Results: Orbital and neuro-ophthalmological symptoms were the most common clinical presentation at diagnosis (n = 25). The venous drainage of the fistula involved the ipsilateral superior ophthalmic vein in 24 patients, the contralateral cavernous sinus in 6 and a leptomeningeal vein in 5 patients. Thrombosis of at least one petrosal sinus was found in 23 patients. 7 patients did not receive endovascular treatment: 3 had spontaneous DCCF obliteration, and 4 had only minor clinical symptoms and no leptomeningeal venous drainage on an angiogram. 20 patients received endovascular treatment via either a transvenous (n = 16) or a transarterial approach (n = 4). Complete occlusion of the fistula was obtained in 14 of 16 (87%) patients treated by the transvenous approach and in 1 of 4 (25%) patients treated by the transarterial approach. 16 patients had early clinical improvement after endovascular treatment. One patient had a cerebral haemorrhage after transvenous embolisation of a DCCF with leptomeningeal drainage. On follow-up, all patients treated by the transarterial route remained symptomatic, whereas 10 of 14 (71%) patients cured by the transvenous route were asymptomatic. Conclusions: Transvenous embolisation is a safe and efficient endovascular approach to treat patients with DCCF. However, this technique requires a long learning curve.

Percutaneous vertebroplasty for pain management in malignant fractures of the spine with epidural involvement.

PURPOSE To evaluate the feasibility, efficacy, and safety of percutaneous vertebroplasty (PV) in the treatment of pathologic fractures owing to malignancy with epidural involvement, with or without neurologic symptoms of spinal cord or cauda equina compression. MATERIALS AND METHODS This study was approved by the local ethics committee; informed consent was obtained from all patients. This retrospective review was performed for 51 consecutive patients with metastatic disease or multiple myeloma treated by means of vertebroplasty, who presented with at least one vertebral lesion with epidural involvement, with or without clinical symptoms of spinal cord or cauda equina compression. All patients with neurologic deficit were terminally ill. A neurologic examination was performed before and after treatment in all patients. All imaging examinations and treatments were reviewed, and chi(2), Mann Whitney, or Fisher exact testing was performed for univariate analysis of variables. RESULTS A total of 74 vertebrae were treated in 51 patients, 22 women and 29 men with a mean age of 62.5 years (range, 28-85 years). Fifteen (29%) patients presented symptoms of complete or incomplete spinal cord or cauda equina compression before vertebroplasty and no further clinical deterioration was observed after treatment. The analgesic efficacy of vertebroplasty was satisfactory for 94% (48 of 51) of patients after 1 day, 86% (31 of 36) patients after 1 month, and 92% (11 of 12) patients after 1 year. One patient with no clinical neurologic deficit before treatment experienced symptoms of cauda equina compression 2 days after vertebroplasty. No other major complication was observed. CONCLUSION The feasibility, efficacy, and safety of PV were confirmed in patients experiencing pain related to malignant spinal tumors with epidural extension, with a low complication rate. PV should become part of the palliative analgesic treatment for such patients. (c) RSNA, 2010.

Should decompressive surgery be performed in malignant cerebral venous thrombosis?: a series of 12 patients.

Background and Purpose— In malignant cerebral venous thrombosis (CVT) patients, emergency decompressive surgery has been suggested as a life-saving procedure. We report 12 patients with malignant CVT, among whom 8 underwent operation. Methods— Retrospective study of 12 patients from 3 stroke units who had a malignant CVT as defined: (1) supratentorial cortical lesions attributable to superficial venous system thrombosis with or without sinus involvement; (2) with clinical (decreased consciousness and dilated pupils) or radiological signs of transtentorial herniation; (3) either at onset or after worsening despite heparin therapy. Surgery or abstention was decided individually by neurosurgeons on call. Results— There were 9 women and 3 men with a mean age of 45±15 years. The delay between heparin therapy and signs of malignancy ranged from 2 to 30 hours. At malignant worsening all but 1 patient had hemorrhagic lesions; the median deviation of septum pellucidum was 12 mm (interquartile range, 6.7–13); 5 patients (including 3 who underwent operation) had a unilateral dilated pupil; and 4 (2 who underwent operation) had bilateral dilated pupils. Eight patients underwent surgical decompression, external decompression in 4, both external and internal decompression in 3, and internal decompression in 1. The 4 patients who did not undergo operation died within 1 to 5 days after diagnosis. One patient who underwent operation died of a pulmonary embolism. The 7 others survived, with, at last follow-up (median, 23.1 months; interquartile range, 19.7–45.6), an excellent recovery of mRS 0 or 1 in 6 and mRS 3 in 1. Conclusion— Decompressive surgery may save lives and may even allow a good functional outcome in malignant CVT, even in patients with bilateral dilated pupils.

A Comparative Study of Perfusion Measurement in Brain Tumours at 3 Tesla MR: Arterial Spin Labeling versus Dynamic Susceptibility Contrast-Enhanced MRI

Purpose: To prove the feasibility of arterial spin labeling (ASL) to explore brain tumors by comparing dynamic susceptibility contrast-enhanced MRI to ASL at 3T MR. Materials and Methods: Twenty-seven patients were included presenting 9 gliomas, 10 metastases and 8 meningiomas. All were explored by a pseudo-continuous ASL and dynamic susceptibility contrast-enhanced T2* perfusion sequence. Two neuroradiologists analyzed the cerebral blood flow (CBF) maps to assess feasibility, examination quality and quantitative comparison. The Spearman nonparametric correlation test and the Bland-Altman graphic test were used to analyze our quantitative results. Results: 92% of ASL CBF maps were informative. ASL detected all lesions as well as dynamic susceptibility contrast-enhanced MRI. Both sequences provide relative quantitative CBF values closely correlated. Conclusion: On a 3T MR unit, ASL is a good alternative to dynamic susceptibility contrast-enhanced MRI when contrast medium is contraindicated or intravenous injection is not possible. Its results on relative CBF parameters are similar to contrast-injected perfusion.

Stroke due to lyme neuroborreliosis: changes in vessel wall contrast enhancement.

Neuroborreliosis is a rare cause of stroke in children. We aim here to demonstrate the diagnostic value of gadolinium‐enhanced magnetic resonance imaging (MRI) for demonstrating vessel wall abnormality in a child with brainstem stroke.

Subcallosal artery stroke: infarction of the fornix and the genu of the corpus callosum. The importance of the anterior communicating artery complex. Case series and review of the literature

IntroductionDespite the variable anatomy of the anterior communicating artery (AcoA) complex, three main perforating branches can be typically identified the largest of which being the subcallosal artery (ScA). We present a case series of infarction in the vascular territory of the ScA to highlight the anatomy, the clinical symptomatology, and the presumed pathophysiology as it pertains to endovascular and surgical management of vascular pathology in this region.MethodsIn this retrospective multicenter case series study of patients who were diagnosed with symptomatic ScA stroke, we analyzed all available clinical records, MRI, and angiographic details. Additionally, a review of the literature is provided.ResultsWe identified five different cases of ScA stroke, leading to a subsequent infarction of the fornix and the genu of the corpus callosum. The presumed pathophysiology in non-iatrogenic cases is microangiopathy, rather than embolic events; iatrogenic SCA occlusion can present after both surgical and endovascular treatment of AcoA aneurysms that may occur with or without occlusion of the AcoA.ConclusionStroke in the vascular territory of the ScA leads to a characteristic imaging and clinical pattern. Ischemia involves the anterior columns of the fornix and the genu of the corpus callosum, and patients present with a Korsakoff’s syndrome including disturbances of short-term memory and cognitive changes. We conclude that despite its small size, the ScA is an important artery to watch out for during surgical or endovascular treatment of AcoA aneurysms.

Varicella-zoster virus acute myelitis in a patient with MS treated with natalizumab

We report a case of varicella-zoster virus (VZV) myelitis in a woman with relapsing-remitting multiple sclerosis (RRMS) receiving natalizumab, a humanized monoclonal antibody that induces an immunosuppression localized to the CNS.

Cerebral peritumoral oedema study: Does a single dynamic MR sequence assessing perfusion and permeability can help to differentiate glioblastoma from metastasis?

Our purpose was to differentiate glioblastoma from metastasis using a single dynamic MR sequence to assess perfusion and permeability parameters. 24 patients with glioblastoma or cerebral metastasis with peritumoral oedema were recruited and explored with a 3T MR unit. Post processing used DPTools software. Regions of interest were drawn around contrast enhancement to assess relative cerebral blood volume and permeability parameters. Around the contrast enhancement Glioblastoma present high rCBV with modification of the permeability, metastasis present slight modified rCBV without modification of permeability. In conclusion, peritumoral T2 hypersignal exploration associating morphological MR and functional MR parameters can help to differentiate cerebral metastasis from glioblastoma.

Dynamic contrast-enhanced T2*-weighted MR imaging: A peritumoral brain oedema study

BACKGROUND AND PURPOSE Glioma and meningioma are the two most common types of primary brain tumor. The aim of the present study was to analyze, using dynamic susceptibility contrast MR perfusion imaging, the effect of angiogenesis on peritumoral tissue. METHODS In this prospective study, conducted from December 2003 to March 2005, out of 18 patients recruited, 12 were included (six with meningioma, six with glioblastoma). Using rates of maximum signal drop (MSD), we drew regions of interest (ROI) starting near the lesion, and gradually moving outwards to areas of distant edema in axial and sagittal planes at 10, 20 and 30 mm from the tumor. We also drew ROI on the contralateral brain white matter to obtain a normal baseline for comparison (relative MSD; rMSD). RESULTS In regions of peritumoral T2 hypersignals, we observed a decrease in rMSD with distance from glioblastoma due to reduced angiogenesis, and an increase in rMSD with distance from meningioma, probably due to a reduced mass effect. CONCLUSION In our study, dynamic susceptibility contrast MR perfusion imaging, using MSD as a parameter, revealed differences between meningioma and glioblastoma peritumoral tissue due to changes in angiogenesis.

Clinical features and outcomes of spinal cord arteriovenous malformations: comparison between nidus and fistulous types.

Background and Purpose— As a result of the rarity of spinal cord arteriovenous malformations (AVM), there are only a few series available that describe clinical features, outcome after treatment, and natural history of these lesions. In this article, we aim to describe our experience with both nidus- and fistulous-type spinal cord AVMs. Methods— Forty-four consecutive patients with spinal cord AVMs were retrospectively reviewed. There were 26 patients with a nidus-type and 18 patients with a fistulous-type AVM. Treatments were performed with embolization (n=23), surgery (n=13), combined embolization–surgery (n=3), or conservative management (n=5). Clinical features, radiological findings, treatment results, and clinical outcomes were assessed. Results— Patients with nidus-type AVMs were younger at presentation and more often presented with hemorrhage, with a higher proportion of hematomyelia than fistulous-type AVMs (P<0.05). Progression of clinical presentation from hemorrhage to congestive myelopathy during follow-up was noted in 5 patients, all of which had AVMs of the nidus type. Complete obliteration could be achieved more often in the fistulous type (72%) than in the nidus type (27%). Improved or stable clinical status at last follow-up was noted in 100% of fistulous-type and 77% of nidus-type patients. Long-term clinical deterioration was noted in 6 of 26 patients with nidus-type (23%) AVMs and was related to recurrent bleeding (n=3) or progressive venous congestion (n=3). Overall rebleed rate after presentation with hemorrhage was 7 in 145.5 patient-years (4.8%/y) if the lesion was not treated, 3 in 102 patient-years (2.9%/y) after partial treatment, and 0 in 47.5 patient-years (0%) after complete treatment. Conclusions— Nidus and fistulous spinal cord AVMs have different clinical features and obliteration rates, which may affect their long-term prognosis.