bluuebunny/crossref_metadata_2025 huggingface dataset:
Intravascular Ultrasound to Assess Extracranial Vertebral Artery Restenosis: Case Report
Authors: Gupta Rishi , Bhatt Archit , Kassab Mounzer , Majid Arshad
Published: October 2009

We present a case report of a patient who developed restenosis 5 months after initial stent placement. computed tomography (CT) angiography revealed a 70% stenosis, while conventional angiography revealed a 40% stenosis. An intravascular ultrasound (IVUS) was used to assess the degree of narrowing along with the mechanism causing the stenosis. IVUS can be utilized to resolve discrepancies between imaging modalities for degree of stenosis and also aid in determining the mechanism of restenosis after stent placement in the extracranial vertebral arteries.
Leo Stent‐Assisted Coil Embolization of a Giant Middle Cerebral Artery Aneurysm
Authors: Ahn Jung Yong , Hong Chang Ki , Suh Sang Hyun , Cho Jun Hyung , Shim Yo Shik , Huh Ji Soon
Published: October 2009

We report a case of a 70‐year‐old man harboring a wide‐necked thrombosed giant aneurysm of the left middle cerebral artery (MCA) on the M1 segment. The patient presented with generalized tonic‐clonic seizures. A computerized tomography scan showed a calcified aneurysmal wall with perianeurysmal swelling. The aneurysm was successfully embolized using closed‐cell nitinol stent‐assisted coiling (Leo, BALT Co., Montmorency, France).
Normalized Upper Cervical Spinal Cord Atrophy in Multiple Sclerosis
Authors: Song Feng , Huan Yi , Yin Hong , Ge Yali , Wei Guangquan , Chang Yingjuan , Zhao Haitao
Published: October 2009

BACKGROUND AND PURPOSE

To find an optimal normalizing factor for upper cervical spinal cord area (UCCA) and to establish whether, in a cross‐sectional study, the normalized UCCA correlates better with the neurological disability than the absolute measurement in multiple sclerosis patients.

METHODS

UCCA and three potential normalizing factors were estimated from magnetic resonance imaging data in 51 control subjects. Their reliability was assessed and the linear relationships between UCCA and three potential correction factors were investigated. UCCA was then normalized by these factors respectively. On the basis of these results, an optimal factor was selected and applied to 29 MS subjects.

RESULTS

An extremely strong correlation between UCCA and LECA was seen (r= .88, P < .01). The coefficient of variation (COV) of UCCA was reduced to 4.4% from 9.3% after correction by LECA. The normalized measurement of UCCA correlated better with the expanded disability status scale (EDSS) than the absolute measurement especially in relapsing‐remitting multiple sclerosis patients. Moreover, more spinal cord atrophy was identified in corrected data than uncorrected data.

CONCLUSION

Our findings suggest that LECA is an optimal correction factor for UCCA and normalized UCCA is preferable to absolute measurement in cross‐sectional study.
Reversible Hyperintense Lesion after Balloon Occlusion Test
Authors: Haraguchi Koichi , Houkin Kiyohiro , Koyanagi Izumi , Nonaka Tadashi , Baba Takeo
Published: October 2009

We report a unique case of a reversible high signal intensity lesion observed on a magnetic resonance (MR) image accompanied by transient neurological deficits related to a balloon occlusion test. This abnormality was considered to be vasogenic edema caused by the disruption of the blood‐brain barrier (BBB) due to a long history of uncontrolled hypertension and transient ischemia induced by the balloon occlusion test.
CT Imaging Features of Carotidynia: A Case Report
Authors: Park Ji Kang , Choi Jay Cheol , Kim Bong Soo , Choi Gukmyung , Kim Seung Hyung
Published: October 2009

Despite denial as a disease entity, carotidynia had shown relatively concordant imaging finding as an inflammatory process surrounding the carotid bifurcation area. We report serial computed tomography (CT) images of a case with carotidynia that showed the layered thickening of the carotid wall with self‐limiting disease course.
Qureshi Grading Scheme Predicts Subsequent Volume of Brain Infarction Following Intra‐Arterial Thrombolysis in Patients with Acute Anterior Circulation Ischemic Stroke
Authors: Mohammad Yousef M. , Christoforidis Greg A. , Bourekas Eric C. , Slivka Andrew P.
Published: October 2009

BACKGROUND

The importance of the site of occlusion and the presence or absence of collaterals on initial angiography in patients with acute ischemic stroke has been recognized. Qureshi recently proposed a scheme that categorizes patients with ischemic stroke based on findings observed on initial angiography.

METHODS

We determined the relationship between severity of angiographic occlusion using Qureshi grading scheme and volume of brain infarction on follow‐up computed tomography in 55 patients with anterior circulation ischemic stroke who underwent intra‐arterial thrombolysis.

RESULTS

A strong association was observed between Qureshi grades and volume of brain infarction (F ratio 6.2, P= .0005) after adjusting for patients' age, sex, National Institutes of Health Stroke Scale (NIHSS) score, thrombolytic used, and time interval between symptom onset and angiography. The relationship persisted after further adjustment for final angiographic recanalization (F ratio 5.1, P= .001). A significant relationship between initial grades and volume of brain infarction was separately observed in both patients with or without recanalization following treatment.

CONCLUSIONS

Qureshi grading scheme can be effectively used to stratify patients with anterior circulation ischemic stroke undergoing intra‐arterial thrombolysis using initial angiographic findings.
Real‐Time Hemodynamic Assessment of Intracranial Stenosis in a Patient with Orthostatic Aphasia: Potential Applications of Transcranial Doppler
Authors: Aladdin Yasser , Hussain Muhammad S. , Saqqur Maher
Published: October 2009

BACKGROUND

Intracranial atherosclerotic stenosis is thought to be responsible for 8% of all ischemic stroke subtypes. Transcranial Doppler (TCD) ultrasonography allows for noninvasive and dynamic evaluation of the cerebral circulation within the circle of Willis. We present a case of recurrent, orthostatic transient ischemic attacks in which, using TCD, we were able to correlate dynamically between the orthostatic symptomatology and a significant drop in the mean flow velocity (MFV) across the stenotic middle cerebral artery (MCA) segment.

METHODS

A 56‐year‐old male presented with recurrent episodes of orthostatic right‐sided weakness and expressive aphasia. Diagnostic TCD revealed a stenotic signal in the left internal carotid artery (ICA) siphon. Subsequent TCD monitoring of both MCAs demonstrated a significant orthostatic drop in MFV of the left MCA, which closely correlated with his symptoms. The cerebral angiogram confirmed a high‐grade stenosis at the supraclinoid segment of the left ICA.

CONCLUSION

TCD is a useful, noninvasive, and dynamic tool for assessment of the intracranial circulation, and should be considered in the workup of patients with hypoperfusion cerebrovascular events.
Contrast‐Enhanced Transcranial Color‐Coded Duplex Sonography Criteria for Basilar Artery Stenosis
Authors: Tateishi Yohei , Iguchi Yasuyuki , Kimura Kazumi , Inoue Takeshi , Shibazaki Kensaku , Eguchi Katsumi
Published: October 2009

BACKGROUND AND PURPOSE

The aim of this study is to assess contrast‐enhanced transcranial color‐coded duplex sonography (CE‐TCCS) diagnosis of basilar artery (BA) stenosis.

METHODS

CE‐TCCS and cerebral angiography were performed in 120 consecutive patients. The patients were angiographically divided into five groups: (1) intracranial arteries (ICA) stenosis but no BA stenosis as intracranial stenosis (ICS) group, (2) both ICA and BA stenoses as internal carotid arteay and basilar arteay stenoses (IBS) group, (3) BA stenosis as basilar artery stenosis (BAS) group, (4) BA occlusion as basilar artery occlusion (BAO) group, and (5) no arterial lesions as Control group. We compared the peak systolic flow velocity (PSV) of BA using CE‐TCCS.

RESULTS

PSV was highest in the BAS group (n= 9, 206.1 ± 118.6 cm/sec), followed by the ICS (n= 27, 74.9 ± 36.1 cm/sec) and Control (n= 70, 58.2 ± 17.3 cm/sec) groups. IBS group had two patients (PSV: 102 cm/sec and 167 cm/sec). Sensitivity–specificity curve analysis revealed a cutoff PSV of 120 cm/sec to distinguish the BAS group from other groups, and then we calculated sensitivity of 100%, specificity of 95%, positive predictive value of 64%, negative predictive value of 100%, and accuracy of 95%.

CONCLUSION

Measurement of PSV of the BA using CE‐TCCS is useful for the identification of BA stenosis.
Reversible Parkinsonism After Treatment of Dural Arteriovenous Fistula
Authors: Nogueira Raul G. , Baccin Carlos E. , Rabinov James D. , Pryor Johnny C. , Buonanno Ferdinando S. , Hirsch Joshua A.
Published: October 2009

BACKGROUND AND PURPOSE

The most common causes of parkinsonism are degenerative and irreversible. Structural causes of reversible parkinsonism are exceptionally rare, but have been reported in association with deep cerebral venous thrombosis and dural arteriovenous fistula (DAVF). We now report a case of parkinsonian syndrome reversed by treatment of a dural arteriovenous malformation.

METHODS

Case report with retrospective review of relevant clinical, imaging, and treatment data.

RESULTS

A 79‐year‐old man presented with complaints of a slowly progressive parkinsonian syndrome and tinnitus. Brain magnetic resonance imaging (MRI) showed numerous serpiginous flow voids highly suggestive of a vascular malformation. Cerebral angiography revealed a Cognard grade IIa + b left transverse sinus DAVF. The patient underwent combined endovascular and surgical treatment in three stages over a week's time, with total obliteration of the DAVF and complete normalization of his symptoms and neurological examination.

CONCLUSION

Although rare, DAVF should always be considered as a potential cause of progressive parkinsonism. This diagnosis is of great importance because of its potential reversibility.
Arterial Vasospasm During Mechanical Thrombectomy for Acute Stroke
Authors: Gupta Rishi
Published: October 2009

OBJECTIVE AND IMPORTANCE

Mechanical maneuvers are being utilized more frequently to treat large artery occlusion responsible for acute ischemic stroke. Vasospasm due to vessel irritation during interventions may represent an etiology of poor recanalization in some patients.

CASE REPORTS

This report describes 2 patients who developed arterial vasospasm at the site of deployment of the L5 Merci retrieval device. The vasospasm was significant in nature and occlusive to one division of the middle cerebral artery. Both patients were treated with infusion of calcium channel antagonists with resolution of the narrowing.

CONCLUSIONS

Vasospasm after mechanical thrombectomy may represent a potential etiology for poor recanalization particularly if this is severe enough to cause complete occlusion. The use of pharmacological agents to treat suspected vasospasm should be considered during endovascular revascularization procedures for acute ischemic stroke, but care must be taken in monitoring decreases in blood pressure.
MRI Showing White Matter Lesions and Multiple Lobar Microbleeds in a Patient with Reversible Encephalopathy
Authors: Alcalay Roy N. , Smith Eric E.
Published: October 2009

Cerebral amyloid angiopathy (CAA) can rarely be complicated by vascular and perivascular inflammation. Patients typically present with subacute cognitive decline, seizures, headaches, and hyperintensities on T2‐weighted or fluid‐attenuated inversion recovery (FLAIR) magnetic resonance imaging (MRI) sequences. Little is known about the cause and natural history of inflammatory CAA, but recent case series show that some patients respond well to steroids. Here, we describe a patient who presented with severe subacute encephalopathy and was diagnosed with probable CAA‐related inflammation based on characteristic MRI, showing subcortical FLAIR hyperintensities with mass effect and multiple cortical microbleeds, after excluding other possible causes of subacute delirium. Mental status examination markedly improved after a course of intravenous methylprednisolone, initially without significant change in MRI appearance. An MRI 4 months later, however, showed marked reduction in the volume of white matter T2 hyperintensities. Mental status remained improved with mild residual retrograde and anterograde amnesia. We propose that the diagnosis of CAA‐related inflammation should be considered in patients with profound subacute mental status changes and typical MRI findings. In steroid‐responsive patients, clinical improvement can precede radiographic improvement.
Relationship between Flow Diversion on Transcranial Doppler Sonography and Leptomeningeal Collateral Circulation in Patients with Middle Cerebral Artery Occlusive Disorder
Authors: Kim Yosik , Sin Dae‐Soo , Park Hyun‐Young , Park Man‐Seok , Cho Ki‐Hyun
Published: October 2009

BACKGROUND

Flow diversion (FD) has been considered as indirect evidence of intracranial artery occlusion, and it was associated with early improvement in patients with MCA occlusion. It is not known whether FD can represent leptomeningeal collateral circulation or not in patients with middle cerebral artery (MCA) occlusive disorder.

PATIENTS AND METHODS

FD was defined by increased velocity (>30%) in anterior or posterior cerebral artery (ACA, PCA) compared to contralateral analogs artery in patients with MCA occlusive disorder. The leptomeningeal collateral channel (LMC) was identified using digital subtraction angiography.

RESULTS

A total of 51 patients were enrolled in this analysis. Transcranial Doppler (TCD) showed a FD in 47% (24) of patients. Twenty‐three patients had FD in ACA, and 1 patient in PCA. LMC was identified in 41% (21) of patients. Sensitivity of FD for leptomeningeal collateral circulation was 81%, specificity 76.7%, positive predictive value 70.8%, and negative predictive value 85.2%. Presence of FD showed good correlation with presence of LMCs in patients with MCA stenosis (r= .568, P= .00)

CONCLUSION

FD on TCD suggests the presence of leptomeningeal collateral circulation in patients with MCA occlusive disorder.
Leptomeningeal Collateral Volume Flow Assessed by Quantitative Magnetic Resonance Angiography in Large‐Vessel Cerebrovascular Disease
Authors: Ruland Sean , Ahmed Aiesha , Thomas Kurian , Zhao Meide , Amin‐Hanjani Sepideh , Du Xinjian , Charbel Fady T.
Published: October 2009

BACKGROUND/PURPOSE

Leptomeningeal collateral volume flow has not been previously quantified. Quantitative magnetic resonance angiography (QMRA) can determine flow in the large vessels of the intracranial circulation.

METHODOLOGY

We reviewed consecutive QMRA studies performed between December 1, 2004 and August 30, 2005, for cases showing asymmetrically higher flow in a posterior cerebral artery (PCA) just distal to the origin of the posterior communicating artery ipsilateral to a hemodynamic middle cerebral artery (MCA) or internal carotid artery lesion. The mean, range, and standard deviation (SD) of the flow rate in the PCAs, MCAs, and PCA ipsilateral‐contralateral difference were calculated. Ipsilateral and contralateral PCA flow rates were compared using the Student's t‐test.

RESULT

Sixteen studies met selection criteria. Mean age was 52 years (range 21‐79) and 9 were female. MCA flow was below QMRA detection limits in 6 studies. Mean measurable ipsilateral MCA flow reduction was 84 mL/min (range 9‐147, SD 51.4). Mean ipsilateral PCA flow was 118 mL/min (range 72‐206, SD 38.5) and mean contralateral PCA flow was 68 mL/min (range 35‐144, SD 30.5, P < .001); mean difference was 50 mL/min (range 10‐93, SD 24.3).

CONCLUSION

Leptomeningeal collateral flow can be assessed with QMRA and may be substantial.
Granulomatosis with CNS Involvement: A Neuroimaging Clinicopathologic Correlation
Authors: Baaj Ali A. , Vale Fernando L. , Carter John D. , Rojiani Amyn M.
Published: October 2009

BACKGROUND AND PURPOSE

To present a rare case of a rheumatologic disorder with a central nervous system manifestation.

METHODS

A 48‐year‐old female with history of nasal and auricular pain and inflammation developed bilateral intermittent scleritis that was refractory to several immunosuppressive medications. She later presented with headaches and right upper extremity parasthesias. Brain magnetic resonance imaging (MRI) was obtained and she was referred to a neurosurgeon.

RESULTS

Neurological examination did not reveal any focal deficits. Laboratory analysis demonstrated an elevated erythrocyte sedimentation rate (ESR). Brain MRI with and without gadolinium contrast revealed an extra‐axial, enhancing, left frontoparietal convexity lesion. The patient was taken to the operating room for biopsy and resection of the mass. Final pathology demonstrated dural granulomatosis with vasculitis, most consistent with intracranial Wegener's granulomatosis. The patient was discharged to follow‐up with her rheumatologist for further medical management.

CONCLUSIONS

Enhancing, intracranial dural lesions are associated with a variety of disease entities. Wegener's granulomatosis is one such entity and should be considered in the correct context.
Ultrasonographic Reference Values for Assessing the Normal Median Nerve in Adults
Authors: Cartwright Michael S. , Shin Hae W. , Passmore Leah V. , Walker Francis O.
Published: October 2009

BACKGROUND AND PURPOSE

Several studies have evaluated the cross‐sectional area of the median nerve at the wrist, but none have examined other sites along the median nerve. Nerve enlargement has been demonstrated in entrapment, hereditary and acquired neuropathies, as well as with intraneural masses, and cross‐sectional area reference values at sites along the nerve will help in the evaluation of these conditions. In addition, muscle intrusion into the carpal tunnel has been implicated in carpal tunnel syndrome, but the normal amount of muscle intrusion has not been quantified.

METHODS

Fifty asymptomatic volunteers (100 arms) were evaluated to determine the mean cross‐sectional area of the median nerve at 6 sites and the mean amount of muscle intruding into the carpal tunnel.

RESULTS

The cross‐sectional area of the nerve was consistent along its course (7.5 to 9.8 mm2). The amount of muscle within the carpal tunnel varied greatly, with the mean area of flexor digitorum being 15.5 mm2 and lumbricals 13.5 mm2.

CONCLUSIONS

These reference values are necessary for advancing the field of neuromuscular ultrasound, because they facilitate studies of the median nerve in conditions such as entrapment, hereditary neuropathy, acquired neuropathy, and intraneural masses.
HLA‐DR2 and White Matter Lesion Distribution in MS
Authors: Sepulcre Jorge , Masdeu Joseph C. , Palacios Ricardo , Goñi Joaquín , Moreno Beatriz , Tainta Mikel , Bejarano Bartolomé , Villoslada Pablo
Published: October 2009

Human leukocyte antigen DR2 (HLA‐DR2) is a well‐established genetic risk factor for multiple sclerosis (MS). However, it is still unknown whether this factor is associated with a specific disease phenotype, and in particular, to a regional distribution of white matter (WM) lesion phenotype on magnetic resonance imaging (MRI). On a voxel‐by‐voxel basis, we analyzed the T1 and T2 MRI‐derived lesion maps of 50 patients with MS in order to determine the possible influence of HLA‐DR2 genotype on the lesional MRI pattern at early stages of the disease. HLA‐DR2 was present in 15 (30%) patients of our cohort. They displayed similar WM lesion distribution as the subjects without this factor. Thus, lesion distribution in MS seems to be independent of the DR2 genotype.
Reduced Fractional Anisotropy in Early‐Stage Cerebellar Variant of Multiple System Atrophy
Authors: Oishi Kenichi , Konishi Junya , Mori Susumu , Ishihara Hiroyuki , Kawamitsu Hideaki , Fujii Masahiko , Kanda Fumio
Published: October 2009

BACKGROUND

In patients with the cerebellar variant of multiple system atrophy (MSA‐C), reduced fractional anisotropy (FA) has been reported in several brain areas. However, since previous studies have employed predetermined regions of interest (ROI), the brain areas showing the earliest alterations in FA are unknown. The sensitivity of detecting early‐stage MSA‐C and the time course of the FA reduction are also unknown. The purpose was to address these issues to determine the diagnostic value of FA for early diagnosis.

METHODS

Twenty‐one patients with MSA‐C were investigated. Voxel‐based FA analysis and morphometry were used to detect the differences between early‐stage MSA‐C and normal controls. An ROI‐based FA analysis was also used to clarify the temporal profile.

RESULTS

From the early‐stage, MSA‐C patients exhibited reduced FA and white matter atrophy in the middle cerebellar peduncle, the inferior cerebellar peduncle, and the ventral pons. The FA of these areas decreased rapidly during the first few years after onset, after which a rather gradual reduction occurred. The receiver operating characteristics analysis revealed a high sensitivity and specificity for discriminating early MSA‐C from normal controls.

CONCLUSIONS

FA measurement could potentially be used to make an early diagnosis and monitor progression in MSA‐C patients.
Primary Non‐Hodgkin Lymphoma of the Skull Base Presenting with Garcin Syndrome: MRI Manifestations
Authors: Nakamura Ayami , Toyoda Keiko , Shozawa Yasunobu , Saito‐Arai Yuko , Shimizu Teruo , Matsumura Kiichiro
Published: October 2009

Primary non‐Hodgkin lymphoma of the skull base is a rare disorder. We report a case of primary non‐Hodgkin lymphoma of the skull base presenting with Garcin syndrome. MRI revealed peculiar lesions in the cavernous sinus, clivus, and occipital bone. Diagnosis was made by biopsy of the tumor in the cavernous sinus.
The Usefulness of CT Perfusion in Differentiation between Neoplastic and Tuberculous Disease of the Spine
Authors: Shankar J. , Jayakumar P. , Vasudev M. , Ravishankar S. , Sinha N.
Published: October 2009

INTRODUCTION

Routine diagnostic techniques are not sufficient to confidently differentiate diseases of the axial skeleton. Purpose of study was to determine whether CT perfusion (CTP) can differentiate inflammatory diseases like tuberculosis from neoplastic diseases of spine.

METHODS

Fifty‐one patients with vertebrdraft%freshal body lesions associated with paraspinal mass underwent CT guided bone biopsy and histopathological evaluation. CTP was done before doing bone biopsy. Perfusion parameters like blood volume (BV), blood flow (BF), and time to peak (TTP) were calculated. Values are correlated with histopathological report of bone biopsy. Statistical analysis was done using Mann‐Whitney test. P value < .05 was considered significant.

RESULTS

Of 51, 32 had infective osteomyelitis and 19 neoplastic disease (9 metastasis, 5 plasmacytoma, 4 lymphoma and 1 chordoma. Mean rBF was [inflammatory lesions, 1.79 and neoplastic lesions, 9.42 (P < .000)]. Mean rBV was [inflammatory disease, 1.63 and neoplastic lesions, 9.37 (P < .000)].

CONCLUSION

CTP technique has potential for differentiating inflammatory from neoplastic lesions affecting spine associated with paraspinal mass noninvasively.
Safety of Angioplasty and Stenting Without Thrombolysis for the Treatment of Early Ischemic Stroke
Authors: Abou‐Chebl Alex , Vora Nirav , Yadav Jay S.
Published: October 2009

BACKGROUND

Strokes from large‐vessel atherosclerotic occlusions or severe stenoses are often resistant to re‐canalization with thrombolytic agents. As in acute coronary syndromes, angioplasty and stenting for stroke may be used to achieve timely reperfusion with possibly less risk for hemorrhagic complications.

METHODS

From a prospectively collected database, we have retrospectively reviewed cases of patients presenting acutely with an ischemic stroke or subacutely with fluctuating ischemic deficits due to a large‐vessel atherosclerotic stenosis and who were treated with angioplasty and stenting without thrombolytics. Endpoints were reperfusion based on the Thrombolysis in Myocardial Infarction (TIMI) score, procedural complications, parenchymal hematoma formation leading to neurologic decline, and 30‐day clinical improvement based on the National Institutes of Health Stroke scale (NIHSS).

RESULTS

Nine patients with a mean age of 70 ± 9 years and mean NIHSS of 18.3 ± 5.0 were treated. Culprit stenotic lesions were located in the extracranial internal carotid artery (ICA) origin (2), intracranial ICA (2), tandem stenosis in the extra‐ and intracranial ICA (3), and middle cerebral artery (2). Eight patients were treated with angioplasty and adjunctive stenting; one of these patients also required snaring of thrombus from the middle cerebral artery. One patient was treated with angioplasty of an intracranial ICA stenosis alone. TIMI 3 reperfusion was achieved in 8 (88.9%) patients. The mean 30‐day improvement in the NIHSS was 15.5 ± 5.6. Six patients had a NIHSS of 0 or 1 at 30 days. One patient died due to reasons unrelated to stroke or interventional procedure. There were no significant complications or parenchymal hemorrhages.

CONCLUSIONS

In appropriately selected patients with ischemic deficits due to large artery atherosclerotic stenoses, angioplasty with adjunctive stenting can be safely performed. Such interventions may improve outcome without the use of thrombolysis.
Visual Analysis or Semi‐Automated Gray‐Scale‐Based Color Mapping of the Carotid Plaque: Which Method Correlates the Best with the Presence of Cerebrovascular Symptoms and/or Lesions on MRI?
Authors: Momjian Isabelle , Momjian Shahan , Albanese Stéphane , Comelli Mario , Lovblad Karl , Sztajzel Roman
Published: October 2009

BACKGROUND AND PURPOSE

To determine the correlation between carotid plaque morphology, assessed by two different ultrasonographic methods, and presence of cerebrovascular events and/or lesions on magnetic resonance imaging (MRI).

PATIENTS AND METHODS

Visual analysis of plaque echogenicity using a five‐type classification was performed. Further, a semi‐automated gray‐scale‐based color mapping of the whole plaque and of its surface was achieved.

RESULTS

There were 31 (35%) symptomatic (23 strokes and 8 transitory ischemic attacks [TIAs]) and 58 (65%) asymptomatic carotid stenoses. MRI lesions related to the carotid stenosis if located in the ipsilateral cortical, subcortical, or watershed area, were present in 27 cases (30%). In a multivariate logistic regression model, degree of stenosis (P= .03) and a predominant red color on the surface (P= .04) were independent factors associated with the presence of cerebrovascular events and/or lesions on MRI. Sensitivity and specificity were, respectively, 80% and 63% by combining degree of stenosis and color mapping of plaque surface.

CONCLUSION

Degree of stenosis and a predominant red color on plaque surface were independent factors associated with the presence of cerebrovascular events and/or lesions on MRI. No correlation was observed with any particular type of plaque based on visual analysis alone.
Internal Carotid Artery Stenting in Patients over 80 Years of Age: Single‐Center Experience and Review of the Literature
Authors: Linfante Italo , Andreone Vincenzo , Akkawi Nabil , Wakhloo Ajay K.
Published: October 2009

BACKGROUND

Thirty percent to 40% of strokes in the elderly are secondary to carotid bifurcation disease. The treatment of internal carotid artery (ICA) stenosis in this patient population is a clinical dilemma. Age more than 80 years is a risk factor for carotid endarterectomy (CEA). Carotid artery stenting (CAS) may be also associated with increased peri‐procedural complications in this age group.

DESIGN

This study was a single‐center, retrospective database analysis evaluating CAS in patients more than 80 years old. Primary outcome included death, myocardial infarction (MI), or ipsilateral stroke. Secondary outcome included re‐stenosis at 30 days, 6 months, and 1‐year post‐procedure.

RESULTS

Between March 2001 and March 2004, CAS was performed in 178 patients. Twenty‐four patients were more than 80 years old (range 80‐91), and 16 men, 70.8%, were symptomatic. Success rate was 100% with residual stenosis of <20%. At the 30 days follow‐up there was 1 non‐Q wave MI (4.2%), 1 transitory ischemic attack (TIA), and 1 femoral occlusion in the symptomatic group. There were no deaths at 1‐year follow‐up evaluation as well as no ICA re‐stenosis.

CONCLUSIONS

CAS can be performed in patients more than 80 years old. Complications may be higher than in younger patients. However, because of the high prevalence of stroke in octogenarians, randomized trials should include this patient population.
Isolated Temporal Lobe Involvement in Japanese Encephalitis
Authors: Lu Suat‐Jin , Goh Poh‐Sun
Published: October 2009

Temporal lobe involvement on neuroimaging is extremely rare in Japanese encephalitis (JE) and isolated temporal lobe involvement on neuroimaging has rarely been described in the literature. With isolated temporal lobe involvement, distinguishing JE from the treatable Herpes simplex encephalitis (HSE) can be difficult. Both JE and HSE should be considered in patients who present clinically with acute encephalitis and have radiological evidence of temporal lobe involvement, especially in JE endemic areas.
Frequent Hemorrhagic Lesions in Cerebral Toxoplasmosis in AIDS Patients
Authors: Bhagavati Satyakam , Choi Jai
Published: October 2009

Cerebral toxoplasmosis is a frequent complication in immunosuppressed patients such as AIDS (acquired immunodeficiency syndrome). Frequently, lesions are located deep in the brain which are inaccessible for biopsy making rapid diagnosis dependent on accurate interpretation of neuroimaging findings. The commonest cranial CT findings reported in toxoplasmosis are ring enhancing hypodense lesions in basal ganglia or cortical gray matter. Hemorrhage has only rarely been described and is usually seen following antitoxoplasma treatment. We reviewed the records of 11 AIDS patients with cerebral toxoplasmosis and found multiple hemorrhagic cerebral, cerebellar, or brain stem lesions in 7 of 11 patients. Six patients had hemorrhage at the time of initial clinical presentation and one developed hemorrhage following 2 weeks of antitoxoplasma treatment. We conclude that hemorrhagic lesions are frequently found on cranial MRI scans in cerebral toxoplasmosis. AIDS patients presenting with hemorrhagic cerebral lesions should be considered for a trial of presumptive antitoxoplasma treatment.
Unilateral versus Bilateral Middle Cerebral Artery Detection of Right‐to‐Left Shunt by Power M‐Mode Transcranial Doppler
Authors: Jesurum Jill T. , Fuller Cindy J. , Moehring Mark A. , Renz Joshua , Harley Meryl , Spencer Merrill P.
Published: October 2009

BACKGROUND AND PURPOSE

Comparison was performed between unilateral and bilateral power M‐mode transcranial Doppler to detect right‐to‐left circulatory shunt (RLS).

METHODS

Recorded Doppler data from 87 patients with confirmed RLS referred for transcatheter closure of patent foramen ovale were reanalyzed for embolic tracks (ET) counted from left and right temporal bone windows during bubble study. Unilateral counts were obtained by multiplying each side by 2; bilateral counts were obtained by summing left and right ET. Both unilateral and bilateral ET were converted to a 6‐point logarithmic grade. Sex and age group subanalyses were performed.

RESULTS

At rest, significantly more ET were detected with bilateral versus unilateral detection (P= .01), but not following Valsalva (P= .13). Unilateral and bilateral detection were equally able to detect large RLS (grades IV or V) following Valsalva (P= 1.00). For the group aged ≥55 years, the right‐hand side yielded greater ET than the left‐hand side (mean difference 9%± 37; 95% confidence interval −3 to 21%) at rest (P= .01), but not following Valsalva (mean difference 1%± 25; 95% confidence interval −7 to 9%, P= .10).

CONCLUSIONS

Unilateral detection of ET by power M‐mode transcranial Doppler is equivalent to bilateral detection to assess RLS.
Variant of Subclavian Steal in the Setting of Ipsilateral Common Carotid Artery Occlusion: Case Report
Authors: Tummala Ramachandra P. , Ecker Robert D. , Levy Elad I.
Published: October 2009

Subclavian steal is a well‐described angiographic finding and clinical syndrome that rarely results in vertebrobasilar ischemic symptoms. In classic subclavian steal, left subclavian artery (SA) stenosis occurs proximal to the left vertebral artery (VA) origin. We report a symptomatic variant of this syndrome that occurred in the setting of left common carotid artery occlusion and anomalous origin of the left VA directly from the aortic arch. The steal and symptoms resolved after stenting of the left SA stenosis.
Ultrasound Velocity Criteria for Vertebral Origin Stenosis
Authors: Koch Sebastian , Romano Jose G. , Park Hannah , Amir Murtaza , Forteza Alejandro M.
Published: October 2009

BACKGROUND

Despite remaining an important cause of posterior circulation stroke, the non‐invasive diagnosis of vertebral artery origin (VAo) stenosis is problematic. We here examine peak systolic velocity (PSV) criteria for the diagnosis of VAo stenosis and assess if the PSV ratio at the origin to the distal segments improves diagnostic accuracy.

METHODS

We performed a retrospective analysis of patients studied by catheter cerebral angiography and extracranial Duplex ultrasonography. The angiographic degree of stenosis, PSV at the VAo, proximal vertebral artery (VA1), and intra‐foraminal (VA2) segment were recorded. We calculated the VAo/VA1 and VAo/VA2 PSV ratio. A receiver operator curve was obtained (ROC) and the area under the curve (AUC) was compared for three different diagnostic criteria: PSV VAo, VAo/VA1, and VAo/VA2 PSV ratio.

RESULTS

A total of 386 vertebral arteries were angiographically examined and VAo stenosis 50‐99% was found in 36 (9%) vessels. The PSV VAo was the most accurate diagnostic parameter with an AUC .821 ± .052 (SE) (CI: .72, .92). A PSV of 114 cm/second maximized sensitivity (71%) and specificity (90%).

CONCLUSION

Our results support the use of PSV as a diagnostic criterion for VAo stenosis compared to a PSV ratio of VAo/V1 and VAo/V2.
Event‐Related fMRI of Inhibitory Control in the Predominantly Inattentive and Combined Subtypes of ADHD
Authors: Solanto Mary V. , Schulz Kurt P. , Fan Jin , Tang Cheuk Y. , Newcorn Jeffrey H.
Published: October 2009

BACKGROUND AND PURPOSE

To examine the neurophysiological basis for the pronounced differences in hyperactivity and impulsiveness that distinguish the predominantly inattentive type of attention‐deficit/hyperactivity disorder (ADHD‐PI) from the combined type of the disorder (ADHD‐C).

METHODS

Event‐related brain responses to a go/no‐go test of inhibitory control were measured with functional magnetic resonance imaging (fMRI) in 11 children with ADHD‐C and 9 children with ADHD‐PI, aged 7 to 13 years, who were matched for age, sex, and intelligence.

RESULTS

There were no significant group differences in task performance. Children with ADHD‐C and ADHD‐PI activated overlapping regions of right inferior frontal gyrus, right superior temporal lobe, and left inferior parietal lobe during inhibitory control. However, the magnitude of the activation in the temporal and parietal regions, as well as in the bilateral middle frontal gyrus, was greater in children with ADHD‐PI than those with ADHD‐C. Conversely, children with ADHD‐C activated bilateral medial occipital lobe to a greater extent than children with ADHD‐PI.

CONCLUSIONS

The results provide preliminary evidence that phenotypic differences between the ADHD‐C and ADHD‐PI subtypes are associated with differential activation of regions that have previously been implicated in the pathophysiology of ADHD and are thought to mediate executive and attentional processes.
Self‐Referral of Imaging Does Not Imply Overutilization
Authors: Hutchinson Michael , Chawluk John B. , Gomez Camilo , Greenberg Jack , Hussey Francis D. , Preston William G. , Zimmerman Earl
Published: October 2009

For several years, some sectors of the specialty of Radiology have complained about the practice of self‐referral, where a nonradiologist physician provides and interprets an imaging procedure. It is argued that such practice leads to increased costs since a physician will overutilize technology because of financial incentives. Here we review the literature. The most extensive analysis to date is at odds with the conclusions drawn in the older literature in that it provides little, if any, evidence for overutilization. We performed our own investigation using a poll study and found no suggestion of overutilization in 33 self‐referring neurologists when compared with 900 neurologists who referred imaging to radiologists. The main period of growth in demand for imaging was between 1999 and 2002. Since 2002 there has been a steep decline in the rate of growth, so that it is possible to predict roughly zero growth in MRI utilization by 2009 without any intervention. It is shown why the rise in demand for imaging studies cannot be explained by self‐referral, and it is argued that the sudden expansion of demand 8 years ago was caused by simultaneous technological improvements in the 3 major imaging modalities. Finally, it is shown how self‐referral may actually reduce costs by facilitating the transfer of care from the hospital and ER to the office.
Ear Necrosis Resulting from the Endovascular Onyx‐18 Embolization of a Dural Arteriovenous Fistula Fed by the Posterior Auricular Artery
Authors: Jankowitz Brian T. , Vora Nirav , Jovin Tudor , Horowitz Michael
Published: October 2009

BACKGROUND AND PURPOSE

The treatment of a dural arteriovenous fistula (DAVF) can involve surgery, radiosurgery, or endovascular embolization. New embolization techniques and agents have expanded the role of endovascular treatment.

METHODS

We report the endovascular embolization with Onyx‐18 of a DAVF fed by the posterior auricular artery.

RESULTS

The DAVF was successfully embolized; however, the patient's ear developed ischemic necrosis of the superolateral pinna.

CONCLUSIONS

Onyx‐18 can provide high rates of success in the treatment of DAVFs in well‐selected patients. Risks of end organ ischemia must be considered during endovascular embolization and when counseling patients regarding procedural risk.
Subcortical Vascular versus Amnestic Mild Cognitive Impairment: Comparison of Cerebral Glucose Metabolism
Authors: Seo Sang Won , Cho Sang Soo , Park Aram , Chin Juhee , Na Duk L.
Published: October 2009

BACKGROUND AND PURPOSE

Most studies on mild cognitive impairment (MCI) have been focused on amnestic MCI (aMCI) that is the preclinical stage of Alzheimer's disease (AD). In contrast, only a few studies have involved patients in the preclinical stages of subcortical vascular dementia (subcortical vascular MCI, svMCI). We tried to compare the overall glucose metabolism in patients with svMCI with that of patients with aMCI.

METHODS

We compared the regional metabolic patterns shown on 18 F‐FDG (fluro deoxy glucose) positron emission tomography (PET) images from 18 patients with svMCI with those from 25 aMCI patients matched for age, sex, education, and mini‐mental state examination (MMSE) score and with those from 35 healthy subjects using a voxel‐wise analysis. SPM 2 was used for statistical analysis.

RESULTS

Relative to normal controls, the hypometabolic regions in the aMCI patients were in the bilateral parahippocampal, bilateral posterior cingulate, left superior temporal gyri, left inferior parietal lobule, and right inferior frontal gyrus while those in the svMCI patients were located in the thalamus, insula, superior temporal gyrus, anterior cingulate gyrus, cingulum, right basal ganglia, cerebellum, and brainstem. A direct comparison of glucose metabolism between svMCI and aMCI showed that the glucose hypometabolism in patients with svMCI was more severe in the thalamus, brainstem, and cerebellum.

CONCLUSION

Our study suggested that svMCI was distinct from aMCI in terms of neuropsychological and PET findings, which may explain their clinical manifestations.
Visual Symptoms in the Heidenhain Variant of Creutzfeldt‐Jakob Disease
Authors: Cornelius Jason R. , Boes Christopher J. , Ghearing Gena , Leavitt Jacqueline A. , Kumar Neeraj
Published: October 2009

BACKGROUND AND PURPOSE

The distinguishing feature in Heidenhain variant Creutzfeldt‐Jakob disease (HvCJD) is the presence of visual symptoms preceding the appearance of other clinical manifestations. The purpose of this report is to describe the broad range of visual symptomatology in a patient with HvCJD.

METHODS

The authors describe the clinical, neuroimaging, and EEG features of a 51‐year‐old man with progressive visual symptoms that were most likely due to HvCJD. Migraine and epilepsy were initial diagnostic considerations.

RESULTS

Our patient presented with progressive visual decline and superimposed spells of visual dysfunction that had complex characteristics. Evolution of an abnormal signal in the parieto‐occipital cortex on diffusion weighted MRI, changes on EEG, and clinical course were consistent with HvCJD.

CONCLUSIONS

HvCJD should be considered in all patients who present with unexplained visual phenomena. A remarkable spectrum of visual disturbances can be seen. Close follow‐up as well as serial MRI and EEG can help clarify the underlying disease process. Diffusion‐weighted and FLAIR sequences should be included in the MRI protocol.
Quantitative Magnetic Resonance Angiography in the Evaluation of the Subclavian Steal Syndrome: Report of 5 Patients
Authors: Bauer Andrew M. , Amin‐Hanjani Sepideh , Alaraj Ali , Charbel Fady T.
Published: October 2009

BACKGROUND AND PURPOSE

The indications for surgical or endovascular treatment of patients with subclavian stenosis (SS) or occlusion remain controversial. Multiple studies have shown that in most patients, SS results in steal that is evident radiographically, but requires no treatment.

METHODS

This report describes 5 cases of SS, analyzed with phase contrast quantitative MRA (QMRA). QMRA provides quantitative blood flow data previously unavailable. A quantitative ischemic forearm challenge is also introduced using the QMRA technique.

RESULTS

A basilar flow index, basilar artery (BA) flow as a percentage of total intracranial flow was defined. This varied from 12.6% to 20.4%. All patients in this report had VA flow reversal. None had BA flow reversal

CONCLUSION

This report features novel methods using QMRA to identify ischemic patterns in the BA indicative of significant subclavian steal syndrome (SSS) in patients with SS.
Early Contrast‐Enhanced Magnetic Resonance Imaging with Fluid‐Attenuated Inversion Recovery in Multiple Sclerosis
Authors: Kataoka Hiroshi , Taoka Toshiaki , Ueno Satoshi
Published: October 2009

OBJECTIVE

Contrast‐enhanced magnetic resonance imaging (MRI) with fluid‐attenuated inversion recovery (contrast FLAIR) is particularly useful for the detection of meningeal lesions. However, whether contrast FLAIR is useful in multiple sclerosis (MS) remains uncertain. This study evaluated the usefulness of contrast FLAIR in MS.

PATIENTS AND METHODS

We prospectively studied the clinical histories and brain MRI studies of 6 patients with clinically definite MS diagnosed according to the new McDonald criteria. Contrast FLAIR (repetition time [TR] 9,000 ms; echo time [TE] 120 ms; inversion time [TI] 2,200 ms; 5‐mm slice thickness, with a 1‐mm interslice gap) was obtained with the use of a bolus of gadolinium diethylenetriamine pentaacetic acid.

RESULTS

Three enhancing plaques located in the periventricular or juxtacortical areas showed higher intensity on contrast FLAIR than on other MR sequences. In contrast, 8 enhancing plaques in the deep white matter or infratentorial areas showed no increased signals on contrast FLAIR.

CONCLUSION

Our findings suggest that early contrast‐enhanced imaging with FLAIR may be helpful for the further detection of MS plaques, particularly those located in periventricular and juxtacortical lesions.
Perfusion SPECT Findings in a Suspected Case of Rasmussen Encephalitis
Authors: Tessonnier Laetitia , Thomas Pierre , Benisvy Danielle , Chanalet Stephane , Chaborel Jean Philippe , Bussière Françoise , Darcourt Jacques
Published: October 2009

We report the case of a 35‐year‐old who was referred for brain perfusion single photon emission computed tomography (SPECT) for pharmacoresistant epilepsy. Her medical history included brain surgery for an inflammatory lesion of unknown origin at age 23 before partial epilepsy occurred. The seizures became refractory to standard antiepileptic drugs and she developed epileptic negative myoclonus of the right upper limb, nocturnal motor seizures, and progressive intellectual impairment. Neurological symptoms slowly worsened with mild aphasia and right visual neglect.

Inter‐ictal brain SPECT showed decreased cerebral blood flow on the left hemisphere corresponding on magnetic resonance imaging (MRI) with moderate left hemiatrophy, a left frontal defect in accordance with the history of surgery, and a crossed cerebellar diaschisis.

Clinical and imaging data were in favor of a late‐onset form of Rasmussen encephalitis.

Rasmussen syndrome is a rare unilateral devastating disease with childhood onset that can also occur in adulthood, characterized by intractable epileptic seizures associated with progressive neurological deterioration and unilateral progressive atrophy. Brain perfusion SPECT can speed up the diagnosis when exhibiting a strictly unilateral hemispheric hypoperfusion in such a clinical context. It can also guide brain biopsy in cases of inconclusive MRI.
Reversible Cytotoxic Edema in a Cirrhotic Patient Following TIPS
Authors: Babington James R. , Stahl Justin H. , Coy David L.
Published: October 2009

The authors report the magnetic resonance imaging (MRI) findings in a 52‐year‐old man with cirrhosis from chronic hepatitis C who developed episodic acute hepatic encephalopathy Type C following placement of transjugular intrahepatic portosystemic shunt (TIPS). Brain MRI revealed hyperintense T2 signal and restricted diffusion distributed through the cerebral cortex. The patient's mentation improved with treatment of his hyperammonemia. Brain MRI performed 5 months later revealed diffuse cerebral atrophy and new areas of hyperintense T2 signal in the cerebral white matter. The cortical signal abnormalities and low apparent diffusion coefficient values on the initial MRI resolved with exception of a mild amount of hyperintense FLAIR signal in the cingulate cortex.

Acute hepatic encephalopathy following portosystemic shunting—either from placement of TIPS or from development of spontaneous shunts—is a widely recognized complication of portal hypertension and cirrhosis. We report MRI findings of reversible cytotoxic edema in a patient with acute hepatic encephalopathy following placement of TIPS.