bluuebunny/crossref_metadata_2025 huggingface dataset:
Neuroimaging of the Complications of Epilepsy Surgery
Authors: Kelley Roger E. , DellaBadia John , Minagar Alireza , Kelley Bradford J. , Brunson Regina
Published: November 2009

Background and Purpose. Stroke‐like symptoms can be associated with the invasive evaluation and surgical resection of epileptic foci in patients with intractable epilepsy. Neurological deficits following surgical procedures for epilepsy are not uncommon, but most are relatively minor and transient. The authors investigated the neuroimaging patterns of cerebral tissue insults in patients suffering neurological deficits directly related to procedures performed to evaluate and treat intractable epilepsy. They attempted to discern potential secondary vascular insults from the not unexpected tissue loss that can be associated with various epilepsy procedures. Methods. The authors prospectively assessed 7 consecutive patients who underwent either the invasive electocortigraphic monitoring or surgical resection of epileptic foci. All had some degree of neurological deficit postoperatively. The authors evaluated for tissue injury type with postoperative computed tomography and magnetic resonance brain imaging. They also review pertinent medical literature addressing potential complications of epilepsy surgery. Results. Three patients had primarily ischemic tissue injuries, 2 had tissue loss with minor bleeding, and 1 transient deficit appeared to reflect the amount of tissue removed. Another patient had choreiform movements and gait ataxia 1 week after the procedure, but no follow‐up neuroimaging was available. The primary ischemic insults appeared to be related to vascular traction or compression or possibly vasospasm. The tissue loss/hemorrhagic insults were presumably related to tissue loss, with seepage of blood or bleeding from a resected cavernous hemangioma. No patients died, but 1 was left with a persistent, moderately severe neurological deficit. Conclusions. It is important to distinguish the not unexpected neurological deficits associated with inadvertent trauma to normal brain tissue during procedures associated with epilepsy surgery from vascular insults. Postoperative neuroimaging can be useful in this endeavor.
Cortical Reorganization Allows for Motor Recovery after Crossed Cerebrocerebellar Atrophy
Authors: Feydy Antoine , Krainik Alexandre , Bussel Bernard , Maier Marc A.
Published: November 2009

The authors report the case of a 33‐year‐old woman who exhibited, at the age of 17, a left‐sided hemiplegia, which was followed by good motor recovery, though with a permanent deficit in fine finger movements. She had a widespread loss of neural tissue in the right hemisphere (crossed cerebrocerebellar atrophy), including (1) marked atrophy and thinning of the precentral and postcentral gyri; (2)widespread deep white matter destruction, including the corticospinal tract; and (3) crossed cerebellar atrophy. Except over the supplementary motor area (SMA), transcranial magnetic stimulation did not elicit motor evoked potentials in the affected hand. Nevertheless, during opening and closing of the affected hand, functional magnetic resonance imaging showed an activation of the lesioned primary sensorimotor cortex (SMC), as well as of the intact SMA and the parietal areas, but not of the ipsilateral motor areas. The authors speculate that recovery was achieved by a motor command generated in the SMC and the parietal cortex, passing through corticospinal axons originating in the SMA.
Heidenhain Variant of Creutzfeldtjakob Disease: Diffusion‐Weighted MRI and PET Characteristics
Authors: Tsuji Yoshihisa , Kanamori Hiroshi , Murakami Gaku , Yokode Masayuki , Mezaki Takahiro , Doh‐Ura Katsumi , Taniguchi Ken , Matsubayashi Kozo , Fukuyama Hidenao , Kita Toru , Tanaka Makoto
Published: November 2009

Creutzfeldt‐Jakob disease (CJD) is characterized by rapidly progressive dementia with a variety of neurological disorders and a fatal outcome. The authors present a case with visual disturbance as a leading symptom and rapid deterioration in global cognitive functions. The cerebrospinal fluid was positive for 14‐3‐3 protein, and diffusion‐weighted magnetic resonance imaging (MRI) showed marked hyperintensity in the parieto‐occipital cortices, where hypometabolism was clearly detected on positron emission tomography (PET). Pattern‐reversal visual evoked potentials showed prolonged P100 latencies and increased N75/P100 amplitudes. All these findings supported a diagnosis of the Heidenhain variant of CJD, whereas a long clinical course, a lack of myoclonus, and an absence of periodic synchronous discharges on electroencephalography were atypical. Diffusion‐weighted MRI and PET in combination with visual evoked potential recording and 14‐3‐3 protein detection may be useful for the early diagnosis of CJD.
Aberrant Ascending Pharyngeal Artery Mimicking a Partially Occluded Internal Carotid Artery
Authors: Wei Chao‐Jung , Chang Feng‐Chi , Chiou See‐Ying , Teng Michael M. , Hu Han‐Hua , Chung Chih‐Ping , Chou Yi‐Hon , Chang Cheng‐Yen
Published: November 2009

Doppler sonography has become a primary imaging modality for the diagnosis of carotid arterial stenosis. Carotid stenting for a severely stenotic but not completely occluded carotid artery is becoming an alternative to carotid endarterectomy in selected groups of patients. The authors discuss a case of complete occlusion of the internal carotid artery associated with an ipsilateral aberrant ascending pharyngeal artery originating from the proximal internal carotid artery, which mimicked a stenotic internal carotid artery on sonography. Meticulous Doppler sonographic examination may provide clues for this extraordinary condition, yet angiography is indicated for a definite diagnosis.
Cerebral Metastasis from Heart Angiosarcoma Presenting as Multiple Hematomas
Authors: Liassides Charalambos , Katsamaga Maria , Deretzi Georgia , Koutsimanis Vasilios , Zacharakis Georgios
Published: November 2009

The authors present the case of a 24‐year‐old woman with cerebral metastasis from a primary heart angiosarcoma, which appeared as multiple cerebral hematomas. Primary or metastatic brain angiosarcomas are exceedingly rare, and only a few cases have been reported with hemorrhage. Initial neurological symptoms were mild hemiparesis with numbness, and chest pain was first misdiagnosed as pericarditis. A computed tomography (CT) scan and magnetic resonance imaging showed 2 hematomas in the left parietal and occipital lobes. A thoracic CT scan revealed angiosarcoma of the right atrium of the heart with multiple infiltrations of the lung. The patient underwent surgical removal and systemic chemotherapy. She died 6 months after surgery.
Ultrasound‐Enhanced Thrombolysis for Acute Ischemic Stroke: Phase I. Findings of the CLOTBUST Trial
Authors: Alexandrov Andrei V. , Demchuk Andrew M. , Burgin W. Scott , Robinson David J. , Grotta James C.
Published: November 2009

Background. Tissue plasminogen activator (TPA) activity may be enhanced with ultrasound, potentially 2 MHz transcranial Doppler (TCD). The authors present Phase I data of the CLOTBUST (Combined Lysis of Thrombus in Brain ischemia using transcranial Ultrasound and Systemic TPA). Subjects and Methods. Nonrandomized stroke patients with proximal arterial occlusion on a prebolus TCD receiving intravenous 0.9 mg/kg TPA within 3 hours after stroke onset were monitored with portable diagnostic TCD equipment and a standard headframe. Complete recanalization was defined as thrombolysis in brain ischemia (TIBI) flow grades 4–5. Results. 55 patients (mean age 69 ± 15 years, median baseline NIH Stroke Scale [NIHSS] 18, range 4–29, 90% with 39 points) were treated at 125 ± 36 minutes from symptom onset. TCD monitoring began at 117 ± 39 minutes. Complete recanalization on TCD within 2 hours after bolus was found in 20 patients (36%). Dramatic recovery (NIHSS score = 3) occurred in 20% at 2 hours and in 24% at 24ours. Overall improvement by = 4 NIHSS points was found in9% at 24 hours. Improvement was associated with recanalization during or shortly after TPA infusion (•r 2= .5, P=03); however, in 6/20 patients with complete recanalization (30%), no immediate clinical change was noticed within 2 hours. Overall symptomatic hemorrhage rate was 5.5%. Conclusions. Continuous TCD insonation for up to 2 hours at maximum intensities allowed by current bio‐safety guidelines is safe. Dramatic recovery and complete recanalization shortly after TPA bolus are feasible goals for thrombolysis given with TCD monitoring.
In Which Patients is Diffusion‐Weighted Magnetic Resonance Imaging Most Useful in Routine Stroke Care?
Authors: Keir S. L. , Wardlaw J. M. , Bastin M. E. , Dennis M. S.
Published: November 2009

Background and Purpose. Magnetic resonance (MR) diffusionweighted imaging (DWI) has been used extensively in hyperacute cortical ischemic stroke, but its broader role in the assessment of patients presenting at later times after a wider variety of strokes has been less widely studied. Methods. The uthors assessed the clinical usefulness of DWI across a range of patients referred prospectively as either inpatients or outpatients. Detailed clinical information was collected. Diffusion DWI) and T2‐weighted images were read separately and blindly to clinical details. The presence of any infarct and its type were noted. Results. In 153 stroke patients, imaged at a median of 2 days (range, 6 hours to 77 days) after stroke, recent infarcts were identified more often on DWI (70%) than on T2‐weighted MRI (32%) in all severities of stroke. The proportion of scans on which relevant lesions were only seen on DWI was greatest among milder strokes due to small cortical or lacunar infarcts and among patients imaged later rather than earlier after the stroke. Conclusions. DWI is clinically useful up to several weeks after stroke, not just within the first few hours, and especially in patients with minor strokes.
The Use of PWI and DWI Measures in the Design of “Proof‐of‐Concept” Stroke Trials
Authors: Barber P. Alan , Parsons Mark W. , Desmond Patricia M. , Bennett Donald A. , Donnan Geoffrey A. , Tress Brian M. , Davis Stephen M.
Published: November 2009

Background and Purpose. The authors used serial magnetic resonance perfusion‐weighted imaging (PWI) and diffusionweighted imaging (DWI) to determine whether major reperfusion and the attenuation of infarct expansion are associated with improved stroke outcome.Methods. Forty‐nine patients were studied with serial magnetic resonance imaging within 6 hours of stroke onset and again at 4 days (subacute studies) and 3 months (outcome studies). Two imaging parameters were examined: infarct expansion between acute and outcome studies and major reperfusion between acute and subacute studies.Results. Patients with major reperfusion (45% of those with acute PWI lesions) were more likely to have little or no disability at outcome (National Institutes of Health Stroke Scale [NIHSS] score = 4,P= .0176; Barthel Index [BI] score = 90,P= .0547)fter adjustment for baseline differences. In contrast, patients with infarct expansion (48%) were more likely to be dead or dependent at outcome (BI < 90,P= .0414; NIHSS scoreP= .082; modified Rankin Scale score > 2,P< .0001). These measures were used to generate sample size calculations based on hypothetical treatment effects. Therapies postulated to double the proportion of patients with major reperfusion from one third to two thirds would require 41 patients in each group (treated and untreated) to be sufficiently powered to show a difference. Interventions postulated to halve the number of patients with infarct expansion from 50% to 25% would require 66 patients in each group to show a difference.Conclusions. Infarct expansion and major reperfusion are associated with clinically meaningful changes in stroke outcome. These measures could be used as surrogate markers of outcome in late phase II proof‐of‐concept stroke studies designed to provide efficacy signals before embarking on large phase III studies with definitive clinical endpoints.
The Thickness of the Temporal Squama and Its Implication for Transcranial Sonography
Authors: Jarquin‐Valdivia A. A. , McCartney J. , Palestrant D. , Johnston S. C. , Gress D.
Published: November 2009

Background and Purpose. The difficult transtemporal ultrasound window is a relatively frequent occurrence. The authors assessed if the thickness of the temporal bone squama as measured in the “bone window” of the head computerized tomography (CT) scan can predict the transtemporal acoustic window. Methods. The authors retrospectively reviewed the head CTs on their bone window setting of patients in which nonimaging transcranial Dopplers (TCDs) had been performed. The thickness of the temporal squama in its thinnest portion was measured. The temporal TCD windows were graded in three classes: class 1 as good, class 2 when only a partial study is possible, and class 3 as an impossible ultrasonic window. In a case‐control design, for every patient with any class 2 and 3 TCD temporal window, a patient with a class 1 window was randomly included from the same time period. Results. Fifty‐five temporal bones (56%) were class 1, 17 (17%) were class 2, and 27 (27%) were class 3. Bone thicknesses (in mm, mean ± SD) were greater in those with poorer windows: class 1 = 2.67 ± 0.70, class 2 = 4.06 ± 0.56, and class 3 = 5.04 ± 1.06, P= .0001y Cusick's nonparametric test of trend. Temporal squama thickness of = 5 mm portends 86% sensitivity, 90% specificity,0% positive predictive value, and a positive likelihood ratio of 8.6 for a class 3 transtemporal ultrasound window. Conclusion. Measurement of temporal bone thickness on the bone window setting of the head CT scan may be useful in identifying patients who are poor candidates for transcranial ultrasound.
Functional Magnetic Resonance Imaging of Working Memory among Multiple Sclerosis Patients
Authors: Sweet Lawrence H. , Rao Stephen M. , Primeau Margaret , Mayer Andrew R. , Cohen Ronald A.
Published: November 2009

Background and Purpose. Verbal working memory (VWM) deficits have been a well‐replicated finding among patients with multiple sclerosis (MS). Functional magnetic resonance imaging (FMRI) studies have described a VWM system in healthy samples; however, functional neuroimaging of this system among MS patients is just beginning to appear. Methods. Fifteen MS patients and 15 sex‐, age‐, education‐, and IQ‐matched healthy control (HC) participants completed a 2‐Back VWM task as whole‐brain FMRI was conducted. Results. Each group exhibited increased brain activity compared to the 0‐Back control task in regions associated with the 2‐Back in previous neuroimaging studies. These included Broca's area, supplementary motor area (SMA), premotor cortices (PMC), and dorsolateral prefrontal cortices (DLPFC). MS patients exhibited greater cortical activity than did HC participants in left primary motor and somatosensory cortices, PMC, DLPFC, anterior cingulate, and bilateral SMA. MS patients exhibited relatively less activation in Broca's area, bilateral cerebellum, and other regions not typically associated with the 2‐Back (eg, right fusiform gyrus, left lingual gyrus, right hippocampus). Performance accuracy and reaction time did not differ between groups. Conclusions. Normal performance of a challenging VWM task among high‐functioning MS patients is associated with a shift toward greater activity in regions related to sensorimotor functions and anterior attentional/executive components of the VWM system. Posterior memory storage systems appeared unaffected, while portions of the visual processing and subvocal rehearsal systems were less active. Although a shift in neural activity was noted relative toHC participants, deviation from regions normally involved in VWM function was not observed in this patient sample.
Cerebral Vasospasm in Childhood Migraine During the Intermigrainous Period
Authors: Boasso Lauren E. , Fischer Asma Q.
Published: November 2009

Background and Purpose. The aims of this study were to evaluate the changes in intracranial hemodynamics and assess the presence of vasospasm in children with migraine during the intermigrainous period. Methods. Transcranial Doppler (TCD) sonography findings, clinical examinations, and the vasospastic index of Lindegaard were analyzed for children who fulfilled the criteria for childhood migraine. The significance of the presence of vasospasm and abnormal hemodynamics were statistically analyzed using the normal approximation to the binomial test method. TCD sonography was performed using the standard published techniques for children. Results. Sixty‐two patients between the ages of 5 and 17 years who had undergone at least one TCD sonographic examination were selected for this study. A total of 113 TCD sonographic examinations were performed on the patients. Elevated mean blood flow velocities were found in 23 of 62 patients (37%) (P< .001). Early vasospasm was found in 4 of 62 patients (6.5%) (P< .001). Bruits were noted in 35 of 62 patients (56%). Conclusions. This study raises the possibility of cerebral vasospasm in the intermigrainous period in childhood migraine. Further studies are needed to elaborate on the pathophysiology of cerebrovascular behavior during this period. These findings may have a significant impact on the current clinical treatment of childhood migraine.
Is Magnetic Resonance Spectroscopy Superior to Conventional Diagnostic Tools in Hypoxic‐Ischemic Encephalopathy?
Authors: Wartenberg Katja E. , Patsalides Athos , Yepes Manuel S.
Published: November 2009

Anoxic brain injury carries a poor prognosis. Therefore, a diagnostic tool sensitive enough to predict its outcome is needed. The authors describe the case of a 51‐year‐old woman who suffered cardiorespiratory arrest. Electroencephalography, somatosensory evoked potentials, and magnetic resonance imaging did not prove to be useful in establishing a definitive prognosis. Magnetic resonance spectroscopy demonstrated the presence of significant neuronal loss in the cortex and cerebellum and was the only diagnostic procedure closely associated with this patient's prognosis.
Qureshi Grading Scheme for Angiographic Occlusions Strongly Correlates With the Initial Severity and In‐Hospital Outcome of Acute Ischemic Stroke
Authors: Mohammad Yousef , Xavier Andrew R. , Christoforidis Greg , Bourekas Eric , Slivka Andrew
Published: November 2009

Background. The thrombolysis in myocardial infarction (TIMI) grading scheme and other classification systems have limitations in evaluating patients with ischemic stroke because they do not account for occlusion location or collateral circulation. The Qureshi grading scheme has been recently proposed to evaluate the severity of arterial occlusion in acute ischemic stroke because of limitations in existing grading systems. Methods. The Qureshi grading scheme assigns a score from 0 to 5 on the basis of occlusion site and collateral supply. The authors determined the relationship between initial severity of stroke and outcome at discharge measured by the National Institutes of Health Stroke Scale (NIHSS) and the Qureshi grading scale assessed from initial angiography (by a neuroradiologist blinded to the clinical examination) in 57 patients who underwent intra arterial therapy for acute ischemic stroke within 6 hours of symptom onset. Results. A strong association was observed between the initial severity of neurological deficits and Qureshi scheme on angiography (F ratio = 2.6, P = .03). The initial NIHSS for grade 1 was 11 ± 4 and progressively increased to 23 ± 6 for grade 5. In the multivariate analysis, initial NIHSS was significantly associated with Qureshi scheme on angiography (R2 = 358, P = .03). The mean discharge NIHSS was 12 ± 10 (range, 0–40). There was also a direct relationship between the Qureshi scheme and discharge NIHSS (F ratio = 2.8, P = .02).Conclusion. The Qureshi grading scheme can be effectively used to determine the severity of ischemic stroke (brain at risk) from the initial angiography.
Dot‐like Hemosiderin Spots on Gradient Echo T2*‐Weighted Magnetic Resonance Imaging Are Associated With Past History of Small Vessel Disease in Patients With Intracerebral Hemorrhage
Authors: Imaizumi Toshio , Horita Yoshifumi , Chiba Masahiko , Hashimoto Yuji , Honma Toshimi , Niwa Jun
Published: November 2009

Background and Purpose. Lipohyalinosis is considered an important cause of cerebral small vessel disease (SVD), including hypertensive intracerebral hematoma (ICH) and lacunar infarction. Dot‐like low‐intensity spots (dot‐like hemosiderin spots [dotHSs]) on gradient‐echo T2*‐weighted (T2*‐w) magnetic resonance imaging (MRI) have been histologically diagnosed as old microbleeds associated with microangiopathies (lipohyalinosis, amyloid angiopathy) and located in territories of perforating arteries (deep dotHSs) and subcortical regions (subcortical dotHSs). If dotHSs indicate the severity of lipohyalinosis, larger numbers of deep dotHSs may be associated with past history of SVD.Methods. The number of dotHSs was investigated in 213 patients with deep ICH (106 men, 107 women, 37 to 94 years old, mean age = 65.8 ± 11.2 years). Patients were divided into 2 subgroups according to past history of SVD. Odds ratio (OR) for the history was estimated from logistic regression analyses of the number of deep or subcortical dotHSs, as well as other factors.Results. Of 213 patients, 36 had a past history of SVD (symptomatic deep ICH in 18, symptomatic lacunar infarction in 17, and both in 1). An increased rate of history of SVD was found for patients with subcortical dotHSs. The OR per 1 subcortical dotHS was 1.09 (95% confidence internal (CI), 1.03–1.17;P= .005), and per deep dotHS, the OR was 1.07 (95% CI, 1.00–1.13;P= .039). Conclusions. The findings suggest that deep and subcortical dotHSs on T2*‐w MRI may indicate the severity of microangiopathy and may predict recurrence of SVD in patients with deep ICH.
Diagnosis of Moyamoya Disease with Transcranial Doppler Sonography: Correlation Study with Magnetic Resonance Angiography
Authors: Lee Yong‐Seok , Jung Keun‐Hwa , Roh Jae‐Kyu
Published: November 2009

Background and Purpose. Although the diagnosis of moyamoya disease may be confirmed by digital subtraction angiography, recent studies have shown the accuracy of mag netic resonance angiography. Characteristics of transcranial Doppler, a noninvasive and cost‐effective method, and specific transcranial Doppler parameters reflecting distinct vascular status in moyamoya disease are explored. Method and Patients. Consecutive patients (> 15 years of age) diagnosed with moyamoya disease by a typical clinical history and digital sub traction angiography or magnetic resonance angiography were included. The statuses of the anterior, middle, and posterior cerebral arteries were graded as stage 1, stage 2, and stage 3 by magnetic resonance angiography. Mean flow velocity and pulsatility index were compared between these groups, and the receiver operating characteristic analysis was used to define transcranial Doppler criteria for distinct vascular status. Results. Forty‐five patients were included (37 women; mean age, 34.9 ± 11.4 years). Mean flow velocity was higher and pulsatility index was lower in stage 2 (P < .01), while mean flow velocity was lower and pulsatility index was higher in stage 3 than in stage 1 (P < .01). Cutoff values reflecting stenosis or occlusion with substantial sensitivity and specificity were as follows: mean flow velocity > 85 cm/s or pulsatility index < 0.60 for stage 2, and mean flow velocity < 50 cm/s for stage 3 of middle cerebral artery; mean flow velocity > 80 cm/s or pulsatility index < 0.60 for stage 2 of anterior cerebral artery; and mean flow velocity > 60 cm/s or pulsatility index < 0.60 for stage 2 of posterior cerebral artery. Conclusion. Transcranial Doppler may help to refine magnetic resonance angiography findings and thus help clinicians differentiate severity or stages of moyamoya disease.
Changes in the Heterogeneity of Cerebral Glucose Metabolism with Healthy Aging: Quantitative Assessment by Fractal Analysis
Authors: Lee Jae Sung , Lee Dong Soo , Park Kwang Suk , Chung June‐Key , Lee Myung Chul
Published: November 2009

Background and Purpose. It has been shown that heterogeneity of cerebral glucose metabolism is increased in neuropsychiatric degenerative diseases. However, proper assessment of older patients requires knowledge about the effect of aging on hetero geneity. This study characterized the effects of aging on the heterogeneity of the distribution of cerebral glucose metabolism in healthy volunteers. Methods. Sixty‐six healthy volunteers (age range, 19–75 years) underwent flurodeoxyglucose brain positron emission tomography (PET), and all the PET images were spatially normalized onto a previously segmented standard brain template to parcel the brain regions automatically. Fractal dimension was regarded as a quantitative measurement for the heterogeneity of cerebral glucose metabolism and obtained for 9 brain regions. Participants were subdivided into young/midlife and elderly groups, and the Student t test was applied to the comparison of fractal dimensions in those groups. Analysis of covariance was performed for each region to explore the effects of age, gender, age‐by‐gender interaction, and total counts in the brain on the observed metabolic heterogeneity. Results. Fractal dimensions were higher for elderly volunteers in most brain regions. Differences between the 2 groups in fractal dimension emerged within the whole gray matter, temporal lobe, striatum, and cingulate. No significant gender differences, age‐by‐gender interactions, or total counts were observed. Significant age effects were observed in the whole gray matter, frontal lobe, temporal lobe, striatum, and cingulate gyrus. Con clusions. Heterogeneity in the cerebral glucose metabolism of healthy volunteers increased with age, and individual variations of heterogeneity were higher in older volunteers. However, there was no significant difference between male and female volunteers of the same age. The effect of age on heterogeneity was not regionally uniform.
Spontaneous Hyperacute Postischemic Hemorrhage Leading to Death
Authors: Smith Eric E. , Fitzsimmons April L. , Nogueira Raul G. , Singhal Aneesh B.
Published: November 2009

Hyperacute, spontaneous, and severe parenchymal postischemic hemorrhage is considered rare but might be frequently misdiagnosed as primary intracerebral hemorrhage. The authors report 2 patients with catastrophic postischemic hemorrhage unrelated to anticoagulation, thrombolytics, or coagulopathy. Patient 1 was a 73‐year‐old woman with left posterior frontal lobe infarction, followed at 5.5 hours by massive postischemic hemorrhage leading to death. Patient 2 was a 52‐year‐old man with recent brain irradiation who developed left middle cerebral artery occlusion and basal ganglia infarction. Initial gradient‐echo magnetic resonance imaging (MRI) showed petechial hemorrhage within areas of infarction and widespread old microbleeds. He developed massive postischemic hemorrhage at 12 hours, leading to death. The authors conclude that early brain imaging is essential to distinguish postischemic from primary brain hemorrhage. In patients with ischemic stroke, MRI findings such as hyperacute petechial hemorrhage or chronic cerebral microbleeds might predict subsequent parenchymal hemorrhage and thus have implications for tissue plasminogen activator use.
Simple Partial Status Epilepticus Localized by Single‐Photon Emission Computed Tomography Subtraction in Chronic Cerebral Paragonimiasis
Authors: Joo Eun Yeon , Kim Jee Hyun , Tae Woo Suk , Han Sun Jung , Kim Seunghwan , Kim Myoung‐Hee , Byun Hong Sik , Hong Seung Bong
Published: November 2009

A patient with chronic cerebral paragonimiasis began to have new motor seizures of the right face manifested by clonic contractions that occurred several hundred times a day, consistent with simple partial status epilepticus. Ictal electroencephalogram discharges started from the left frontal region and then spread to the left hemisphere with left frontal maximum. But clinical seizures were limited to the right face. The frequent partial seizures were controlled by the intravenous infusion of phenytoin. Brain magnetic resonance imaging showed multiple conglomerated round nodules with encephalomalacia in the left temporal and occipital lobes. Applying the technique of ictal‐interictal single‐photo emission computed tomography subtraction, the authors were able to localize the focal ictal‐hyperperfusion on left precentral cortex adjacent to the lesions that correspond to the anatomical distribution of left face motor area.
Proton Magnetic Resonance Spectroscopy and Magnetic Resonance Imaging Findings in a Patient with Central Nervous System Paracoccidioidomycosis
Authors: Faria Andréia V. , Dabus Guilherme C. , Zanardi Verônica A. , Cendes Fernando
Published: November 2009

The authors describe a patient with brain paracoccidioidomycosis whose magnetic resonance image (MRI) showed multiple hypointense lesions on T2‐weighted images with peripheral enhancement after gadolinium injection. Single‐voxel proton magnetic resonance spectroscopy (H‐MRS) of one of the lesions showed 2 peaks at 0.9 and 1.32 ppm, corresponding to lipid signals, indicating intense necrosis. The other characteristic peaks of H‐MRS were undifferentiated from baseline. These findings, although not specific, may help to differentiate fungal abscess from tumoral lesions and other types of abscess.
Unsuccessful Tissue Plasminogen Activator Treatment of Acute Stroke Caused by a Calcific Embolus
Authors: Halloran John I. , Bekavac Ivo
Published: November 2009

Intravenous (IV) administration of tissue plasminogen activator (tPA) given to patients during acute cerebral ischemia according to National Institute of Neurological Disorders and Stroke (NINDS) guidelines improves clinical outcome by 11% to 14%. The success of IV tPA stroke therapy is dependent on several previously reported factors. The authors suggest that the presence of calcification within an embolus may represent an additional important factor. This report describes a patient with an acute stroke secondary to a spontaneous calcific cerebral embolus who had a negative outcome despite receiving proper thrombolytic therapy.
Pathogenesis of Brain and Spinal Cord Atrophy in Multiple Sclerosis
Authors: Minagar Alireza , Toledo Eduardo Gonzalez , Alexander J. Steven , Kelley Roger E.
Published: November 2009

For more than a century, multiple sclerosis was viewed as a disease process characterized by oligodendrocyte and myelin loss, and research into the pathogenesis of multiple sclerosis was mainly focused on the mechanisms of inflammation. However, with development of more sophisticated neuroimaging and molecular biology techniques, attention has shifted to new aspects of pathogenesis of multiple sclerosis: axonal loss and neurodegeneration. Evidence is increasing that tissue destruction, primarily axonal loss and neurodegeneration, is a key element in the pathogenesis of multiple sclerosis. In addition, it is now known that brain and spinal cord atrophy begins early in the disease process of multiple sclerosis and advances relentlessly throughout the course of the disease. Cumulative data suggest that axonal loss is the major determinant of progressive neuro logic disability in patients with multiple sclerosis. Magnetic resonance imaging and magnetic resonance spectroscopy in patients with multiple sclerosis for < 5 years indicate brain atrophy and loss of axonal integrity. Neurodegeneration and axonal loss in patients with multiple sclerosis are initially accompanied by a local response from oligodendrocyte progenitor cells and some remyelination. However, these repair mechanisms eventually fail, and patients typically develop generalized brain atrophy, cognitive decline, and permanent disability. Although the exact mechanisms underlying central nervous system atrophy in patients with multiple sclerosis are largely unknown, evidence exists that atrophy may represent an epiphenomenon related to the effects of dynamic inflammation within the central nervous system, including demyelination, axonal injury, neuronal loss, Wallerian degeneration, and possibly iron deposition. This article summarizes the potential mechanisms involved in central nervous system atrophy in patients with multiple sclerosis.
Measurement of Spinal Cord Atrophy in Multiple Sclerosis
Authors: Lin Xia , Tench Christopher R. , Evangelou Nikos , Jaspan Timothy , Constantinescu Cris S.
Published: November 2009

In multiple sclerosis (MS), the spinal cord is a common area of involvement, and its dysfunction is likely to be responsible for much of motor disability. It has been reported that atrophy in the cervical spinal cord occurs early and is detectable in patients presenting with a clinically isolated syndrome. This finding has important implications for the early treatment of patients with MS because atrophy is thought to reflect destructive, irreversible pathology and subclinical impairment. Recent clinical trials of disease‐modifying agents have included spinal cord imaging and, in particular, the measurement of atrophy as a secondary or exploratory measure of treatment efficacy. This review summarizes the underlying pathology responsible for spinal cord atrophy and the methods available to measure it. The relationships between spinal cord atrophy, other magnetic resonance imaging parameters, and clinical disability are also discussed.
Central Nervous System Atrophy and Clinical Status in Multiple Sclerosis
Authors: Zivadinov Robert , Bakshi Rohit
Published: November 2009

In this review, the authors focus on clinical aspects of central nervous system (CNS) atrophy in multiple sclerosis (MS), including the relationship between atrophy and disability, disease course, disease duration, quality of life, and fatigue. Crosssectional studies have demonstrated a moderate but significant correlation between brain or spinal cord atrophy and physical disability in patients with MS. Longitudinal studies ([.greaterequal] 5 years) have shown that CNS atrophy is a significant predictor of subsequent long‐term neurologic deterioration. The clinical relevance of CNS atrophy is reinforced by studies showing that atrophy accounts for more variance than conventional lesion measures in predicting disability. Impaired quality of life and both urodynamic and sexual dysfunction, but not fatigue, are associated with brain atrophy. It is likely that once the level of CNS atrophy reaches a critical threshold, patients begin to suffer clinical impairment and disease progression. Longitudinal studies suggest that CNS atrophy may occur in patients with clinically isolated demyelinating syndromes who are at high risk for developing clinically definite MS. Longitudinal natural history studies in relapsing‐remitting, secondary progressive, and primary progressive MS have suggested that patients develop CNS atrophy at a faster rate in the first few years of disease than later in the disease course. Similarly, long‐term follow‐up studies have shown a poor relationship between disease duration and the rate of brain atrophy. The authors conclude that measurement of atrophy of the CNS is emerging as a clinically relevant biomarker of the MS disease process.
Correlating Brain Atrophy With Cognitive Dysfunction, Mood Disturbances, and Personality Disorder in Multiple Sclerosis
Authors: Benedict Ralph H. B. , Carone Dominic A. , Bakshi Rohit
Published: November 2009

Neuropsychological impairment is a common feature of multiple sclerosis. Affected patients often have deficits in informationprocessing speed and memory and exhibit psychopathological states such as depression. A minority of patients have rarer affect/mood disorders such as euphoria sclerotica and pathological laughter/crying. Neuropsychological impairment is a major predictor of low quality of life, unemployment, and caregiver distress. Studies evaluating correlations between neuropsychological impairment and findings on magnetic resonance imaging show that neuropsychological dysfunction is associated with lesion burden and diffuse disease in normalappearing brain tissue. However, measures of tissue atrophy including whole‐brain and central atrophy are especially well correlated with and predictive of cognitive impairment. Moreover, recent studies have shown that conventional measures of brain atrophy explain more variance in neuropsychological dysfunction than do measures of lesion burden. In particular, neuropsychological outcomes correspond highly with linear measures of subcortical atrophy such as ventricle enlargement. Within the domain of emotional dysfunction, both lesion burden and atrophy are related to major depressive disorder. Brain atrophy also predicts euphoria and disinhibition. The preliminary data suggest that although lesion burden primarily predicts depressive disorder, both lesion burden and atrophy predict the presence of euphoria. Euphoria and disinhibition likely represent personality change associated with worsening cognition as the disease progresses. Taken together, this growing body of data on magnetic resonance imaging to neuropsychological correlations supports the clinical relevance and validity of brain atrophy as a measure of disease progression in multiple sclerosis. Continuing research focuses on the possible relationship between measures of regional brain atrophy and cognitive and emotional impairment.
Impact of Disease‐Modifying Therapies on Brain and Spinal Cord Atrophy in Multiple Sclerosis
Authors: Rudick Richard A.
Published: November 2009

Brain and spinal cord atrophy occur early in the course of multiple sclerosis (MS) and continue throughout this lifelong illness, resulting in substantial parenchymal tissue loss at later disease stages. Treatments that slow or prevent atrophy may reduce disability progression in the long term. Disease‐modifying agents (DMAs) such as interferon [.beta]‐1b (IFN[.beta]‐1b), IFN[.beta]‐1a, and glatiramer acetate inhibit inflammatory events believed to initiate and perpetuate the disease process. DMAs have been shown to inhibit aspects of MS related to brain inflammation such as relapses and gadolinium‐enhanced lesions. Because brain inflammation has been linked to irreversible brain tissue injury, DMAs should be effective in reducing the rate of brain atrophy progression. Weekly IFN[.beta]‐1a (Avonex or Rebif) has been shown to slow the rate of brain atrophy; a large study of a frequent injection regimen with IFN[.beta]‐1a (Rebif) showed continued atrophy progression despite IFN[.beta]‐1a at a rate similar to placebo‐treated patients. It is not clear why weekly treatment regimens with lower total doses of IFN[.beta]‐1a would show beneficial effects on brain atrophy compared with frequent injections with larger weekly doses. This article reviews results of clinical trials that have examined the effects of DMAs on brain and spinal cord atrophy in patients with MS. Some of these agents have demonstrated positive effects in well‐controlled studies, suggesting that anti‐inflammatory therapy can delay or prevent the emergence of irreversible central nervous system pathology.
Quantitation of Contrast TCD in Patients With and Without Atrial Septal Aneurysm
Authors: Ziai Wendy C. , Oh Sangjin , Razumovsky Alexander Y. , Wityk Robert J.
Published: November 2009

Background and Purpose. Patients with a combination of atrial septal aneurysm (ASA) and patent foramen ovale (PFO) have a substantially higher rate of recurrent ischemic events as com pared to PFO alone. One possible explanation is a greater de gree of right‐to‐left shunting with the combination. Methods. Retrospective study using contrast transcranial Doppler ultrasonography (c‐TCD) to study the degree of shunting in 46 patients with PFO with either transient ischemic attack or cryp togenic ischemic stroke. Eight patients with PFO+ASA identified on transesophageal echocardiogram were compared to 38 pa tients with PFO but without ASA. Results. The number of em bolic counts was no different with or without an ASA. Valsalva maneuver increased number of emboli, especially in patients with large PFOs. Conclusions. Patients with ASA in addition to PFO do not appear to have an increased risk of right‐to‐left shunting as measured by c‐TCD as compared to PFO alone.
Etiology of Perfusion‐Diffusion Magnetic Resonance Imaging Mismatch Patterns
Authors: Restrepo Lucas , Jacobs Michael A. , Barker Peter B. , Beauchamp Norman J. , Skolasky Richard L. , Keswani Sanjay C. , Wityk Robert J.
Published: November 2009

Background and Purpose. Diffusion‐and perfusion‐weighted magnetic resonance imaging (DWI and PWI) are useful tools for the assessment of brain ischemia. Discrepancies between the extent of DWI and PWI abnormalities are thought to depend pre dominantly on time from symptom onset to magnetic resonance imaging (MRI) examination. However, underlying ischemic stroke etiology can also be important. A mismatch may indicate the presence of tissue at risk for infarction, whereas the rele vance of other DWI/PWI patterns is uncertain. The authors therefore investigated the etiology of brain ischemia in patients with different DWI/PWI patterns. Methods. Retrospective study of 130 patients with acute brain ischemia and detailed stroke workup, including MRI within a week after symptom onset (40 ± 39 hours). Patients were divided into the following groups: mis‐match (PWI > DWI), reverse mismatch (DWI > PWI), and match (<25% difference between PWI and DWI). Results. Mismatch occurred in 49% of patients, whereas 22% had reverse mis‐match and 29% matched lesions. Time from symptom onset to MRI examination was similar between the 3 groups. Largeartery atherosclerosis increased by almost 4‐fold the odds of mismatch (odds ratio: 3.89, 95% confidence interval: 1.72–8.78; P < .001), whereas patients with reverse mismatch were likely to have cryptogenic stroke. Patients with matched lesions were similarly distributed among different stroke subtypes. Con clusions. Ischemic stroke etiology appears to influence the development of specific DWI/PWI patterns. Prospective studies are needed to confirm these observations.
Aortic Dissection Presenting as an Acute Ischemic Stroke for Thrombolysis
Authors: Uchino Ken , Estrera Anthony , Calleja Sergio , Alexandrov Andrei V. , Garami Zsolt
Published: November 2009

Thrombolysis for the treatment of acute ischemic stroke requires careful selection of patients. The authors report a case of aortic dissection presenting with acute ischemic stroke for which emergent ultrasonographic evaluation was helpful in the diagnosis and subsequent treatment. The patient presented with acute middle cerebral artery ischemic stroke symptoms and complained of bilateral ear and chest pain. Chest x‐ray, cardiac enzymes, and transthoracic echocardiogram were normal, and she was considered for thrombolytic therapy. Carotid ultrasound revealed right common carotid occlusion that led to the diagnosis of aortic dissection, confirmed by chest computed tomography. An experienced sonographer with skills to perform rapid intra‐ and extracranial examinations may help to change the treatment plan for acute stroke patients.
Wyburn‐Mason Syndrome
Authors: Lester Jacobo , Ruano‐Calderón Luis Angel , González‐Olhovich Irene
Published: November 2009

Wyburn‐Mason syndrome is an uncommon condition in which arteriovenous malformations coexist in the visual brain area, in the retina, and in some cases, in the face. As a consequence, it has recently been defined as a brain‐retino‐facial angiomatosis. The syndrome results from an embryonary insult in the development of the optic nerve path and the related vessels from its origin in the mesencephalon all the way to the projection to the retina where it usually causes unilateral manifestations. Here the authors present an interesting case of this ailment and a review of the literature.
Talairach‐Based Parcellation of Neonatal Brain Magnetic Resonance Imaging Data: Validation of a New Approach
Authors: Haidar Haissam , Warfield Simon K. , Soul Janet S.
Published: November 2009

Background and Purpose. Talairach‐based parcellation (TP) of human brain magnetic resonance imaging (MRI) data has been used increasingly in clinical research to make regional measurements of brain structures in vivo. Recently, TP has been applied to pediatric research to elucidate the changes in regional brain volumes related to several neurological disorders. However, all freely available tools have been designed to parcellate adult brain MRI data. Parcellation of neonatal MRI data is very challenging owing to the lack of strong signal contrast, variability in signal intensity within tissues, and the small size and thus difficulty in identifying small structures used as landmarks for TP. Hence the authors designed and validated a new interactive tool to parcellate brain MRI data from newborns and young infants. Methods. The authors' tool was developed as part of a postprocessing pipeline, which includes registration of multichannel MR images, segmentation, and parcellation of the segmented data. The tool employs user‐friendly interactive software to visualize and assign the anatomic landmarks required for parcellation, after which the planes and parcels are generated automatically by the algorithm. The authors then performed 3 sets of validation experiments to test the precision and reliability of their tool. Results. Validation experiments of intra‐and interrater reliability on data obtained from newborn and 1‐year‐old children showed a very high sensitivity of >95% and specificity >99.9%. The authors also showed that rotating and reformatting the original MRI data results in a statistically significant difference in parcel volumes, demonstrating the importance of using a tool such as theirs that does not require realignment of the data prior to parcellation. Conclusions. To the authors' knowledge, the presented approach is the first TP method that has been developed and validated specifically for neonatal brain MRI data. Their approach would also be valuable for the analysis of brain MRI data from older children and adults.
Emergent Basilar Artery and Bilateral Posterior Cerebral Artery Angioplasty, Urokinase Thrombolysis, and Stenting for Acute Basilar Artery Occlusion Secondary to Diagnostic Cardiac Catheterization: Case Presentation
Authors: Horowitz Michael , Jovin Tudor , Levy Elad , Anderson William
Published: November 2009

This case presentation describes the use of emergent neurointerventional procedures to revascularize a patient who developed a symptomatic stroke during coronary artery angiography. Rapid identification of a neurologic deficit in the coronary angiography suite and notification of a skilled neurointerventionalist permit for early revascularization and improved patient outcomes.
Transcranial Doppler Ultrasonographic Evaluation of Middle Cerebral Artery Hemodynamics During Mild Hypothermia
Authors: Mahmood M. Asim , Voorhees Marc E. , Parnell Mel , Zweifler Richard M.
Published: November 2009

Background and Purpose. Induced hypothermia holds promise as an effective neuroprotective strategy following cerebral ischemia. The effect of mild hypothermia on cerebral hemodynamics is not well known. The authors investigated the influence of brain temperature on middle cerebral artery (MCA) mean flow velocity (MCA FV) and pulsatility index (MCA PI) in nonintubated, healthy volunteers undergoing mild induced hypothermia. Methods. Mild hypothermia (target tympanic membrane temperature [T tym]°C) was induced in subjects using the Arctic Sun® Temperature Management System (Medivance®, Inc, Louisville, CO). MCA FV and MCA PI were recorded bilaterally with a 2 MHz pulsed probe every 30 minutes via the transtemporal window. Results. Eighteen subjects (8 males, 10 females) 32 ± 8 years of age were studied. Multivariate analysis indicated that MCA FV increased with increasing change in temperature (baseline tympanic temperature – tympanic temperature [. Ttym]) (P< .001), heart rate (HR) (P< .001), end‐tidal CO2(P= .025), arterial oxygen saturation (O2%) (P= .001), and with decreasing mean arterial blood pressure (P= .004). Multivariate analysis also indicated that ln(MCA PI) (natural logarithm of MCA PI) decreased with decreasing T tym(P< .001) and increasing HR (P< .001). Conclusions. Mild induced hypothermia is associated with an increase in MCA FV and a decrease in MCA PI. The increase in MCA FV may be partially due to microcirculatory vasodilation.