bluuebunny/crossref_metadata_2025 huggingface dataset:
Comparison between Contrast‐Enhanced Magnetic Resonance Imaging and Selvester QRS Scoring System in Estimating Changes in Infarct Size between the Acute and Chronic Phases of Myocardial Infarction
Authors: Geerse Daniël A. , Wu Katherine C. , Gorgels Anton P. , Zimmet Jeffrey , Wagner Galen S. , Miller Julie M.
Published: October 2009

Background: The Selvester QRS score was developed as a method to estimate infarct size (IS) using the ECG and has been validated during the prereperfusion era. Few comparisons exist with contrast‐enhanced magnetic resonance imaging (ceMRI) in reperfused patients. This study evaluates the ability of the Selvester QRS score to estimate serial changes in IS during the acute and chronic phases of the infarct evolution in patients who have received reperfusion therapy.

Methods: Thirteen patients with acute myocardial infarction underwent serial ceMRI studies in the acute (<1 week) and chronic phase (>2 months) after their initial myocardial infarction. QRS scoring was performed on the corresponding ECGs. The correlation between ceMRI measurement and QRS score estimation of IS was determined at both time points and for the difference between the two phases.

Results: The mean IS was 20.1 ± 11.0% of total left ventricular mass (% LV) in the acute phase and 13.3 ± 6.4% LV in the chronic phase ceMRI. The mean IS estimated by Selvester QRS score in the acute and chronic phases were 18.7 ± 8.2% and 16.4 ± 8.5% LV, respectively. A modest correlation was found for the acute (r = 0.57) and chronic phase IS (r = 0.54). However, there was no correlation for the difference in IS between the acute and chronic phases.

Conclusions: In this pilot study, the Selvester QRS score correlates modestly to IS by ceMRI during both the acute and chronic phases of the infarction process. The serial changes over time in the Selvester QRS score and IS by ceMRI show no correlation.
Technical Mistakes during the Acquisition of the Electrocardiogram
Authors: García‐Niebla Javier , Llontop‐García Pablo , Valle‐Racero Juan Ignacio , Serra‐Autonell Guillem , Batchvarov Velislav N. , De Luna Antonio Bayés
Published: October 2009

In addition to knowledge of normal and pathological patterns, the correct interpretation of electrocardiographic (ECG) recordings requires the use of acquisition procedures according to approved standards. Most manuals on standard electrocardiography devote little attention to inadequate ECG recordings. In this article, we present the most frequent ECG patterns resulting from errors in limb and precordial lead placement, artifacts in 12‐lead ECG as well as inadequate filter application; we also review alternative systems to the standard ECG, which may help minimize errors.
Amygdalae Calcifications Associated with Disease Duration in Lipoid Proteinosis
Authors: Appenzeller Simone , Chaloult Erik , Velho Paulo , Macedo de Souza Elemir , Zanardi Araújo Verônica , Cendes Fernando , Li Li Min
Published: October 2009

Objectives. To describe imaging findings of central nervous system involvement in patients with lipoid proteinosis. Methods. Patients with lipoid proteinosis followed in the dermatology and neurology departments of the State University of Campinas between 2002 and 2004 were evaluated using high‐resolution MRI and computerized tomography (CT). Results. We reviewed the charts of three patients (two women) with lipoid proteinosis with, ages ranging from 5 to 44 years. Symptomatic disease duration ranged from 2 to 39 years. MRI scans showed hypointense signal in FLAIR and T2 images in the amygdalae in two of three patients. Brain CT scans from two patients showed that MRI findings were calcifications. The calcification was more evident in patients with longer disease duration. Epilepsy was identified in one patient with longer disease duration. No other epileptogenic lesion was identified on MRI in this patient. Conclusion. Lipoid proteinosis is associated with bilateral amygdalae calcification. These findings were more evident in patients with longer disease duration. Epilepsy, when present, may be related to these calcifications. Patients with lipoid proteinosis should be followed with MRI/CT in order to identify these abnormalities.
Almost Perfect Concordance Between Simultaneous Transcranial Doppler and Transesophageal Echocardiography in the Quantification of Right‐to‐Left Shunts
Authors: Belvís Robert , Leta Ruben Gabriel , Martí‐Fàbregas Joan , Cocho Dolores , Carreras Francesc , Pons‐Lladó Guillem , Martí‐Vilalta Josep Lluis
Published: October 2009

Background and Purpose. Transesophageal echocardiography (TEE) and transcranial Doppler (TCD) are the methods of choice to study patent foramen ovale (PFO), but there are discrepancies between the 2 concerning PFO detection. No study has analyzed right‐to‐left shunt (RLS) quantification concordance. The 2 methods are carried out in different hemodynamic states, and the Valsalva maneuver (VM) required in each also differs. The authors compared PFO detection and concordance of RLS quantification classifications performing the 2 studies simultaneously. Methods. The authors prospectively included consecutive stroke patients undergoing TEE and applied the TCD protocol of the Consensus Conference. Echocardiographic PFO was diagnosed when at least 3 microbubbles (MBs) were detected in the left atrium within 3 heartbeats after opacification of the right atrium. RLS quantification was (1) TCD: minimum (1‐10 MBs), moderate (11‐25 MBs), and massive (>25 MBs) and (2) TEE: small (3‐10 MBs), moderate (11‐30 MBs), and large (>30 MBs). Statistics: contingency tables (χ2 and K test). Results. The authors studied 110 patients whose mean age was 56.7 ± 12.1 years, and 60.9% were men. PFO was detected at the first VM in 30% of patients with TCD and in 31.8% with TEE. At the second VM, both methods detected the same patients (32.7%). RLS was minimum (14), moderate (5), and massive (17) in TCD and small (13), moderate (3), and large (20) in TEE. There was an almost perfect concordance in RLS quantification (K = 0.928, P= .001), with only 4 discrepancies. Conclusions. Simultaneous study with TCD and TEE showed an almost perfect concordance in PFO detection and RLS quantification.
Thickening of Multiple Cranial Nerves in a Patient with Extranodal Peripheral T‐cell Lymphoma
Authors: Matano Sadaya , Shirasaki Hiroe , Terahata Shintarou , Nobata Koji , Sugimoto Tatsuho
Published: October 2009

A 57‐year‐old male became aware of a subcutaneous tumor in March 2001. Histopathological examination showed peripheral T‐cell lymphoma. He achieved complete remission after chemotherapy. Later the lymphoma relapsed in the subcutaneous lesion and chemotherapy was performed again. In April 2003, he developed diplopia, dysarthria, and dysphagia. Abnormal lymphoid cells were found in the cerebrospinal fluid. An immunophenotypical study disclosed that CD2, CD3, CD5, and CD8 were positive. Rearrangement of TCR was detected by Southern blotting. Cranial magnetic resonance imaging did not detect any intraparenchymal lesions, but thickening of multiple cranial nerves was detected. These nerves were homogenously enhanced by gadolinium‐DTPA. After intrathecal chemotherapy, atypical cells disappeared from the cerebrospinal fluid and thickening of the cranial nerves was resolved. Finally, lymphoma spread to the bone marrow, and the patient died in July 2003.
Neuroform Stent‐Assisted Coil Embolization of a Ruptured A1 Segment Anterior Cerebral Artery Aneurysm
Authors: Gupta Rishi , Horowitz Michael B. , Gilman Steven
Published: October 2009

We report a case of a 71‐year‐old woman who presented with a ruptured wide‐necked proximal anterior cerebral artery (ACA) aneurysm that was successfully embolized using Neuroform stent‐assisted coiling.
Sources of Variability in the Detection of Cerebral Emboli with Transcranial Doppler During Cardiac Surgery
Authors: Rodriguez Rosendo A. , Rubens Fraser , Rodriguez Carlos D. , Nathan Howard J.
Published: October 2009

Objective. The application of intensity thresholds for embolus detection with transcranial Doppler (TCD) can exclude from analysis an unrecognized proportion of high‐intensity transient signals (HITS))whose intensities are below the threshold. The lack of consistent threshold criteria between clinical trials may explain part of the discrepancy in the reported HITS counts. We investigated the effect of choosing different thresholds on the sensitivity and specificity of detecting HITS during cardiopulmonary bypass (CPB). Methods. Two observers independently analyzed TCD recordings from 8 patients under CPB. Doppler signals were classified as true HITS, equivocal HITS, artifacts, and Doppler speckles according to preestablished criteria. The relative intensity of Doppler signals was measured by two different methods (TCD software vs manual). Receiver Operating Characteristic curves determined the optimal threshold for each of the two intensity methods. Results. Reviewers achieved agreement in 96% of 2190 Doppler signals (κ= 0.90). Relative intensities calculated with the TCD‐software method were 3 dB (95% CI: 3.0‐3.4) higher than the manual method. The optimal threshold was found at 10 dB (sensitivity: 99%; specificity: 90.8%) with the software method and at 7 dB with the manual method (sensitivity: 96%; specificity: 83%). The use of an intensity threshold 2 dB higher than the optimal increased the rejection of true HITS by 8% and 14%, respectively. Conclusions. Using intensity thresholds higher than the optimal for embolus detection decreases HITS counts. Choosing a threshold depends on the type of method used for measuring the signal intensity. Uniform threshold criteria and comparative studies between different Doppler devices are necessary for making clinical trials more comparable.
Measurement of Cortical Thickness in 3D Brain MRI Data: Validation of the Laplacian Method
Authors: Haidar Haissam , Soul Janet S.
Published: October 2009

Objectives. We aimed to determine the precision of the Laplacian approach for cortical thickness measurement due to changes in computational and acquisition parameters. We compared these results to two other methods widely used in clinical research using brain MRI data. Materials and Methods. Brain MRI scans were obtained in 10 healthy adults using three different sets of acquisition parameters. The first and the second acquisitions used different slice thickness but the same head position. The third scan was performed after head repositioning. We measured cerebral cortical thickness in all brain segmentations using three thickness methods: Laplacian, nearest distance, and the orthogonal projection. Results. The Laplacian method demonstrated the least variability with regard to the effect of interchange of boundaries, slice thickness, and repositioning of the head, compared with the other two methods. Conclusion. The Laplacian method is the most precise and reliable tool for in vivo cortical thickness measurement using brain MRI data.
Prevalence of White Matter Hyperintensities in a Young Healthy Population
Authors: Hopkins Ramona O. , Beck Callie J. , Burnett David L. , Weaver Lindell K. , Victoroff Jeff , Bigler Erin D.
Published: October 2009

Background and Purpose. White matter hyperintensities (WMHs) are bright objects observed in the white matter on brain magnetic resonance (MR) imaging. WMHs are often reported as “normal” findings but may represent pathological changes. The prevalence of WMHs appears to increase with increasing age although both the typical timing and clinical significance of their appearance among medically and neurologically healthy persons remains unclear. We assessed the prevalence of WMHs in a cohort of younger healthy subjects. Methods. Our study comprised 243 healthy subjects ages 16‐65 years from our prospective normative MR imaging database. MR scans were rated for presence of periventricular and centrum semiovale WMHs using a four‐point visual semi‐quantitative scale. Results. WMHs occurred in 5.3% (13 of 243) of subjects. All WMHs were small (rating of 0.5) except one subject age 65 years who had large WMHs (ratings of 2). The median age for subjects with no WMHs was 34.5 years compared to 57.0 years for subjects with WMHs. There were no gender differences (P= .76). Older age correlated with presence of WMHs (r= 0.24; P= .01). Age greater than 55 years had a 10‐fold increase in the prevalence of WMHs compared to age ≤55 years (odds ratio = 10.01; 95% confidence interval = 3.1‐32.3; P < .001). Conclusion. WMHs were uncommon in a younger healthy population screened for comorbid diseases, but increased 10‐fold in subjects over 55 years of age. When present, the WMHs are generally small (rating of 0.5). While large WMHs appear to be associated with cognitive deterioration, the optimum threshold for identification, clinical significance, and prognostic value of smaller white matter changes requires further research.
Diagnostic Accuracy of MRI for Middle Cerebral Artery Stenosis: A Postmortem Study
Authors: Chen Xiang‐Yan , Lam Wynnie Wai Man , Ng Ho Keung , Zhao Hai‐Lu , Wong Ka Sing
Published: October 2009

Background and Purpose. Magnetic resonance imaging (MRI) has been widely applied in detecting intracranial large artery stenosis, but there have been few validation studies to compare with histopathology. The aim of the postmortem study is to assess the accuracy of MRI in identifying middle cerebral artery (MCA) stenosis. Methods. We recruited, consecutively, Chinese postmortem autopsies in our hospital during 19 months. MRI was performed in the postmortem brains to scan the cross‐sections of MCAs with barium expanding the artery lumen. The MCAs were then removed for histopathologic studies. With histopathology as a reference standard, the accuracy of MRI was evaluated, and the correlation between MCA stenosis identified by MRI and radiologically or histopathologically evident brain infarcts was investigated. Results. Seventy‐six consecutive autopsies were recruited. The sensitivity and specificity of MRI in detecting more than 30% MCA stenosis were 38.6% and 92.2%, with a positive predictive value of 87.2% and negative predictive value of 52.2%, and the corresponding values of MRI in identifying more than 50% MCA stenosis were 57.1%, 90.8%, 50%, and 83.0%, respectively. Both more than 30% and more than 50% MCA stenosis identified by MRI were found to be associated with infarctions in the corresponding MCA territory (P= 0.001, odds ratio = 4.365, 95% CI: 1.684‐11.313; and P= 0.039, odds ratio = 2.694, 95% CI: 1.139‐6.377). Conclusions. Our study demonstrates the agreement between ex vivo MRI and histopathology in identifying MCA stenosis, and the correlation between the MCA stenosis identified by MRI and radiologically or histopathologically evident brain infarcts.
T2‐Weighted and T2 Relaxometry Images in Patients with Medial Temporal Lobe Epilepsy
Authors: Coan Ana Carolina , Bonilha Leonardo , Morgan Paul S. , Cendes Fernando , Li Li Min
Published: October 2009

Purpose. Quantification of increased T2‐weighted MRI signal that is associated with hippocampal sclerosis (HS) can be performed through (1) mean of hippocampal signal in single‐echo T2 MRI and (2) hippocampal T2 relaxometry. It is not clear whether these two techniques are equivalent. In this study, we compare the hippocampal signal, detected by single‐echo T2 quantification and by T2 relaxometry, in patients with medial temporal lobe epilepsy (MTLE). Methods. We studied magnetic resonance images from 50 MTLE patients and 15 healthy subjects. We compared the quantification of a T2 signal from single echo images to T2 relaxometry, both obtained from a manually traced region of interest (ROI) in coronal slices involving the whole hippocampus. Repeated measures ANOVA was used to evaluate the differences in the distribution of the Z‐scores from single‐echo T2 quantification and T2 relaxometry within subjects. Results. We observed a significant difference between the measurements obtained from single‐echo T2 quantification and T2 relaxometry (P < .001). Measurements from head, body, and tail of the hippocampus were different (P=.04), with a significant interaction between anatomic location and type of measurement used (P= .008). Post hoc paired comparisons revealed that T2 relaxometry yielded greater Z‐scores for the body (P= .002) and tail (P < .0001). Conclusions. For each subject with MTLE, T2 relaxometry was able to detect a higher signal in the body and tail of the hippocampus compared to single‐echo T2. This is a possible indicator that T2 relaxometry is more sensitive in detecting T2 abnormalities within the body and tail of the hippocampus in patients with MTLE.
Mapping the Relative Contribution of Gray Matter Activity vs. Volume in Brain PET: A New Approach
Authors: Berkouk K. , Quarantelli M. , Prinster A. , Landeau B. , Alfano B. , Baron J.C.
Published: October 2009

Interpretation of brain positron emission tomography (PET) in terms of function vs. structure is ambiguous owing to the partial volume effect (PVE). Therefore, observed differences in tracer distribution could reflect differences in either activity or volume, a problem that applies principally to gray matter (GM) since white matter (WM) virtually always has uniform activity. To assess the contribution of GM volume vs. activity, we implemented a method to directly compare PET images with underlying structure, and applied it to resting‐state 18Fluoro‐deoxy‐glucose‐PET (FDG) of healthy subjects. Methods. Average GM and WM PVE‐corrected mean FDG uptake values were applied onto co‐registered segmented magnetic resonance imaging data sets to generate a “virtual PET” in which activity is proportional to GM volume and resolution set to that of PET. The raw PET and virtual PET values were then compared across the sample of subjects, first voxel‐wise to detect clusters with significant activity–volume mismatch, and second within regions‐of‐interest (ROI) to quantify mismatches between unsmoothed voxel values. Results. Relative to volume, there was significant hyperactivity of most GM structures of the dorsal brain—except the thalamus—and significant hypoactivity of the temporal lobe, hippocampal region, and cerebellum, consistent across the voxel‐ and ROI‐based analyses. Conclusion. As applied to normals, our method documented the expected contribution of functional activity independently of local differences in GM volume in the normal pattern of FDG uptake, and disclosed marked heterogeneities in functional activity per unit GM volume among structures. This generic method should find applications in pathological states as well as for other PET and SPECT radiotracers.
Patients with Diffusion‐Perfusion Mismatch on Magnetic Resonance Imaging 48 Hours or More After Stroke Symptom Onset: Clinical and Imaging Features
Authors: Perez Angelica , Restrepo Lucas , Kleinman Jonathan T. , Barker Peter , Beauchamp Norman , Wityk Robert J.
Published: October 2009

Background. Abnormalities in diffusion‐weighted (DWI) and perfusion‐weighted (PWI) magnetic resonance imaging (MRI) are thought to reflect the presence of brain tissue at risk for ischemic stroke. Many patients with acute ischemic stroke have a mismatch pattern in which the PWI volume is larger than the DWI lesion. This mismatch typically resolves over 24‐48 hours. Little is known about the presence of DWI‐PWI mismatch in later stages of stroke.

Methods. This is a retrospective study of 122 patients admitted with a diagnosis of acute ischemic stroke who had DWI and PWI abnormalities on studies performed within 7 days of onset of symptoms. Patients were divided into two groups: those with MRI performed <48 hours and those with MRI performed ≥48 hours from onset of symptoms.

Results. Among 42 patients with MRI performed ≥48 hours after onset of stroke symptoms, 15 of 42 (36%) showed a mismatch pattern, compared to 45 of 80 (56%) in the <48 hours group (P < 0.05). Most of the patients in the ≥48 hours group with mismatch had large artery occlusive disease and many had neurological fluctuations. A subset of these patients were treated with induced hypertension and showed clinical improvement.

Conclusions. Some patients have persistent DWI‐PWI mismatch up to several days after stroke onset. Further studies are needed to determine if these patients should be candidates for reperfusion therapy.
The Thickness and Texture of Temporal Bone in Brain CT Predict Acoustic Window Failure of Transcranial Doppler
Authors: Kwon Jee‐Hyun , Kim Jong S. , Kang Dong‐Wha , Bae Kyun‐Seop , Kwon Sun U.
Published: October 2009

Background and Purpose: Although transcranial Doppler (TCD) is useful for evaluation and treatment of ischemic stroke, temporal acoustic window failure (TAWF) limits its application. We performed this study to reveal whether initial brain CT of acute stroke patients predicted TAWF.

Methods: We performed TCD in 92 acute ischemic stroke patients (57 males, aged 38‐84 years) with brain CT scans. We measured the thickness (BTW) and evaluated the texture of the temporal bone in acoustic windows shown in the CT scan with the use of picture archiving and communication system. The bone mineral density (BMD) of the vertebral bodies, femurs, and whole body was also measured.

Results: Doppler signals were adequately obtained in 121 (65.8%) of the 184 middle cerebral arteries (MCA) from both cerebral hemispheres. BTW and inhomogeneity of temporal bone, besides age, sex, and hypercholesterolemia, was strongly correlated with TAWF. BMD was not directly correlated with TAWF, but inhomogeneous temporal bone was correlated with lower BMD scores. If the brain CT scan showed thick (BTW ≥ 2.7 mm) and inhomogeneous temporal bone, the possibility of TAWF was 93.5%, while if brain CT scan showed thin (BTW < 2.7 mm) and homogenous temporal bone, it was only 5.4%.

Conclusions: The texture as well as the thickness of the temporal bone was the most important determinant of TAWF. When acute stroke patients had thin and homogeneous temporal bones in initial brain CT scan, TAWF was very rare, and loss of MCA signals on TCD specifcally indicated the absence of blood flow in MCA.
Stroke Caused by Small Vessel Occlusion in a Patient Taking Etoricoxib and Thalidomide
Authors: Wong Edward H.C. , Leung Thomas W.H. , Wong K.S. Lawrence
Published: October 2009

We report a 33‐year‐old man with seronegative arthritis who had an acute infarct at the left lentiform nucleus while taking etoricoxib and thalidomide regularly. Extensive investigations did not find any evidence of large artery atherosclerosis, vasculitis, cardioembolic source or anti‐phospholipid antibodies. While it is possible that a short smoking history, hyperlipidemia, and the use of thalidomide could have contributed to the thrombosis of a small penetrator vessel, we postulated that the prolonged use of etoricoxib is another possible contributing factor.
Serial Imaging Changes of Cerebral Whipple's Disease: From Onset to the End
Authors: Yu Changliang , Jiang Anhong , Yu Yongqiang
Published: October 2009

A case with multiple cerebral Whipple disease is reported. The neuroradiological evolution from multiple macrophagic encephalitis to diffuse cerebral infarct in this case is described.
Primary Percutaneous Transluminal Angioplasty for Early Moyamoya Disease
Authors: Rodriguez Gustavo J. , Kirmani Jawad F. , Ezzeddine Mustapha A. , Qureshi Adnan I.
Published: October 2009

Moyamoya disease is a progressive steno‐oclusive arteriopathy of the circle of Willis that manifests on cerebral angiography with a characteristic net of vessels at the base of the brain representing collateralization. Described initially in Japan where children present with cerebral ischemia and adults with hemorrhagic stroke, it was recognized to have a more benign course in the United States, mainly causing cerebral ischemic events in young adults. Medical treatment is not intended to stop the progression of the disease and surgery is not exempt of risks. We present a patient with early moyamoya disease in the United States in whom primary transluminal angioplasty, a less invasive procedure, was performed to treat the stenotic arteriopathy with good immediate and sustained clinical and angiographic results, without evidence of restenosis at the site of angioplasty 2 years later.
Nonspecific Perichondritis of the Lumbar Spine
Authors: Semnic Robert , Milosevic Biljana , Vuckovic Nada , Semnic Marija , Sener R. Nuri
Published: October 2009

A teenage girl with soft tissue inflammation involving the L2‐S1 region of the lumbar region is reported. Magnetic resonance (MR) imaging revealed high‐signal lesions on T2‐weighted images in association with contrast enhancement. Histology revealed nonspecific perichondritis with mononuclear inflammatory infiltration of the perichondrium and connective tissue. Six months after treatment, MR imaging was normal. No similar case of perichondritis with involvement of the lumbar region could be found in the current literature.
Cerebral Atrophy Measurement in Clinically Isolated Syndromes and Relapsing Remitting Multiple Sclerosis: A Comparison of Registration‐Based Methods
Authors: Anderson Valerie M. , Fernando Kryshani T.M. , Davies Gerard R. , Rashid Waqar , Frost Chris , Fox Nick C. , Miller David H.
Published: October 2009

Background and Purpose. Brain atrophy is a proposed marker of disease progression in multiple sclerosis (MS). Many magnetic resonance imaging‐based methods of atrophy quantification exist, but their relative sensitivity and precision is unclear. Our aim was to compare atrophy rates from the brain boundary shift integral (BBSI), structural image evaluation, using normalization of atrophy (SIENA) (both registration‐based methods) and segmented brain volume difference, in patients with clinically isolated syndromes (CIS), relapsing remitting MS (RRMS), and controls. Methods. Thirty‐seven CIS patients, 30 with early RRMS and 16 controls had T1‐weighted volumetric imaging at baseline and 1 year. Brain atrophy rates were determined using segmented brain volume difference, BBSI, and SIENA. Results. BBSI and SIENA were more precise than subtraction of segmented brain volumes and were more sensitive distinguishing RRMS subjects from controls. A strong correlation was observed between BBSI and SIENA. Atrophy rates were greater in CIS and RRMS subjects than controls (RRMS P < .001). With all methods, significantly greater atrophy rates were observed in CIS patients who developed clinically definite MS relative to subjects who did not. Conclusion. Registration‐based techniques are more precise and sensitive than segmentation‐based methods in measuring brain atrophy, with BBSI and SIENA providing comparable results.
Guidelines for Screening of Extracranial Carotid Artery Disease: A Statement for Healthcare Professionals from the Multidisciplinary Practice Guidelines Committee of the American Society of Neuroimaging; Cosponsored by the Society of Vascular and Interventional Neurology
Authors: Qureshi Adnan I. , Alexandrov Andrei V. , Tegeler Charles H. , Hobson Robert W. , Dennis Baker J. , Hopkins L. Nelson
Published: October 2009

The aim of this new statement is to provide comprehensive and timely evidence‐based recommendations on the screening for asymptomatic carotid artery stenosis in the general population and selected subsets of patients. Recommendations are included for high‐risk persons in the general population; patients undergoing open heart surgery including coronary artery bypass surgery; patients with peripheral vascular diseases, abdominal aortic aneurysms, and renal artery stenosis; patients after radiotherapy for head and neck malignancies; patients following carotid endarterectomy, or carotid artery stent placement; patients with retinal ischemic syndromes; patients with syncope, dizziness, vertigo or tinnitus; and patients with a family history of vascular diseases and hyperhomocysteinemia. The recommendations are based on prevalence of disease, anticipated benefit, and concurrent guidelines from other professional organizations in selected populations.
Demonstration of Significant Resolution of Cerebral Sino‐Venous Thrombosis Associated with Intravenous Recombinant Tissue Plasminogen Activator
Authors: Misra Vivek , Elliott Debra G. , Gonzalez‐Toledo Eduardo , Kelley Roger E.
Published: October 2009

BACKGROUND

Cerebral sino‐venous thrombosis (CVT) is commonly treated with anticoagulant therapy. There are reports of response to endovascular thrombolysis with or without mechanical aspiration in patients with clinical deterioration.

CASE

We present a 29‐year‐old man with acute onset of severe headache, found to have extensive CVT by magnetic resonance venography (MRV). His atypical presentation led to cerebral angiography that was complicated by global aphasia and right hemiparesis from left middle cerebral artery distribution ischemia. He received intravenous rt‐PA (recombinant tissue plasminogen activator) within an hour of the procedure followed, 24 hours later, by intravenous heparin infusion with significant clinical improvement. The headache severity and CVT, on follow‐up MRV, resolved significantly within 2 days.

CONCLUSIONS

We demonstrate clinical and neuroimaging response to systemic rt‐PA in CVT. Thrombolysis may have a role in CVT management with an extended therapeutic window.
Cranio‐Spinal Subdural Empyema due to S. Intermedius: a Case Report
Authors: Pompucci Angelo , De Bonis Pasquale , Sabatino Giovanni , Federico Giovanni , Moschini Massimo , Anile Carmelo , Mangiola Annunziato
Published: October 2009

BACKGROUND AND PURPOSE

Subdural empyema represents a loculated infection between the dura and the arachnoid. It has been described either intracranially or in the spinal canal, the latter localization being quite rare. While treatment guidelines for a single (either brain or spinal) localization of a subdural empyema are more or less established, its management when a massive involvement of CNS is evident represents a challenge.

METHODS

The authors describe a unique case of a 65‐year‐old woman having a massive involvement of the entire CNS with multiple localizations, both intracranial and spinal. Early diagnosis was obtained through brain CT scans followed by cranio‐spinal contrast enhanced MRI scans. Patient was treated with external ventricular drainage and suboccipital craniectomy, while on antibiotic therapy.

RESULTS

Patient's neurological condition gradually improved. By the end of the eighth hospital week, she was discharged without any neurological deficit.

CONCLUSIONS

Spinal subdural empyema and brain subdural empyema are not always, as in our case, two different entities. Prompt diagnosis and treatment constitute the major variables affecting outcome.
MRI Changes in Thrombotic Microangiopathy Secondary to Malignant Hypertension
Authors: Garewal Mandeep , Yahya Sofia , Ward Christopher , Singh Niranjan , Cruz‐Flores Salvador
Published: October 2009

Thrombotic microangiopathy with thrombocytopenia and intravascular hemolysis are characteristic of three disorders: malignant hypertension (MH), disseminated intravascular coagulation (DIC), and thrombocytopenic thrombotic purpura (TTP). We describe a patient with thrombotic microangiopathy secondary to malignant hypertension that caused extensive bilateral cortical ischemic infarction.
Focal Atrophy and Cerebrovascular Disease Increase Dementia Risk among Cognitively Normal Older Adults
Authors: Rosano Caterina , Aizenstein Howard J. , Wu Minjie , Newman Anne B. , Becker James T. , Lopez Oscar L. , Kuller Lewis H.
Published: October 2009

Background and Purpose. This study investigated the association of medial temporal lobe (MTL) atrophy and cerebrovascular disease (white matter hyperintensities [WMH], subclinical infarcts) with the risk of developing Alzheimer's disease (AD) among cognitively normal older adults. Methods. Risk of developing AD was examined for 155 cognitively normal older adults (77.4 years, 60% women, 81% white). The MTL volumes and the presence of WMH and of subclinical infarcts were determined from brain magnetic resonance imaging (MRI) at the beginning of the study. Follow‐up cognitive evaluations (average 4.3 years) identified those who developed AD. Results. The presence of either MTL atrophy or subclinical infarcts was independently and significantly associated with a greater risk to develop AD (OR [95% CI]: 4.4 [1.5, 12.3] and 2.7 [1.0, 7.1], respectively). In addition, those participants with both MTL atrophy and at least one brain infarct had a 7‐fold increase in the risk of developing AD (OR [95% CI]: 7.0 [1.5, 33.1]), compared to those who had neither of these conditions. Conclusions. In cognitively normal older adults, markers of neurodegeneration (as reflected by MTL atrophy) and of cerebrovascular disease (as reflected by infarcts on MRI) independently contribute to the risk to develop AD.
MR Findings of Intrathecal Chemotherapy‐Related Myelopathy in Two Cases: Mimicker of Subacute Combined Degeneration
Authors: Lu Chia‐Hung , Yao Ming , Liu Hon‐Man , Chen Ya‐Fang
Published: October 2009

We report the findings of spinal magnetic resonance imaging (MRI) in 2 patients who had undergone intrathecal chemotherapy and presented with the subacute onset of ascending numbness and weakness. MRI revealed a symmetric hyperintensity at the posterior columns of the spinal cord from the lower cervical region down to the conus medullaris level on T2‐weighted images, and no abnormal enhancement. The imaging findings are similar to those seen in subacute combined degeneration (SCD), but the serum vitamin B12 levels were normal in these 2 cases.
Multislice Brain Myelin Water Fractions at 3T in Multiple Sclerosis
Authors: Oh Joonmi , Han Eric T. , Lee Michael C. , Nelson Sarah J. , Pelletier Daniel
Published: October 2009

Purpose. To evaluate a multislice nonlinearly‐spaced 12‐echo imaging sequence at 3T covering the supratentorial brain for the quantification of myelin water fraction (MWF) in multiple sclerosis (MS) patients. Methods. Eighty‐nine patients with, or at risk of, MS (69 relapsing remitting MS [RRMS], 7 secondary progressive MS [SPMS], 13 clinically isolated syndrome [CIS]) and 28 controls were studied. Twelve‐echo datasets were acquired using a multislice T2 prep spiral imaging sequence and were fitted using a nonnegative least squares algorithm. The mean MWF within normal appearing white matter (NAWM), contrast‐enhancing (CE), and nonenhancing T2 lesions were calculated. Results. Mean MWF in white matter for controls was 11.3%. Mean MWF was significantly reduced in NAWM of MS patients (10.6%, P= .004) relative to controls. SPMS/RRMS patients with disease duration >5 years (10.3%) had lower MWF compared to CIS/RRMS with disease duration ≤5 years (10.8%, P= .03). Mean MWF was reduced by 26% and 29% within both CE (P < .0001) and nonenhancing T2 lesions (P < .0001) relative to controls. Conclusions. Using a multicomponent T2 sequence at 3T, a significant decrease in the supratentorial MWF was observed in MS NAWM and lesions relative to controls. The method was sensitive to detect white matter changes early in the disease process.
Anomalous Origin of the Middle Meningeal Artery from the Basilar Artery: A Case Report
Authors: Shah Qaisar A. , Hurst Robert W.
Published: October 2009

Anomalous courses, anastomoses, and origins of the middle meningeal artery have often been described in the literature; however origin from the basilar artery or its branches is exceedingly rare with only five previous reports. We describe a middle meningeal artery originating from a large lateral pontine branch of the basilar artery. The lateral pontine branch also supplied most of the cerebellar hemispheric territory normally vascularized by both the anterior inferior cerebellar artery and posterior inferior cerebellar artery. We discuss the anatomy and possible embryological development of middle meningeal origin from the basilar artery.
Gliomatosis Cerebri Presenting as a Parkinsonian Syndrome
Authors: Asada Tomohiko , Takayama Yoshihiro , Tokuriki Yasuhiko , Fukuyama Hidenao
Published: October 2009

We report a 70‐year‐old man who was hospitalized after a left‐sided partial seizure progressed to grand mal seizures. Three years before, the patient had presented with the main symptoms of bradykinesia and gait disturbance and was diagnosed with parkinsonism resistant to L‐dopa. At the latest admission, extensive diffuse white matter high‐intensity areas were present on T2‐weighted magnetic resonance imaging images, and stereotactic brain biopsy showed that these lesions were gliomatosis cerebri (GC). This is the first reported case in which extensive lesions in the bilateral white matter have been associated with parkinsonism as the main clinical feature; only one other case has been reported in which GC presented as parkinsonism, and this differed from the current case with respect to localization and symptoms. We speculate that damage to the thalamocortical projections and functional impairment due to demyelination could have caused parkinsonism in our patient, and we discuss the differential diagnosis.
Transbrachial Stent‐Assisted Coil Embolization of Right Posterior Inferior Cerebellar Artery Aneurysm: Technical Case Report
Authors: Zaidat Osama O. , Szeder Viktor , Alexander Michael J.
Published: October 2009

OBJECTIVE AND IMPORTANCE

We describe a case of stent‐assisted coil embolization of a wide neck right posterior inferior cerebellar artery (PICA) aneurysm via a transbrachial artery approach.

CLINICAL PRESENTATION

A 73‐year‐old woman with a past medical history of hypertension, hyperlipidemia, colon cancer, and osteoporosis presented with a throbbing occipital area headache. Magnetic resonance angiography revealed a wide neck right PICA aneurysm. She presented for a planned endovascular stent‐assisted coil embolization.

TECHNIQUE

The initial transfemoral approach was complicated by persistent guide catheter instability due to marked tortuosity of the right vertebral artery (VA). The left VA could not be accessed due to left subclavian occlusion with steal syndrome. Neuroform‐2 (Boston Scientific; Natick, MA) stent‐assisted Matrix (Boston Scientific; Natick, MA) coil embolization was successfully performed through a 6‐French guide catheter using a transbrachial approach.

CONCLUSION

Current advances in technology produce neuroendovascular devices that are smaller with increased flexibility, allowing nonfemoral vascular access to the cerebral circulation via alternate arterial routes. This patient case demonstrates transbrachial access is a viable approach for endovascular aneurysm coil embolization, with or without stent assistance, in cases with an unstable guide catheter due to tortuous vessels or abnormal anatomy when femoral access is complicated or contraindicated.
Suitability of Temporal Bone Acoustic Window: Conventional TCD Versus Transcranial Color‐Coded Duplex Sonography
Authors: Krejza Jaroslaw , Swiat Maciej , Pawlak Mikolaj A. , Oszkinis Grzegorz , Weigele John , Hurst Robert W. , Kasner Scott
Published: October 2009

PURPOSE AND BACKGROUND

To determine whether the proportion of patients with suitable temporal bone acoustic windows is different for conventional transcranial Doppler sonography (TCD) and transcranial color‐coded duplex sonography (TCCS), based on a head‐to‐head comparison in the same population of patients.

SUBJECTS AND METHODS

Ninety patients, age 22–88 years (mean 57.1 ± 11.7 years), 46 women and 44 men, 66 Caucasian, 19 African‐American, and five Hispanic, underwent routine conventional TCD and the TCCS examination close in time to each other. Suitability of temporal bone acoustic window was defined by ability to insonate the middle and posterior and/or anterior cerebral arteries, while partial suitability was defined by ability to detect the posterior cerebral artery but not the middle cerebral artery. To compare proportions of suitable temporal bone windows for both sonographic methods, exact sign test by Liddell was used.

RESULTS.

Bilateral absence of temporal bone acoustic window was reported in six patients when studied with both conventional TCD and TCCS, whereas at least unilateral absence was reported in 10 patients. Partial, at least unilateral, suitability was reported in 11 patients with conventional TCD, and in 7 with TCCS. All differences in proportions were not significant (two‐sided P>0.05).

CONCLUSIONS:

This study suggests that success rate of insonating the intracranial vessels through the temporal bone acoustic window is the same for conventional TCD and imaging TCCS.
Biologic Effects of 3 Tesla (T) MR Imaging Comparing Traditional 1.5 T and 0.6 T in 1023 Consecutive Outpatients
Authors: Weintraub Michael I. , Khoury André , Cole Steven P.
Published: October 2009

Background. The recent use of high and ultra‐high magnetic field (MF) systems (3.0 T and above) have raised concerns about biologic effects and safety. Sensory symptoms (magnetophosphenes, dizziness/vertigo, headaches, metallic taste, pain changes, and cognitive effects) have been reported. We monitored 1023 consecutive outpatients undergoing MRI after recent introduction of a 3 T MR unit in our community. Methods/Design. Observational study utilizing a pretest and posttest symptom rating scale (0‐10) questionnaire presented to subjects undergoing MRI at three different facilities with five MRI machines, specifically a 3 T (Philips), three units with 1.5 T (GE, GE, Philips), and one 0.6 T (Fonar) unit to record symptoms before and after study. Results. 147 subjects (14%) experienced either new (N= 69; 6.7%) or changes (N= 78; 8%) in symptoms. New onset symptoms occurred predominantly with 3 T and female preponderance (75%) [P= .002]. Vertigo/dizziness (N= 28, 5.6%) [P= .001], headache (N= 8), spine pain (N= 11) occurred more frequently on 3 T, whereas magnetophosphenes (N= 8) and metallic mouth symptoms (N= 4) occurred principally in 1.5 T. Seventy‐eight subjects (8%) experienced pain symptoms ↑↓ with 75% occurring with 1.5 T. Females were 60%. Forty‐three percent of individuals had brain MRIs. Symptoms of vertigo/dizziness, headaches, and magnetophosphenes were more commonly seen in individuals undergoing brain MRIs but other body sites were also represented. Conclusions. Although no harmful effects were reported in 1023 cases, an unexpected high rate of 14% of individuals experienced sensory stimulation in both 3 T and 1.5 T units. Females appear to be more magnetically sensitive.
Central Pontine Signal Changes in Wilson's Disease: Distinct MRI Morphology and Sequential Changes with De‐Coppering Therapy
Authors: Sinha Sanjib , Taly Arun B. , Ravishankar Shivashankar , Prashanth Lingappa K. , Vasudev Mandapati K.
Published: October 2009

BACKGROUND AND PURPOSE

Reports of central pontine myelinolysis (CPM)‐like changes in Wilson's disease (WD) and its sequential changes are exceptional. The aim was to study the MRI characteristics of CPM‐like changes in WD and the serial changes.

METHODS

Among the 121 patients of WD, twenty (M:F:9:11, age at onset: 14.2 ± 4.6 years) had features similar to CPM. All had progressive neuropsychiatric form of WD. All except five were on de‐coppering treatment. None had acute deterioration or hepatic failure. Ten patients underwent repeat studies.

RESULTS

Twenty patients with CPM‐like changes manifested with characteristic phenotype of WD. Three distinct patterns of CPM‐like changes were observed: (a) characteristic round shape ‐7, (b) “bisected” ‐9, and (c) “trisected” ‐4. Only one had signal changes suggesting extra‐pontine myelinolysis. All patients had contiguous involvement of midbrain. Serial MRI evaluation in 10 patients, at mean interval period of 17.4 ± 13.2 months, revealed complete reversal in one, partial improvement in five, and no change in three. Clinical and MRI improvement occurred pari passu, except in one.

CONCLUSIONS

CPM‐like changes in WD are perhaps under‐recognized and are distinct from the commonly known “osmotic demyelination.” It is potentially reversible similar to other MRI features of WD.
Magnetic Resonance Imaging of Idiopathic Herniation of the Cuneus Gyrus
Authors: Duarte Maddalena Pizzirusso , Maldjian T. Catherine , Tenner Michael , Adam Richard
Published: October 2009

A 65‐year‐old woman presenting with chronic headaches and without overt visual symptomatology was found to have herniation of the cuneus gyrus into the superior cerebellar cistern. Only one prior case of idiopathic brain herniation has been described, in which the parahippocampal gyrus herniated into the ambient cistern. In that case a biopsy was performed as the herniation was mistaken for a tumor. We describe the features of idiopathic brain herniation that would mitigate the necessity for undergoing brain biopsy.
CTA Quantification of Internal Carotid Artery Stenosis: Application of Luminal Area vs. Luminal Diameter Measurements and Assessment of Inter‐observer Variability
Authors: Bucek Robert A. , Puchner Stefan , Haumer Markus , Reiter Markus , Minar Erich , Lammer Johannes
Published: October 2009

Background and Purpose. In contrast to digital subtraction angiography (DSAdia), computed tomography angiography (CTA) provides exact delineation of the perfused lumen in the axial plane, thus allowing luminal (CTAdia) as well as cross‐sectional area (CTAarea) internal carotid artery stenosis (ICAS) assessment. The purposes of the present study were to correlate CTAdia and CTAarea with DSAdia and to assess the inter‐observer variabilities of both CTA techniques.

Methods. In a retrospective analysis, CTA images were reviewed by two observers and ICAS was assessed according to North American Symptomatic Carotid Endarterectomy Trial applying CTAdia and CTAarea. DSAdia was assessed by a third observer.

Results. Based on 54 consecutive patients (40 males [74.1%] and 14 females [25.9%]; median age 73.3 years), ICAS percentages of CTAdia and CTAarea revealed significant correlations with DSAdia (r= 0.79‐0.87, all P<.001) with median differences in the range of +8% to –6%. Inter‐observer agreement was moderate for CTAdia (κ= 0.60) and excellent for CTAarea (κ= 0.86). Sensitivity of CTAarea for the detection of ICAS >70% was 100% for both observers, corresponding results for CTAdia were 97.1% and 71.4%, respectively, using DSAdia as the gold standard.

Conclusion. CTAarea assessment of ICAS correlates well with the results of DSAdia and provides an excellent sensitivity for the detection of ICAS >70% with superior inter‐observer agreement compared to CTAdia.
Subacute Combined Degeneration Due to Copper Deficiency
Authors: Ferrara Joseph M. , Skeen Mark B. , Edwards Nancy J. , Gray Linda , Massey E. Wayne
Published: October 2009

There is growing clinical evidence supporting a connection between copper deficiency and subacute combined degeneration. While nearly half of patients with copper deficiency myelopathy exhibit MRI abnormalities, signal changes are often ill‐defined in distribution. We report a patient with sensory ataxia and spastic paraplegia from copper deficiency whose MRI demonstrates abnormal signal restricted to the dorsal and lateral columns, providing clear radiological support of an association between hypocupremia and combined system degeneration.
Measuring Brain Atrophy in Multiple Sclerosis
Authors: De Stefano Nicola , Battaglini Marco , Smith Stephen M.
Published: October 2009

The last decade has seen the development of methods that use conventional magnetic resonance imaging (MRI) to provide sensitive and reproducible assessments of brain volumes. This has increased the interest in brain atrophy measurement as a reliable indicator of disease progression in many neurological disorders, including multiple sclerosis (MS). After a brief introduction in which we discuss the most commonly used methods for assessing brain atrophy, we will review the most relevant MS studies that have used MRI‐based quantitative measures of brain atrophy, the clinical importance of these results, and the potential for future application of these measures to understand MS pathology and progression. Despite the number of issues that still need to be solved, the measurement of brain atrophy by MRI is sufficiently precise and accurate. It represents one of most promising in vivo measures of neuroaxonal degeneration in MS, and it should be used extensively in the future to assess and monitor pathological evolution and treatment efficacy in this disease.