Changes in treatment of intracranial aneurysms during the last decade in a large European neurovascular center

OBJECTIVE

Treatment modality for ruptured and unruptured intracranial aneurysms has shifted during the last two decades from microsurgical treatment towards endovascular treatment. We present how this transition happened in a large European neurovascular center.

METHODS

We conducted a retrospective observational study consecutive patients treated for an unruptured or ruptured intracranial aneurysm at Helsinki University Hospital during 2012-2022. We used Poisson regression analysis to report age-adjusted treatment trends by aneurysm location and rupture status.

RESULTS

A total of 2491 patients with intracranial aneurysms were treated (44% ruptured, 56% unruptured): 1421 (57%) surgically and 1070 (43%) endovascularly. A general trend towards fewer treated aneurysms was noted. The proportion of patients treated surgically decreased from 90% in 2012 to 20% in 2022. The age-adjusted decrease of surgical versus endovascular treatment was 6.9%/year for all aneurysms, 6.8% for ruptured aneurysms, and 6.8% for unruptured aneurysms. The decrease of surgical treatment was most evident in unruptured vertebrobasilar aneurysms (10.8%/year), unruptured communicating artery aneurysms (10.1%/year), ruptured communicating artery aneurysms (10.0%/year), and ruptured internal carotid aneurysms (9.0%/year). There was no change in treatment modality for middle cerebral artery aneurysms, of which 85% were still surgically treated in 2022. A trend towards an increasing size for treated ruptured aneurysms was found (p = 0.033).

CONCLUSION

A significant shift of the treatment modality from surgical to endovascular treatment occurred for all aneurysm locations except for middle cerebral artery aneurysms. Whether this shift has affected long-term safety and patient outcomes should be assessed in the future.

Initial Experiences with the Trenza Embolization Device for the Treatment of Wide-Neck Intracranial Aneurysms: A 12-Patient Case Series

The Trenza embolization device is a frame coil implant with flow-disruption properties and is a new alternative to treat challenging mid-to-large-sized broad-neck bifurcation or sidewall aneurysms. We conducted an observational single-center retrospective study of 12 consecutive patients treated for 10 unruptured and 2 ruptured 6- to 12-mm broad-neck bifurcation or sidewall aneurysms with the Trenza device during 2022-2023. The median patient age was 64 years (interquartile range, 59-70 years), 58% were women, the median largest aneurysm diameter was 9.6 mm (interquartile range, 7.5-11.9 mm), the median dome-to-neck ratio was 1.8 (interquartile range, 1.6-1.9), the most common aneurysm locations were the anterior communicating artery (33%) and basilar artery tip (33%). After a median follow-up of 6.5 months, adequate aneurysm occlusion was achieved in 83%. There were 3 major ischemic complications (25%), leading to 2 permanent neurologic deficits (17%) and 1 transient neurologic deficit (8%). There was 1 fatal rupture of a treated aneurysm 1.6 months after the index treatment. Two patients were retreated (17%). Ischemic complications occurred in patients after a too-dense coil packing at the base of the aneurysm. No technical issues related to the device were encountered. In summary, an adequate aneurysm occlusion rate was achieved using the Trenza-assisted coiling technique for otherwise challenging mid-to-large-sized broad-neck aneurysms. Ischemic complications seemed to occur following overdense coiling at the base of the aneurysm.

Flow diversion of ruptured intracranial aneurysms: a single-center study with a standardized antithrombotic treatment protocol

BACKGROUND

The use of antithrombotic medication following acute flow diversion for a ruptured intracranial aneurysm (IA) is challenging with no current guidelines. We investigated the incidence of treatment-related complications and patient outcomes after flow diversion for a ruptured IA before and after the implementation of a standardized antithrombotic medication protocol.

METHODS

We conducted a single-center retrospective study including consecutive patients treated for acutely ruptured IAs with flow diversion during 2015-2023. We divided the patients into two groups: those treated before the implementation of the protocol (pre-protocol) and those treated after the implementation of the protocol (post-protocol). The primary outcomes were hemorrhagic and ischemic complications. A secondary outcome was clinical outcome using the modified Ranking Scale (mRS).

RESULTS

Totally 39 patients with 40 ruptured IAs were treated with flow diversion (69% pre-protocol, 31% post-protocol). The patient mean age was 55 years, 62% were female, 63% of aneurysms were in the posterior circulation, 92% of aneurysms were non-saccular, and 44% were in poor grade on admission. Treatment differences included the use of glycoprotein IIb/IIIa inhibitors (pre-group 48% vs. post-group 100%), and the use of early dual antiplatelets (pre-group 44% vs. 92% post-group). The incidence of ischemic complications was 37% and 42% and the incidence of hemorrhagic complications was 30% and 33% in the pre- and post-groups, respectively, with no between-group differences. There were three (11%) aneurysm re-ruptures in the pre-group and none in the post-group. There were no differences in mortality or mRS 0-2 between the groups at 6 months.

CONCLUSION

We found no major differences in the incidence of ischemic or hemorrhagic complications after the implementation of a standardized antithrombotic protocol for acute flow diversion for ruptured IAs. There is an urgent need for more evidence-based guidelines to optimize antithrombotic treatment after flow diversion in the setting of subarachnoid hemorrhage.

Long-term treatment outcomes and natural course of low-grade intracranial dural arteriovenous fistulas

OBJECTIVE

In contrast to high-grade dural arteriovenous fistula (dAVF), low-grade dAVF is mainly associated with tinnitus and carries a low risk of morbidity and mortality. It remains unclear whether the benefits of active interventions outweigh the associated risk of complications in low-grade dAVF.

METHODS

The authors conducted a retrospective single-center study that included all consecutive patients diagnosed with an intracranial low-grade dAVF (Cognard type I and IIa) during 2012-2022 with DSA. The authors analyzed symptom relief, symptomatic angiographic cure, treatment-related complications, risk for intracerebral hemorrhage (ICH), and mortality. All patients were followed up until the end of 2022.

RESULTS

A total of 81 patients were diagnosed with a low-grade dAVF. Of these, 48 patients (59%) underwent treatment (all primary endovascular treatments), and 33 patients (41%) did not undergo treatment. Nine patients (19%) underwent retreatments. Angiographic follow-up was performed after median (IQR) 7.7 (6.1-24.1) months by means of DSA (mean 15.0, median 6.4 months, range 4.5-83.4 months) or MRA (mean 29.3, median 24.7 months, range 5.9-62.1 months). Symptom control was achieved in 98% of treated patients after final treatment. On final angiographic follow-up, 73% of patients had a completely occluded dAVF. There were 2 treatment-related complications resulting in 1 transient (2%) and 1 permanent (2%) neurological complication. One patient showed recurrence and progression of a completely occluded low-grade dAVF to an asymptomatic high-grade dAVF. No cases of ICH- or dAVF-related mortality were found in either treated patients (median [IQR] follow-up 5.1 [2.0-6.8] years) or untreated patients (median [IQR] follow-up 5.7 [3.2-9.0] years).

CONCLUSIONS

Treatment of low-grade dAVF provides a high rate of symptom relief with small risks for complications with neurological sequela. The risks of ICH and mortality in patients with untreated low-grade dAVF are minimal. Symptoms may not reveal high-grade recurrence, and radiological follow-up may be warranted in selected patients with treated low-grade dAVF. An optimal radiographic follow-up regimen should be developed by a future prospective multicenter registry.

Comparable long-term outcomes in patients undergoing total disc replacement or anterior cervical discectomy and noninstrumented fusion

BACKGROUND CONTEXT

Anterior cervical discectomy and fusion (ACDF) is the leading surgical treatment for cervical radiculopathy. However, ACDF surgery has been suggested for to accelerate the degeneration of the adjacent cervical discs, which causes so-called adjacent segment disease (ASD). Over the past 2 decades, total disc replacement (TDR)/cervical disc arthroplasty (CDA) has become an increasingly common method for treating degenerative cervical diseases. The rationale is that a synthetic disc prosthesis may preserve motion at the operated level, which is expected to lead to reduced stress on the other cervical levels and thus decrease the risk of developing ASD. However, since the method was first introduced in the early 2000s, the long-term outcome after it is still not completely understood.

PURPOSE

Our goal was to compare the long-term outcomes of TDR and ACDF procedures.

STUDY DESIGN

Retrospective case-control study.

PATIENT SAMPLE

All patients who underwent TDR due to degenerative cervical disease at Helsinki University Hospital between 2006 and 2012 (38 patients) and matched control patients who underwent ACDF during this period (76 patients) for degenerative disc disease.

OUTCOME MEASURES

The primary outcome measure was the rate of reoperations and further cervical surgeries. Secondary outcome measures included neck symptoms (Neck Disability Index, or NDI), health-related quality of life (EQ-5D-3L), satisfaction with the surgery, radiological outcomes, and employment status.

METHODS

The medical records of all patients who underwent TDR due to degenerative cervical disease at Helsinki University Hospital between 2006 and 2012 and those of the matched control patients were analyzed retrospectively. Questionnaires were sent to all available patients at the end of the follow-up (median 14 years) to evaluate their employment status, levels of satisfaction with the surgery, current neck symptoms, and health-related quality of life. Radiological outcomes were evaluated from the cervical plain radiographs, which were taken either at the end of the follow-up as a part of the present study or earlier on for other clinical reasons, but at least 2 years after index surgery.

RESULTS

The total rate of reoperations and further cervical surgeries during the follow-up of a median of 14 years was 7/38 (18%) in the TDR group and 6/76 (8%) in the ACDF group (p=.096, ns.). Total disc replacement patients were reoperated earlier, and the 5-year reoperation rate was significantly higher in the TDR group (11% vs 1.3%, p=.026). None of the TDR patients underwent further cervical surgery more than 6 years after index surgery, whereas 5/6 (83%) of the reoperated ACDF patients were reoperated after that time. There were no significant differences in the NDIs between the patient groups. The employment rate and health-related quality of life were slightly higher in the TDR group, but the differences were statistically nonsignificant. TDR was significantly better at maintaining the angular range of motion at the operated level, and the fusion rate was significantly lower among this group.

CONCLUSIONS

There were no significant differences in the long-term outcomes of ACDF and TDR when measured by reoperation rates, employment status, NDI, EuroQoL, and satisfaction with surgery. Reoperation rate and, on the other hand, employment rate and health-related quality of life, were higher in the TDR group, but the differences were statistically nonsignificant. However, TDR patients were reoperated earlier, and the 5-year reoperation rate was significantly higher in the TDR group. Randomized long-term studies in which these methods are compared are needed to further clarify the differences between them.

CLinical EValuation of WEB 17 device in intracranial aneuRysms (CLEVER): procedural, 30-day and 1-year safety results for ruptured and unruptured aneurysms

BACKGROUND

Intrasaccular flow disruption is an endovascular approach for the treatment of wide-neck aneurysms and, more specifically, wide-neck bifurcation aneurysms, which are challenging to treat with previously developed technologies. The Woven EndoBridge (WEB) device has demonstrated its efficacy and safety, for both unruptured and ruptured aneurysms.

METHODS

The CLEVER study was an observational, multicenter, prospective study conducted in 17 European investigational sites using the WEB 17 device, for the treatment of ruptured and unruptured aneurysms. The study objective was to provide safety and efficacy data on the WEB 17 device in the treatment of wide-neck bifurcation aneurysms. Imaging results were assessed independently by a Corelab and adverse events adjudicated by a Clinical Event Adjudicator. This analysis reports procedural results and safety at 30 days and 12 months.

RESULTS

A total of 163 patients (mean age 58.1 years; 68.1% women) with 103 unruptured aneurysms and 60 ruptured aneurysms were enrolled. Most aneurysms were located on the anterior communicating artery (ACom) (37.4%) or the middle cerebral artery (MCA) bifurcation (30.1%). Aneurysm widths ranged from 2.0-9.2 mm, and the mean sac width was 5.0 mm. The WEB procedure was successfully completed in 163 patients (100%). At the 12-month follow-up, major stroke events occurred in 3 of 163 patients (1.8%), and no device-related mortality was observed.

CONCLUSION

Endovascular treatment of ruptured and unruptured wide-neck bifurcation aneurysms using WEB 17 is safe, with a low complication rate and no device-related mortality. In particular, none of the ruptured aneurysms bled again up to 1 year of follow-up.

TRIAL REGISTRATION NUMBER

NCT03844334.

Natural history of intracavernous aneurysms: a consecutive single-center study of 250 patients with 276 aneurysms

OBJECTIVE

The natural history of cavernous carotid aneurysms (CCAs) is not fully understood. For robust clinical decision-making, the behavior of CCAs needs to be fully understood. The objective of this paper was to calculate the mortality and morbidity rates of patients with diagnosed but untreated CCAs from a relatively large single-center cohort.

METHODS

The authors identified 250 patients with 276 CCAs from August 1946 to August 2017 from an aneurysm database including 12,000 intracranial aneurysm patients. Patient and aneurysm characteristics were extracted for further analysis.

RESULTS

The cumulative patient follow-up was 1560 years, with a mean of 6.3 years. For patients presenting with a cranial nerve deficit caused by a CCA, those with a ruptured CCA, and patients who received treatment for a CCA, the cumulative patient follow-up was 121 years, with a mean of 1.3 years. For patients with symptom-free or conservatively treated CCAs, the cumulative patient follow-up was 1093 years, with a mean of 7.2 years. Of the 276 aneurysms, 57 (21%) caused cranial nerve deficits and 18 (6.5%) other symptoms, while 201 (73%) remained symptom free. A total of 264 (96%) of the CCAs remained unruptured, and 2 were considered possibly ruptured. Ten (3.6%) ruptures of the CCAs were found. However, none of the ruptured aneurysms caused subarachnoid hemorrhage or death of the patient. Of the CCAs, 51 were multiple, and 131 patients had ≥ 1 intradural aneurysm. The CCAs were analyzed separately.

CONCLUSIONS

The majority of the CCAs were asymptomatic during follow-up, and none caused the death of the patient. The incidence of symptoms increased with aneurysm size. Because CCAs have a benign natural course, treatment should be considered mainly if the CCA is symptomatic or grows during follow-up.

Ultra-low-dose CBCT: new cornerstone of paranasal sinus imaging

BACKGROUND

This study evaluates the clinical image quality (IQ) and usability of a sinonasal ultra-low-dose (ULD) cone-beam computed tomography (CBCT) scan. The results are compared to those of a high resolution (HR) CBCT scan to identify the strengths and weaknesses of a ULD CBCT protocol.

METHODOLOGY

Sixty-six anatomical sites in 33 subjects were imaged twice using two imaging modalities: HR CBCT (Scanora 3Dx scanner; Soredex, Tuusula, Finland) and ULD CBCT (Promax 3D Mid scanner; Plandent, Helsinki, Finland). IQ, opacification and obstruction, structural features and operative usability were assessed.

RESULTS

The overall IQ in subjects with "no or minor opacification" was excellent: 100% (HR CBCT) and 99% (ULD CBCT) of ratings were evaluated as sufficient for every structure. Increased opacification reduced the quality of both imaging modalities, resulting conchtoethmoidectomy, frontal sinusotomy, sphenotomy and posterior ethmoidectomy in cases with greater opacification.

CONCLUSIONS

IQ of paranasal ULD CBCT is sufficient for clinical diagnostics and should be considered for surgical planning. We recommend it as the primary imaging protocol for all patients who meet imaging criteria due to recurrent or chronic nasal symptoms. Additional or conventional imaging might be needed for patients with extensive chronic rhinosinusitis and/or indications of frontal sinus involvement.

Recurrence of brain arteriovenous malformations in pediatric patients: a long-term follow-up study

BACKGROUND

Previously thought to be congenital, AVMs have shown evidence of de-novo formation and continued growth, thus shifting thoughts on their pathophysiology. Pediatric AVM patients have been reported to be more prone to develop AVM recurrence after a seemingly complete cure. Therefore, we assessed the risk of AVM treated in childhood to recur in adulthood after a long-term follow-up in our own cohort.

METHODS

Control DS-angiography was arranged during 2021-2022 as part of a new protocol for all AVM patients who were under 21 years of age at the time of their treatment and in whom the treatment had occurred at least five years earlier. Angiography was offered only to patients under 50 years of age at the time of the new protocol. The complete eradication of AVM after the primary treatment had been originally confirmed with DSA in every patient.

RESULTS

A total of 42 patients participated in the late DSA control, and 41 of them were included in this analysis after excluding the patient diagnosed with HHT. The median age at the time of admission for AVM treatment was 14.6 (IQR 12-19, range 7-21 years) years. The median age at the time of the late follow-up DSA was 33.8 years (IQR 29.8-38.6, range 19.4-47.9 years). Two recurrent sporadic AVMs and one recurrent AVM in a patient with hereditary hemorrhagic telangiectasia (HHT) were detected. The recurrence rate was 4.9% for sporadic AVMs and 7.1% if HHT-AVM was included. All the recurrent AVMs had originally bled and been treated microsurgically. The patients with sporadic AVM recurrence had been smoking their whole adult lives.

CONCLUSIONS

Pediatric and adolescent patients are prone to develop recurrent AVMs, even after complete AVM obliteration verified by angiography. Therefore, imaging follow-up is recommended.

Long term WEB results - still going strong at 5 years?

OBJECTIVE

The aim of our multi-center study is to examine 5-year radiological outcomes of intracranial aneurysms (IAs) treated with the Woven EndoBridge (WEB).

METHODS

All patients treated with WEB between January 2013 and December 2016 were included. Patient and aneurysm characteristic data was collected from the electronic patient record. Aneurysm occlusion was assessed using a 3-grade scale: complete occlusion, neck remnant, and aneurysm remnant. Complete occlusion and neck remnant were considered as adequate occlusion, whereas aneurysm remnant was assessed as an inadequate occlusion.

RESULTS

A total of 66 patients (72.7% female) with 66 IAs (n = 25 acutely ruptured) were treated with WEB. The mean age of patients was 55.6 years (range: 36-71 years). The mean width of the aneurysm neck was 4.5 mm (range: 2-9 mm). 5-year imaging follow-up data was not available for 16.6% patients (n = 11). During the follow up period, 14.5% of IAs (n = 8/55) required retreatment within 24 months of initial treatment with the WEB. A total of 55 IAs were analyzed for 5-year radiological outcome. Of these, including IAs required retreatment, 47.3% of IAs (n = 26/55) were occluded completely, 36.4% (n = 20/55) had neck remnant and 16.3% (n = 9/55) had recanalized. 83.7% of IAs were occluded adequately. None of the IAs rebled after initial treatment with WEB.

CONCLUSION

WEB can provide acceptable adequate occlusion rates at 5 years. Furthermore, recanalization appears to be unlikely after the first two years post-treatment. The results of large studies are needed to confirm these promising long term radiological outcomes.

Long-Term Follow-Up After Cervical Laminectomy without Fusion for Cervical Spondylotic Myelopathy

OBJECTIVE

The objectives were to study the effect of cervical laminectomy without fusion on the incidence of further cervical surgeries, the risk for cervical misalignment, and current functional status.

METHODS

We retrospectively analyzed the clinical data of 340 patients who had undergone simple laminectomy for cervical spondylotic myelopathy (CSM) at Helsinki University Hospital between 2000 and 2011.

RESULTS

Forty-one patients (12.1%) had later undergone another cervical surgery during the follow-up of a mean of 8.5 years (maximum, 17.5 years). The most common indication for further surgery was residual stenosis at adjacent or other cervical levels (34%). Five patients (1%) required further surgery for correction of a sagittal balance problem. The mean Neck Disability Index was 28% at a median of 9.0 years after laminectomy. The mean EQ-5D (EuroQol 5 Dimension 3 Level) index score was 58.8 for patients and 77.2 for age-matched and gender-matched general population controls (P = 0.000), indicating patients' reduced health-related quality of life. Worse preoperative condition in the Nurick score was related to a lower (i.e., worse) EQ-5D score. In an additional arm of the study with radiographic imaging (40 patients), the mean change in sagittal alignment was 4.0° toward lordotic, and a newly developed kyphosis was found in 7.5% of patients.

CONCLUSIONS

Because CSM is a serious degenerative progressive condition resulting in decreased health-related quality of life even after surgical treatment, the low rate of corrective surgery needed for alignment issues per se indicates that simple laminectomy can be a viable treatment option in treating multilevel CSM.

Finnish flow diverter study: 8 years of experience in the treatment of acutely ruptured intracranial aneurysms

Background

Flow diversion of acutely ruptured intracranial aneurysms (IAs) is controversial due to high treatment-related complication rates and a lack of supporting evidence. We present clinical and radiological results of the largest series to date.

Methods

This is a nationwide retrospective study of acutely ruptured IAs treated with flow diverters (FDs). The primary outcome was the modified Rankin Scale (mRS) score at the last available follow-up time. Secondary outcomes were treatment-related complications and the aneurysm occlusion rate.

Results

110 patients (64 females; mean age 55.7 years; range 12–82 years) with acutely ruptured IAs were treated with FDs between 2012 and 2020 in five centers. 70 acutely ruptured IAs (64%) were located in anterior circulation, and 47 acutely ruptured IAs (43%) were blister-like. A favorable functional outcome (mRS 0–2) was seen in 73% of patients (74/102). Treatment-related complications were seen in 45% of patients (n=49). Rebleeding was observed in 3 patients (3%). The data from radiological follow-ups were available for 80% of patients (n=88), and complete occlusion was seen in 90% of aneurysms (79/88). The data from clinical follow-ups were available for 93% of patients (n=102). The overall mortality rate was 18% (18/102).

Conclusions

FD treatment yields high occlusion for acutely ruptured IAs but is associated with a high risk of complications. Considering the high mortality rate of aneurysmal subarachnoid hemorrhage, the prevention of rebleeding is crucial. Thus, FD treatment may be justified as a last resort option.

Voxel and surface based whole brain analysis shows reading skill associated grey matter abnormalities in dyslexia

Developmental dyslexia (DD) is the most prevalent neurodevelopmental disorder with a substantial negative influence on the individual's academic achievement and career. Research on its neuroanatomical origins has continued for half a century, yielding, however, inconsistent results, lowered total brain volume being the most consistent finding. We set out to evaluate the grey matter (GM) volume and cortical abnormalities in adult dyslexic individuals, employing a combination of whole-brain voxel- and surface-based morphometry following current recommendations on analysis approaches, coupled with rigorous neuropsychological testing. Whilst controlling for age, sex, total intracranial volume, and performance IQ, we found both decreased GM volume and cortical thickness in the left insula in participants with DD. Moreover, they had decreased GM volume in left superior temporal gyrus, putamen, globus pallidus, and parahippocampal gyrus. Higher GM volumes and cortical thickness in these areas correlated with better reading and phonological skills, deficits of which are pivotal to DD. Crucially, total brain volume did not influence our results, since it did not differ between the groups. Our findings demonstrating abnormalities in brain areas in individuals with DD, which previously were associated with phonological processing, are compatible with the leading hypotheses on the neurocognitive origins of DD.

Treatment of intracranial aneurysms using the new Surpass Evolve flow diverter: Safety outcomes and six-month imaging follow-up

BACKGROUND AND PURPOSE

Several studies have reported good long-term results in the occlusion of intracranial aneurysms with flow diverter treatment. The aim of this study was to report the safety and six-month follow-up outcomes using the new Surpass Evolve flow diverter in the treatment of intracranial aneurysms.

MATERIALS AND METHODS

Consecutive patients with intracranial aneurysm treated with Surpass Evolve flow diverter in two high-volume neurovascular centers between May 2019 and January 2020 were retrospectively reviewed. Procedure-related complications, aneurysm occlusion (O'Kelly-Marotta grading scale), and clinical outcomes were assessed.

RESULTS

Twenty-nine patients with 30 aneurysms were included in the study. Favorable aneurysm occlusion (O'Kelly Marotta grading scale C-D) at six-month follow-up was achieved in 21/27 (78%) aneurysms. No clinical procedure related thromboembolic complications were encountered. Twenty-three out of 24 patients with unruptured aneurysms treated with Surpass Evolve remained clinically intact at clinical follow-up. There was one fatal hemorrhagic procedure-related complication (3%). In five patients with ruptured aneurysms, no early or late rebleeds occurred from the aneurysms.

CONCLUSIONS

Surpass Evolve FD worked technically well with no intraprocedural thromboembolic complications and occlusion rates comparable to other FDs.

Flow diversion for internal carotid artery aneurysms: Impact of complex aneurysm features and overview of outcome

OBJECTIVE

Flow diversion is a popular technique used to treat ordinary small, as well as complex internal carotid artery (ICA) aneurysms. We describe aneurysm occlusion rates, complications and patient outcomes in patients with ICA aneurysms treated with flow diverter stents.

PATIENTS AND METHODS

We identified all consecutive patients with ICA aneurysms that were treated with flow diverter stents between 2014 and 2019 at our institution. We divided the aneurysms into two anatomic subgroups (cavernous and supraclinoid segments). All the imaging studies and medical records were reviewed for relevant features in relation to aneurysms, complications and patient outcomes.

RESULTS

A total of 62 patients with 76 ICA aneurysms (72 unruptured; 4 ruptured) were treated with 70 flow diversion procedures, including six re-treatments. Complete aneurysm occlusion was achieved in 61 % of patients at 6-month follow-up (cavernous 69 %, supraclinoid 58 %), and in 69 % at the latest follow-up (mean of 18 months). Postprocedural intracranial ischemia or hemorrhage was seen in 24 % of patients, including two aneurysm ruptures after flow diversion, and related major long-term functional decline or mortality was seen in 6% of patients. Preprocedural dysfunction of extraocular muscles or vision disturbance improved moderately at best (40-60 %). At the latest follow-up, 54 patients (87 %) were functionally independent (mRS ≤2).

CONCLUSION

Flow diversion for cavernous and supraclinoid ICA aneurysms demonstrated acceptable results, but complex aneurysm features cause uncertainty in predicting aneurysm occlusion probability. Patients should be informed of the non-negligible rate of complications, and of only moderate improvement rate of cranial nerve dysfunctions.

Assessing Cut-off Points of Eosinophils, Nasal Polyp, and Lund-Mackay Scores to Predict Surgery in Nasal Polyposis: A Real-World Study

Background

Developing tools to identify chronic rhinosinusitis with nasal polyps (CRSwNP) patients requiring surgical treatment would help clinicians treat patients more effectively. The aim of this retrospective cross-sectional study was to identify cut-off values ​​for eosinophil percentage, nasal polyps (NP), and Lund-Mackay (LM) scores that may predict the need for surgical treatment in Finnish CRSwNP patients.

Methods

Data of CRSwNP patients (N = 378) undergoing consultation for ESS in 2001–19 were used. Data was collected from patient records and Lund-Mackay scores were determined from sinus computed tomography scans. The percentage of eosinophils was microscopically evaluated from the polyp samples available (n = 81). Associations were analyzed by Mann Whitney U test, and cut-off values by the area under the receiver operating characteristic curve (AUROC).

Results

ESS was performed to 293 (77.5%) of patients. Polyp eosinophilia was associated significantly with ESS (p = 0.001), whereas peripheral blood eosinophil count, LM- score and endoscopic NP- score were not (p > 0.05). AUROC values (95% CI) for detecting those needing ESS were for polyp eosinophilia 0.71 (0.60–0.83), p = 0.001, for LM score 0.59 (0.50–0.67), p = 0.054; for NP score 0.56 (0.48–0.64), p = 0.17, and for blood eosinophil count 0.68 (0.46–0.90), p = 0.08. With the threshold value of polyp eosinophilia (>25%), the sensitivity and specificity were optimal for detecting the group needing ESS from the group not undergoing ESS. The cut-off value of blood eosinophil count (>0.26 × 10⁹/L) had relatively good, yet statistically insignificant (underpowered), predictive potential. Moderate cut-off values were found for endoscopic LM score (≥14/24) and NP score (≥4/8).

Conclusions

Polyp eosinophilia (>25%) predicted ESS among Finnish hospital-level CRSwNP patients. A future challenge would be to find less invasive and cost-effective clinical factors predicting uncontrolled CRSwNP.

Flow diversion treatment for acutely ruptured aneurysms

Background and purpose

Flow diverters are sometimes used in the setting of acutely ruptured aneurysms. However, thromboembolic and hemorrhagic complications are feared and evidence regarding safety is limited. Therefore, in this multicenter study we evaluated complications, clinical, and angiographic outcomes of patients treated with a flow diverter for acutely ruptured aneurysms.

Methods

We conducted a retrospective observational study of 44 consecutive patients who underwent flow diverter treatment within 15 days after rupture of an intracranial aneurysm at six centers. The primary end point was good clinical outcome, defined as modified Rankin Scale score (mRS) 0–2. Secondary endpoints were procedure-related complications and complete aneurysm occlusion at follow-up.

Results

At follow-up (median 3.4 months) 20 patients (45%) had a good clinical outcome. In 20 patients (45%), 25 procedure-related complications occurred. These resulted in permanent neurologic deficits in 12 patients (27%). In 5 patients (11%) aneurysm re-rupture occurred. Eight patients died resulting in an all-cause mortality rate of 18%. Procedure-related complications were associated with a poor clinical outcome (mRS 3–6; OR 5.1(95% CI 1.0 to 24.9), p=0.04). Large aneurysms were prone to re-rupture with rebleed rates of 60% (3/5) vs 5% (2/39) (p=0.01) for aneurysms with a size ≥20 mm and <20 mm, respectively. Follow-up angiography in 29 patients (median 9.7 months) showed complete aneurysm occlusion in 27 (93%).

Conclusion

Flow diverter treatment of ruptured intracranial aneurysms was associated with high rates of procedure-related complications including aneurysm re-ruptures. Complications were associated with poor clinical outcome. In patients with available angiographic follow-up, a high occlusion rate was observed.

Successful endovascular coil embolisation of a ruptured V1-segment vertebral artery dissecting aneurysm making a fistula with the adjacent vein

Sudden supraclavicular pain is often associated with myocardial infarction but seldom due to a rupture of V1-segment vertebral artery aneurysm. A ruptured V1 segment of vertebral artery dissecting aneurysm making a fistula with the adjacent vein has rarely been described in literature. Here we present a case of a 29-year-old healthy woman with sudden supraclavicular pain and palpable mass that developed after pain. Initial ultrasound showed suspicion of large haematoma. CT angiogram showed a left-sided dissecting V1-segment vertebral artery ruptured aneurysm. Angiography showed an additional fistula between the aneurysm and the adjacent vein. The patient was treated successfully with coil embolisation. The vertebral artery occlusion was well tolerated without any complications. Endovascular coiling is a fast and effective treatment modality. However, a parent vessel occlusion can be sometimes dangerous if the contralateral vertebral artery supply is not sufficient. Surgical possibilities to reconstruct the parent vessel should also be considered in complex cases.

Diagnostic Accuracy of Symptoms, Endoscopy, and Imaging Signs of Chronic Rhinosinusitis Without Nasal Polyps Compared to Allergic Rhinitis

Objectives The diagnosis of chronic rhinosinusitis without nasal polyps (CRSsNP) and distinguishing it from allergic rhinitis is difficult. Yet, early detection of CRSsNP is important to prevent progressive and severe chronic rhinosinusitis. Our aim was to compare diagnostic accuracy of symptoms, endoscopy, and imaging signs of CRSsNP and allergic rhinitis -only phenotypes. Setting Prospective controlled follow-up study. Participants Forty-two nonsmoking patients visiting tertiary care due to CRSsNP and 19 nonsmoking volunteer controls with allergic rhinitis filled a symptoms questionnaire and underwent nasal endoscopy off-seasonally. All CRSsNP patients underwent computed tomography scans of paranasal sinuses. All the allergic rhinitis control subjects and 14 of the CRSsNP patients underwent sinus magnetic resonance imaging. Results Radiologic Lund-Mackay score, duration of symptoms, visual analogue scale scores of symptoms, and Sinonasal Outcome Test 22 were significantly higher in the CRSsNP group compared to allergic rhinitis control group. These factors also correlated in part with each other. Endoscopic score did not correlate with other factors, nor did it differ between CRSsNP and allergic rhinitis groups. The highest area under curve value was demonstrated for visual analogue scale score of facial pain/pressure (0.93) and score ≥4/10 showed 60% sensitivity and 95% specificity for detecting CRSsNP group ( P < .001). Radiologic sign of obstructed osteomeatal complex showed 100% specificity and 38% sensitivity for detecting CRSsNP group ( P < .001). Conclusions CRSsNP phenotype could be primarily distinguished from allergic rhinitis by higher facial pain/pressure score and secondarily by radiologic sings of obstructed ostiomeatal complex and higher Lund-Mackay score. Endoscopic score has limited value in distinguishing CRSsNP from allergic rhinitis.

A prospective, randomized clinical study comparing drug eluting stent therapy and intranasal corticoid steroid therapy in the treatment of patients with chronic rhinosinusitis

OBJECTIVES

To conduct the first prospective, randomized controlled clinical trial comparing the efficacy of a drug-eluting stent (DES) (the Relieva StratusTM MicroFlow Spacer) and topical intranasal corticosteroid therapy in patients with chronic rhinosinusitis (CRS).

METHODS

Sixty-three adult patients with ethmoiditis were randomized into either the DES group (n=34) or nasal spray group (n=29). The main outcome variable was the Sinonasal Outcome Test 22, Visual Analogue Scale, nasal endoscopy, rhinometric measurements were performed at the beginning of the study, after three months and six months of follow-up.

RESULTS

Both treatments significantly improved quality of the life with no significant difference being found between the two groups. The VAS score decreased in both groups: improvements were significant at three and six months in the nasal spray group, but in the DES group a significant difference was noted only at three months. There was a statistically significant increase in total nasal cavity volumes in the corticosteroid spray group, but not in the DES group.

CONCLUSION

We found that patients benefitted from DES and the corticosteroid nasal spray. We could not find any significant difference between the treatments, except the greater increase in the total nasal cavity volumes favouring the nasal spray group. Because of the very good results for the nasal spray and the much higher material and operating room costs associated with DES, we cannot recommend the use of DES over nasal spray as a monotherapeutic treatment for CRS.

Cerebral vasculitis and intracranial multiple aneurysms in a child with Lyme neuroborreliosis

Introduction. Lyme borreliosis is a multisystem tick-borne disease caused by Borrelia burgdorferi. Neurological manifestations are reported in up to 15 % of adult patients with Lyme disease, while the frequency among children is higher. The most common manifestations are painful radiculopathy, facial nerve paresis and lymphocytic meningitis. Epileptic seizures and cerebral vasculitis with stroke or aneurysms are very rare complications.

Case presentation. We describe a paediatric patient with sensorineural auditory dysfunction, headache, fatigue and epileptic seizures as sequelae of meningoencephalitis/Lyme neuroborreliosis (LNB) caused by B. burgdorferi. Brain magnetic resonance imaging revealed widespread enhancement of the leptomeninges, cranial nerves and artery walls compatible with vasculitis and disturbances in cerebrospinal fluid (CSF) circulation. The patient was treated with ceftriaxone for 2 weeks. Two years later, the patient had an ischemic stroke. Brain magnetic resonance angiography revealed multiple aneurysms, which were not present previously. The largest aneurysm was operated rapidly. The patient was treated with another course of intravenous ceftriaxone for 4 weeks and pulse therapy with corticosteroids. He recovered well.

Quality of life after endoscopic sinus surgery or balloon sinuplasty: a randomized clinical study

OBJECTIVES

To conduct the first prospective randomized controlled trial that evaluates and compares the clinical outcome and impact of ballonsinuplasty and endoscopic sinus surgery (ESS) on the quality of life of patients suffering from chronic or recurrent rhinosinusitis (CRS) of the maxillary sinus.

METHODS

Adult patients with symptomatic chronic or recurrent rhinosinusitis without severe findings in the sinuses, as documented in the sinus’ Computer Tomography scan and clinical exam, were randomized in 2 groups: ESS and Balloon Sinuplasty.The main variable in our study is the Sinonasal Outcome Test-22 (SNOT 22) and its parameters. These parameters were analysed preoperatively and at 3 months, postoperatively.

RESULTS

There was a subjective improvement in symptoms after surgery. We also noticed an objective improvement in the quality of life of our patients seen as a decrease in the total SNOT 22 score. Both balloon sinuplasty and ESS significantly improved almost all the parameters of SNOT22, with no significant difference being found between these two groups.

CONCLUSION

Both balloon sinuplasty and endoscopic sinus surgery improved the quality of life of patients with mild chronic or recurrent rhinosinusitis. However, the remarkably higher material cost of balloon sinuplasty compared to ESS sets limits on its broad use. There is an obvious need for further study to find out if, as an office procedure, balloon sinuplasty could deliver cost-savings high enough to cover the higher material cost of balloon sinuplasty. Our study was, however, too small to enable firm conclusions to be drawn.

Brain activity associated with selective attention, divided attention and distraction

Top-down controlled selective or divided attention to sounds and visual objects, as well as bottom-up triggered attention to auditory and visual distractors, has been widely investigated. However, no study has systematically compared brain activations related to all these types of attention. To this end, we used functional magnetic resonance imaging (fMRI) to measure brain activity in participants performing a tone pitch or a foveal grating orientation discrimination task, or both, distracted by novel sounds not sharing frequencies with the tones or by extrafoveal visual textures. To force focusing of attention to tones or gratings, or both, task difficulty was kept constantly high with an adaptive staircase method. A whole brain analysis of variance (ANOVA) revealed fronto-parietal attention networks for both selective auditory and visual attention. A subsequent conjunction analysis indicated partial overlaps of these networks. However, like some previous studies, the present results also suggest segregation of prefrontal areas involved in the control of auditory and visual attention. The ANOVA also suggested, and another conjunction analysis confirmed, an additional activity enhancement in the left middle frontal gyrus related to divided attention supporting the role of this area in top-down integration of dual task performance. Distractors expectedly disrupted task performance. However, contrary to our expectations, activations specifically related to the distractors were found only in the auditory and visual cortices. This suggests gating of the distractors from further processing perhaps due to strictly focused attention in the current demanding discrimination tasks.

Default Mode and Executive Networks Areas: Association with the Serial Order in Divergent Thinking

Scientific findings have suggested a two-fold structure of the cognitive process. By using the heuristic thinking mode, people automatically process information that tends to be invariant across days, whereas by using the explicit thinking mode people explicitly process information that tends to be variant compared to typical previously learned information patterns. Previous studies on creativity found an association between creativity and the brain regions in the prefrontal cortex, the anterior cingulate cortex, the default mode network and the executive network. However, which neural networks contribute to the explicit mode of thinking during idea generation remains an open question. We employed an fMRI paradigm to examine which brain regions were activated when participants (n = 16) mentally generated alternative uses for everyday objects. Most previous creativity studies required participants to verbalize responses during idea generation, whereas in this study participants produced mental alternatives without verbalizing. This study found activation in the left anterior insula when contrasting idea generation and object identification. This finding suggests that the insula (part of the brain’s salience network) plays a role in facilitating both the central executive and default mode networks to activate idea generation. We also investigated closely the effect of the serial order of idea being generated on brain responses: The amplitude of fMRI responses correlated positively with the serial order of idea being generated in the anterior cingulate cortex, which is part of the central executive network. Positive correlation with the serial order was also observed in the regions typically assigned to the default mode network: the precuneus/cuneus, inferior parietal lobule and posterior cingulate cortex. These networks support the explicit mode of thinking and help the individual to convert conventional mental models to new ones. The serial order correlated negatively with the BOLD responses in the posterior presupplementary motor area, left premotor cortex, right cerebellum and left inferior frontal gyrus. This finding might imply that idea generation without a verbal processing demand reflecting lack of need for new object identification in idea generation events. The results of the study are consistent with recent creativity studies, which emphasize that the creativity process involves working memory capacity to spontaneously shift between different kinds of thinking modes according to the context.

Hidden sources of joy, fear, and sadness: Explicit versus implicit neural processing of musical emotions

Music is often used to regulate emotions and mood. Typically, music conveys and induces emotions even when one does not attend to them. Studies on the neural substrates of musical emotions have, however, only examined brain activity when subjects have focused on the emotional content of the music. Here we address with functional magnetic resonance imaging (fMRI) the neural processing of happy, sad, and fearful music with a paradigm in which 56 subjects were instructed to either classify the emotions (explicit condition) or pay attention to the number of instruments playing (implicit condition) in 4-s music clips. In the implicit vs. explicit condition, stimuli activated bilaterally the inferior parietal lobule, premotor cortex, caudate, and ventromedial frontal areas. The cortical dorsomedial prefrontal and occipital areas activated during explicit processing were those previously shown to be associated with the cognitive processing of music and emotion recognition and regulation. Moreover, happiness in music was associated with activity in the bilateral auditory cortex, left parahippocampal gyrus, and supplementary motor area, whereas the negative emotions of sadness and fear corresponded with activation of the left anterior cingulate and middle frontal gyrus and down-regulation of the orbitofrontal cortex. Our study demonstrates for the first time in healthy subjects the neural underpinnings of the implicit processing of brief musical emotions, particularly in frontoparietal, dorsolateral prefrontal, and striatal areas of the brain.

Perimesencephalic subarachnoid hemorrhage with a positive angiographic finding: case report and review of the literature

The vast majority of perimesencephalic subarachnoid hemorrhage cases are reported as negative-finding etiologies. Recently, high-resolution images allowed us to overcome the previous difficulty of finding the source of bleeding, which underlies the concept of a "negative finding". We discovered a venous etiology, hidden behind the tip of the basilar artery; namely, the lateral pontine vein. Here, we review the literature on perimesencephalic subarachnoid hemorrhage and on venous aneurysm. We highlight this type of aneurysm as a candidate source of perimesencephalic hemorrhage. This case may change our way of dealing with what we have termed a negative finding of subarachnoid hemorrhage.

Decrease of nasal airway resistance and alleviations of symptoms after balloon sinuplasty in patients with isolated chronic rhinosinusitis: a prospective, randomised clinical study

OBJECTIVES

The aim of this study was to evaluate and compare the clinical outcome of balloon sinuplasty and uncinectomy for patients suffering from isolated chronic rhinosinusitis of the maxillary sinus.

DESIGN

A prospective, randomised, non-blinded, controlled trial was conducted.

SETTING

The study was carried out at the Department of Otolaryngology, Tampere University Hospital, Finland.

PARTICIPANTS

Adult patients with symptomatic isolated chronic or recurrent rhinosinusitis without severe findings in the sinuses, as documented in the sinus' Computer Tomography scan and clinical examination, were randomised into two groups: uncinectomy and balloon sinuplasty.

MAIN OUTCOME MEASURES

The variables in our study are the Sinonasal Outcome Test-22 (SNOT 22), acoustic rhinometry and rhinomanometry. These parameters were analysed preoperatively and postoperatively (after 3 and 6 months).

RESULTS

The preliminary results of our study have been previously published. Both balloon sinuplasty and uncinectomy significantly improved almost all the parameters of SNOT22 (P < 0.05), with no significant difference being found between these two groups (P > 0.05). Based on rhinomanometry results, airway resistance decreased after treatment. Regarding adverse effects, balloon sinuplasty was significantly associated with a lesser risk of synechia.

CONCLUSIONS

Both balloon sinuplasty and uncinectomy improved the quality of life and decreased upper airway resistance of patients with mild, isolated chronic or recurrent rhinosinusitis. The smaller risk of postoperative synechiae with balloon sinuplasty combined with its promising efficiency could partially compensate for its high material cost.

The effect of adenoidectomy on occlusal development and nasal cavity volume in children with recurrent middle ear infection

OBJECTIVES

The aim of the study was to examine the effect of adenoidectomy on occlusal/dentoalveolar development and nasal cavity volume in children who underwent tympanostomy tube insertion with or without adenoidectomy due to recurrent episodes of middle ear infection.

METHODS

This prospective controlled study consisted of two randomly allocated treatment groups of children, younger than 2 years, who had underwent more than 3-5 events of middle ear infection during the last 6 months or 4-6 events during the last year. At the mean age of 17 months tympanostomy tube placement without adenoidectomy (Group I, n=63) tympanostomy tube placement with adenoidectomy (Group II, n=74) was performed. At the age of 5 years 41 children of the original Group I (14 females, 27 males, mean age 5.2 yrs, SD 0.17) and 59 children of the original Group II (17 females, 42 males, mean age 5.2 yrs, SD 0.18) participated in the re-examination, which included clinical orthodontic examination defining morphological and functional craniofacial status and occlusal bite index to measure upper dental arch dimensions. Acoustic rhinometry and anterior rhinomanometry was made by otorhinolaryngologist at the same day.

RESULTS

No statistically significant differences were found between the groups in the frequencies of morphological or functional characteristics or upper dental arch measurements or in the minimal cross-sectional areas or inspiratory nasal airway resistance measurements.

CONCLUSION

Combining adenoidectomy with tympanostomy tube insertion in the treatment of recurrent middle ear infection at an early age (under the age of 2 years) does not seem to make any difference in occlusal development in primary dentition at the age of 5 years as compared to tympanostomy tube insertion only. Since adenoid size was not evaluated, the findings do not allow interpretation that hypertrophic adenoids should not be removed in children with continuous mouth breathing or sleep disordered breathing.

De novo giant A2 aneurysm following anterior communicating artery occlusion

BACKGROUND

De novo intracranial aneurysms are reported to occur with varying incidence after intracranial aneurysm treatment. They are purported to be observed, however, with increased incidence after Hunterian ligation; particularly in cases of carotid artery occlusion for giant or complex aneurysms deemed unclippable.

CASE DESCRIPTION

We report a case of right-sided de novo giant A2 aneurysm 6 years after an anterior communicating artery (ACoA) aneurysm clipping. We believe this de novo aneurysm developed in part due to patient-specific risk factors but also a significant change in cerebral hemodynamics. The ACoA became occluded after surgery that likely altered the cerebral hemodynamics and contributed to the de novo aneurysm. We believe this to be the first reported case of a giant de novo aneurysm in this location. Following parent vessel occlusion (mostly of the carotid artery), there are no reports of any de novo aneurysms in the pericallosal arteries let alone a giant one. The patient had a dominant right A1 and the sudden increase in A2 blood flow likely resulted in increased wall shear stress, particularly in the medial wall of the A2 where the aneurysm occurred 2 mm distal to the A1-2 junction.

CONCLUSION

ACoA preservation is a key element of aneurysm surgery in this location. Suspected occlusion of this vessel may warrant closer radiographic follow-up in patients with other risk factors for aneurysm development.

Dynamics of brain activity underlying working memory for music in a naturalistic condition

We aimed at determining the functional neuroanatomy of working memory (WM) recognition of musical motifs that occurs while listening to music by adopting a non-standard procedure. Western tonal music provides naturally occurring repetition and variation of motifs. These serve as WM triggers, thus allowing us to study the phenomenon of motif tracking within real music. Adopting a modern tango as stimulus, a behavioural test helped to identify the stimulus motifs and build a time-course regressor of WM neural responses. This regressor was then correlated with the participants' (musicians') functional magnetic resonance imaging (fMRI) signal obtained during a continuous listening condition. In order to fine-tune the identification of WM processes in the brain, the variance accounted for by the sensory processing of a set of the stimulus' acoustic features was pruned from participants' neurovascular responses to music. Motivic repetitions activated prefrontal and motor cortical areas, basal ganglia, medial temporal lobe (MTL) structures, and cerebellum. The findings suggest that WM processing of motifs while listening to music emerges from the integration of neural activity distributed over cognitive, motor and limbic subsystems. The recruitment of the hippocampus stands as a novel finding in auditory WM. Effective connectivity and agglomerative hierarchical clustering analyses indicate that the hippocampal connectivity is modulated by motif repetitions, showing strong connections with WM-relevant areas (dorsolateral prefrontal cortex - dlPFC, supplementary motor area - SMA, and cerebellum), which supports the role of the hippocampus in the encoding of the musical motifs in WM, and may evidence long-term memory (LTM) formation, enabled by the use of a realistic listening condition.

De Novo and Recurrent Aneurysms in Pediatric Patients With Cerebral Aneurysms

Background and Purpose—

Long-term angiographic follow-up studies on pediatric aneurysm patients are scarce.

Methods—

We gathered long-term clinical and angiographic follow-up data on all pediatric aneurysm patients (≤18 years at diagnosis) treated at the Department of Neurosurgery, Helsinki University Central Hospital, between 1937 and 2009.

Results—

Fifty-nine patients with cerebral aneurysms in childhood had long-term clinical and radiological follow-up (median, 34 years; range, 4–56 years). Twenty-four patients (41%) were diagnosed with altogether 25 de novo and 11 recurrent aneurysms, with 9 (25%) of the aneurysms being symptomatic. New subarachnoid hemorrhage occurred in 7 patients; 4 of these patients died. Eight patients (33%) had multiple new aneurysms. The annual rate of hemorrhage was 0.4%, and the annual rate for the development of de novo or recurrent aneurysm was 1.9%. There were no de novo aneurysms in 7 patients with previously unruptured aneurysms. However, 1 recurrent aneurysm was diagnosed. Current and previous smoking (risk ratio, 2.44; 95% confidence interval, 1.07–5.55) was the only statistically significant risk factor for de novo and recurrent aneurysm formation in patients with previous subarachnoid hemorrhage, whereas hypertension, sex, or age at onset had no statistically significant effect. Smoking was also a statistically significant risk factor for new subarachnoid hemorrhage.

Conclusions—

Patients with ruptured intracranial aneurysms in childhood have a high risk for new aneurysms and new subarachnoid hemorrhage, especially if they start to smoke as adults. Life-long angiographic follow-up is mandatory.

Detection of unruptured cerebral artery aneurysms by MRA at 3.0 tesla: comparison with multislice helical computed tomographic angiography

BACKGROUND

Computed tomographic angiography (CTA) has become the primary non-invasive method for detection of cerebral artery aneurysms in many neurovascular centers.

PURPOSE

To compare MR-angiography at a 3.0 tesla (3T) scanner to CTA in the detection of unruptured intracranial aneurysms.

MATERIAL AND METHODS

CTA and 3T MRA data from 60 patients were evaluated. CTA was obtained with a 4-16-row helical CT-scanner after administration of 120 cc intravenous contrast agent, MRA was performed by a 3T MR-scanner using time-of-flight pulse sequence.

RESULTS

Fifty-five cerebral artery aneurysms were detected by MRA and 47 aneurysms by CTA. Most of the aneurysms detected by MRA but not by CTA were small internal carotid artery (ICA) aneurysms. Bone structures and venous enhancement deteriorated CTA accuracy, especially in skull base. In one patient a fairly large anterior communicating artery aneurysm was not visible in MRA due to spin saturation, although it was clearly visualized in CTA. After contrast injection the aneurysm was also seen in MRA. Although the overall image quality of MRA and CTA were comparable, MRA was more susceptible to artifacts and thus re-formatted surface-shaded volume rendered 3-dimensional images of aneurysms from MRA were inferior compared to those from CTA.

CONCLUSION

MRA at 3T appears to be at least as sensitive as CTA in the detection of unruptured cerebral artery aneurysms, however image quality control is crucial and contrast agent enhances visualization of complex and large aneurysms.

Strength of prefrontal activation predicts intensity of suggestion-induced pain

Suggestion, a powerful factor in everyday social interaction, is most effective during hypnosis. Subjective evaluations and brain-imaging findings converge to propose that hypnotic suggestion strongly modulates sensory processing. To reveal the brain regions that mediate such a modulation, we analyzed data from a functional-magnetic-resonance-imaging study on hypnotic-suggestion-induced pain on 14 suggestible subjects. Activation strengths in the right dorsolateral prefrontal cortex (DLPFC) during initiation of suggestion for pain correlated positively with the subjective intensity of the subsequent suggestion-induced pain, as well as with the strengths of the maximum pain-related activation in the in the secondary somatosensory (SII) cortex. Furthermore, activation of the insula and the anterior cingulate cortex predicted the pain-related SII activation. The right DLPFC, as an area important for executive functions, likely contributes to functional modulation in the modality-specific target areas of given suggestions.

Brain correlates of subjective reality of physically and psychologically induced pain

Meaningful behavior requires successful differentiation of events surfacing from one's mind from those arising from the external world. Such judgements may be especially demanding during pain because of the strong contribution from psychological factors to this experience. It is unknown how the subjective reality of pain (SRP) is constructed in the human brain, and neuronal mechanisms of the subjective reality are poorly understood in general. To address these questions, 14 suggestion-prone healthy subjects rated reality of pain that was induced either by laser pulses to the skin or by hypnotic suggestion during functional MRI. Both pain states were associated with activation of the brain's pain circuitry. During laser stimulation, the sensory parts of this circuitry were activated more strongly, and their activation strengths correlated positively with the SRP. During suggestion-induced pain, the reality estimates were lower and correlated positively with activation strengths in the rostral and perigenual anterior cingulate cortex and in the pericingulate regions of the medial prefrontal cortex; a similar trend was evident during laser-induced pain. These findings support the view that information about sensory-discriminative characteristics of pain contributes to the SRP. Differences in such information between physically and psychologically induced pain, however, could be quantitative rather than qualitative and therefore insufficient for judging the reality of pain without knowledge about the source of this information. The medial prefrontal cortex is a likely area to contribute to such source monitoring.

Cortical activation during a spatiotemporal tactile comparison task

Tactile sensory memory is needed to infer shape or motion from the spatiotemporal pattern of sensory input during manual exploration. Here we applied triplets of pressure pulses to the fingertips of subjects who were asked to respond when successive triplets were the same (COMPARE task) or when a particular stimulus was included in a triplet (CONTROL task). Stimulus sequences (30 s) alternated with rest blocks (30 s) and functional magnetic resonance images (fMRIs) were acquired in a 1.5-T scanner. During the COMPARE task, we found enhanced activation in inferior parietal cortex, supplementary motor area (SMA), and right dorsolateral prefrontal cortex (DLPFC). Activation of DLPFC is likely to be related to the attempt to memorize the stimulus sequences and activations of SMA and inferior parietal cortex to the analysis of temporospatial tactile patterns and, more generally, to guidance of haptic exploration. In addition, task-specific activation was seen in anterior cingulate gyrus, possibly related to the high mental effort required by the comparison task. Our rhythmic tactile stimulus as such, without any task-specific enhancement, activated also left cerebellum and (mainly left) putamen, supporting the idea that these structures are related to perception of temporal order of tactile stimuli.

Magnetic resonance imaging of the liver: true fast imaging with steady state free precession sequence facilitates rapid and reliable distinction between hepatic hemangiomas and liver malignancies

OBJECTIVE

To assess the capability of the true fast imaging with steady state free precession (true FISP) sequence in the distinction between hemangiomas and malignant liver lesions.

METHODS

Sixty-eight patients with 45 hemangiomas and 51 liver malignancies were included in this study. A 1.5-T magnetic resonance system and a phased-array body coil were used. In addition to true FISP, breath-hold and fat-suppressed, T2-weighted, half-Fourier single-shot turbo spin echo (HASTE) and both unenhanced and gadolinium (Gd)-enhanced T1-weighted sequences were acquired. Two radiologists evaluated the magnetic resonance images independently in a blinded fashion. Interobserver variations with true FISP and HASTE were determined. Lesion contrast-to-noise ratios were calculated from true FISP images.

RESULTS

With true FISP, readers 1 and 2 made a correct distinction between hemangiomas and liver malignancies in 43 of 45 (96%) cases and 40 of 45 (89%) cases, respectively. The kappa value was 0.65. With HASTE, the success rates were 40 of 45 cases (89%) and 36 of 45 cases (80%), respectively, and the kappa value was 0.33. With a Gd-enhanced T1-weighted sequence, the correct classifications were 35 of 45 cases (78%) and 37 of 45 cases (82%), respectively. All hemangiomas appeared as bright and well-demarcated lesions on true FISP images. Malignant liver foci were heterogeneous with unsharp margins and nearly isointense relative to liver. The specificities of true FISP in lesion differentiation were 100% and 98% for readers 1 and 2, respectively. The mean contrast to noise ratio value of hemangiomas was 21.2 (standard deviation [SD] = 9.2), and that of malignant lesions was 4.9 (SD = 3.9). This difference was highly significant (P < 0.0001).

CONCLUSION

Noninvasive, rapid, and reliable differentiation between hemangiomas and malignant liver lesions is possible by using the true FISP sequence.