Faculty Bibliography

Amyotrophic Lateral Sclerosis (ALS) is a progressive neurodegenerative disease characterized by degeneration of both upper and lower motor neuron located in the spinal cord and brainstem. Diagnosis of ALS is predominantly clinical, nevertheless, electromyography and Magnetic Resonance Imaging (MRI) may provide support. Several advanced MRI techniques have been proven useful for ALS diagnosis and, indeed, the combination of different MRI techniques demonstrated an improvement in sensitivity and specificity as far as 90%. This review focus on the imaging techniques currently used in the diagnosis and management of ALS with brief considerations on future applications.

OBJECTIVE The Pipeline Embolization Device (PED) is now a well-established option for the treatment of giant or complex aneurysms, especially those arising from the anterior circulation. Considering the purpose of such treatment is to maintain patency of the parent vessel, postembolization occlusion of the parent artery can be regarded as an untoward outcome. Antiplatelet therapy in the posttreatment period is therefore required to minimize such events. Here, the authors present a series of patients with anterior circulation aneurysms treated with the PED who subsequently experienced parent vessel occlusion (PVO). METHODS The authors performed a retrospective review of all anterior circulation aneurysms consecutively treated at a single institution with the PED through 2014, identifying those with PVO on follow-up imaging. Aneurysm size and location, number of PEDs used, and follow-up digital subtraction angiography results were recorded. When available, pre- and postembolization platelet function testing results were also recorded. RESULTS Among 256 patients with anterior circulation aneurysms treated with the PED, the authors identified 8 who developed PVO after embolization. The mean aneurysm size in this cohort was 22.3 mm, and the number of PEDs used per case ranged from 2 to 10. Six patients were found to have asymptomatic PVO discovered incidentally on routine follow-up imaging between 6 months and 3 years postembolization, 3 of whom had documented "delayed" PVO with prior postembolization angiograms confirming aneurysm occlusion and a patent parent vessel at an earlier time. Two additional patients experienced symptomatic PVO, one of which was associated with early discontinuation of antiplatelet therapy. CONCLUSIONS In this large series of anterior circulation aneurysms, the authors report a low incidence of symptomatic PVO, complicating premature discontinuation of postembolization antiplatelet or anticoagulation therapy. Beyond the subacute period, asymptomatic PVO was more common, particularly among complex fusiform or very large-necked aneurysms, highlighting an important phenomenon with the use of PED for the treatment of anterior circulation aneurysms, and suggesting that extended periods of antiplatelet coverage may be required in select complex aneurysms.

Introduction: Reversible cerebral vasoconstriction syndrome (RCVS) is a transient disorder characterized by reversible constriction of the cerebral arteries.It is complicated by ischemic and hemorrhagic strokes with incidence as high as 54%. Methods: We present a case of 34 year old female with history of scleroderma, polymyositis overlap syndrome complicated by interstitial lung disease, systemic and pulmonary hypertension, who presented with chief complaints of worsening dyspnea, blurred vision and headache. Her BP was found to be 220 systolic with non focal neurological exam. MRI demonstrated multiple cortical infarcts in bilateral cerebral hemispheres. MRA revealed multifocal areas of stenosis in multiple intracranial arteries. Results: She was started on oral verapamil for concerns of RCVS. On day 9, she became globally aphasic and plegic in right upper and lower extremities. Repeat MRI showed extension of infarct in multiple vascular territories. Cerebral angiogram showed multiple areas of severe arterial stenoses. Verapamil was injected into bilateral internal carotid arteries and left vertebral artery with a robust response in vessel caliber. On repeat evaluation after 24 hours benefit had subsided and in light of clinical decline decision was made to administer continuous infusion of verapamil in bilateral internal carotid arteries. The infusion was discontinued after 2 days with normal TCD results. MRI and MRA of brain on day13 of admission showed no new infarcts while demonstrating progressive clinical improvement. Conclusions: Continuous intra-arterial verapamil infusion may have a role in treatment of refractory severe RCVS after less invasive options are exhausted

Aneurysms of the anterior cerebral artery (ACA) located distal to the anterior communicating artery complex (ACOM) remain challenging to treat with surgical clip reconstruction as well as with endovascular coil-embolization strategies. We have treated five complex geometry distal ACA aneurysms with endoluminal reconstruction using the Pipeline Embolization Device (PED). Two aneurysms were of the dysplastic fusiform type. Three aneurysms were of complex saccular configuration. Three aneurysms were treated electively at the outset with PED. One patient had previously undergone aborted clip reconstruction, and one was treated for recurrent aneurysm growth after coil embolization. The mean diameter of the ACA in this cohort was 1.96mm proximal to the aneurysm and 1.79mm distal to the aneurysmal segment. A single PED of 2.5mm inner diameter was the sole treatment in four cases. Two PEDs, telescopically overlapped across the aneurysm, were used in the remaining case. All devices were deployed successfully. No parent artery occlusion or stenosis was observed. In all cases an associated branch vessel arising from the vicinity of the aneurysm or incorporated into its neck was covered by the endoluminal construct. At follow-up angiography, robust antegrade flow was maintained in the jailed branch. One patient experienced asymptomatic, delayed occlusion of the jailed branch. Complete aneurysm occlusion was seen in all patients. We confirm that PED can be deployed in parent vessels smaller than 2mm diameter, and that endoluminal reconstruction with the PED may be a safe and effective treatment alternative for selected distal ACA aneurysms.

OBJECTIVE: To assess the relationship between the degree of leukoaraiosis (LA), carotid intima-media thickness (IMT) and intima-media thickness variability (IMTV). MATERIALS AND METHODS: Sixty-one consecutive patients, who underwent a brain MRI examination and a carotid artery ultrasound, were included in this retrospective study, which conformed with the Declaration of Helsinki. Written informed consent was waived. In each patient, right/left carotid arteries and brain hemispheres were assessed using automated software for IMT, IMTV and LA volume. RESULTS: The mean hemispheric LA volume was 2,224 mm3 (SD 2,702 mm3) and there was no statistically significant difference in LA volume between the right and left hemispheres (p value = 0.628). The mean IMT and IMTV values were 0.866 mm (SD 0.170) and 0.143 mm (SD 0.100), respectively, without significant differences between the right and left sides (p values 0.733 and 0.098, respectively). The correlation coefficient between IMTV and LA volume was 0.41 (p value = 0.0001), and 0.246 (p value = 0.074) between IMT and LA volume. CONCLUSIONS: IMTV significantly correlates with LA volume. Further studies are warranted to verify whether this parameter can be used clinically as a marker of cerebrovascular risk. KEY POINTS: * Intima-media thickness variability (IMTV) significantly correlates with leukoaraiosis volume. * IMTV could be used as a marker for cerebrovascular risk. * IMTV seems to be a better predictor of weighted mean difference than IMT.

Introduction: Femoral artery closure devices allow for earlier mobilization and improved comfort for patients after vascular access. The Mynx device (Cardinal Health, Inc.) is an extravascular closure device that deploys a polyethylene glycol plug, and is maximally labeled for 6/7 French sheath closure. Here we report our experience using the device to close 8F sheaths in patients post endovascular treatment of ischemic stroke. Methods: We performed a retrospective analysis of all stroke cases where the 6/7F Mynx device was used with 8F sheaths. Operating room flowsheets, physician and nursing notes up to 2 weeks post angiography were reviewed and data on deployment and complications were analyzed. Results: 87 consecutive stroke embolectomy cases at an academic center were reviewed from 2014 through 2016. 8F short sheaths were utilized in 23 patients, and all 23 were closed with 6/7F Mynx device. Average compression time following Mynx deployment was 18 minutes. The mean patient age was 70.7 years. The average BMI was 27. Ten patients (38%) had received IV tPA; 6 patients were on anticoagulation(27%); and 2 patients had coagulapathies. Two (8%) patients had documented groin bruising post Mynx; both resolved spontaneously. No patients had loss of ipsilateral distal pulses post mynx; in 1 patient, distal pulses changed from palpable to dopplerable. No patient had significant pain or swelling at the site. There were no groin site infections. Conclusions: Off-Label use of 6/7F Mynx for 8F closure is safe and efficacious, and was not associated with an increased complication rate in our small cohort

BACKGROUND: There is substantial overlap between MRI of acute spinal cord lesions from neuromyelitis optica (NMO) and spinal cord infarct (SCI) in clinical practice. However, early differentiation is important since management approaches to minimize morbidity from NMO or SCI differ significantly. OBJECTIVE: To identify MRI features at initial presentation that may help to differentiate NMO acute myelitis from SCI. METHODS: 2 board-certified neuroradiologists, blinded to final diagnosis, retrospectively characterized MRI features at symptom onset for subjects with serologically-proven NMO (N=13) or SCI (N=11) from a single institution. Univariate and multivariate analyses were used to identify factors associated with NMO or SCI. RESULTS: SCI was more common in men and Caucasians, while NMO was more common in non-Caucasian women (P<0.05). MRI features associated with NMO acute myelitis (P<0.05) included location within 7-cm of cervicomedullary junction; lesion extending to pial surface; 'bright spotty lesions' on axial T2 MRI; and gadolinium enhancement. Patient's age, lesion length and cross-sectional area, cord expansion, and the "owl's eyes" sign did not differ between the two groups (P>0.05). CONCLUSION: Along with patient demographic characteristics, lesion features on MRI, including lesion location, extension to pial border and presence of 'bright spotty lesion' can help differentiate acute myelitis of NMO from SCI in the acute setting.

OBJECTIVES: To study the carotid artery plaque composition and its volume changes in a group of patients at baseline and 2 years after head and neck radiation therapy treatment (HNXRT). METHODS: In this retrospective study, 62 patients (41 males; mean age 63 years; range 52-81) who underwent HNXRT and 40 patients (24 males; mean age 65) who underwent surgical resection of neoplasm and did not undergo HNXRT were assessed, with 2-year follow-up. The carotid artery plaque volumes, as well as the volume of the sub-components (fatty-mixed-calcified), were semiautomatically quantified. Mann-Whitney and Wilcoxon tests were used to test the hypothesis. RESULTS: In the HNXRT group, there was a statistically significant increase in the total volume of the carotid artery plaques (from 533 to 746 mm3; p = 0.001), in the fatty plaques (103 vs. 202 mm3; p = 0.001) and mixed plaque component volume (328 vs. 419 mm3; p = 0.034). A statistically significant variation (from 21.8 % to 27.6 %) in the percentage of the fatty tissue was found. CONCLUSIONS: RESULTS: of this preliminary study suggest that HNXRT promotes increased carotid artery plaque volume, particularly the fatty plaque component. KEY POINTS: * HNXRT increases carotid plaque volume. * Plaque volume increase is mainly due to increase.in fatty plaque component * Patients who undergo HNXRT have a progression of carotid artery disease.