Faculty Bibliography

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.

Foreign material emboli following cerebral, cardiac, and peripheral catheterizations have been reported since the mid-1990s. Catheter coatings have been frequently implicated. The most recent surge of interest in this phenomenon within the neurointerventional community is associated with procedures using flow-diversion devices for the treatment of cerebral aneurysms. Following coil-supported Pipeline embolization in 4 cases and stent-supported coiling in 1, 5 patients developed multiple subcentimeter enhancing lesions, usually with surrounding edema and variable magnetic susceptibility in the vascular territories of the treated aneurysms. Conventional angiography findings were unrevealing. Laboratory work-up showed mild CSF protein elevation with no leukocytosis. Brain biopsy in 2 cases revealed granulomatous angiitis encasing foreign material, identical in stain appearance to a polyvinylpyrrolidone catheter coating. Corticosteroid administration typically produced clinical improvement. A heterogeneous radiographic and clinical course was noted, with rise and fall in the number of enhancing lesions in 2 patients and persistence in others. The etiology may be related to widespread adoption of increasingly sophisticated catheterization techniques.

Fungal sinusitis is characterized into invasive and noninvasive forms. The invasive variety is further classified into acute, chronic and granulomatous forms; and the noninvasive variety into fungus ball and allergic fungal sinusitis. Each of these different forms has a unique radiologic appearance. The clinicopathologic and corresponding radiologic spectrum and differences in treatment strategies of fungal sinusitis make it an important diagnosis for clinicians and radiologists to always consider. This is particularly true of invasive fungal sinusitis, which typically affects immuno compromised patients and is associated with significant morbidity and mortality. Early diagnosis allows initiation of appropriate treatment strategies resulting in favorable outcome.

OBJECTIVES: Contrast-enhanced fat-suppressed T1-weighted-2D-TSE and MPRAGE sequence with water excitation are routinely obtained to evaluate orbit pathology. However, these sequences can be marred by artifacts. The Radial-VIBE sequence is a motion-robust fat-suppressed T1W sequence which has demonstrated value in pediatric and body imaging. The purpose of our study is to evaluate its role in assessing the orbit, and to compare it with routinely acquired sequences. METHODS: A HIPAA-compliant and IRB-approved retrospective study was performed in 46 patients (age range: 1-81 years) who underwent orbit studies on a 1.5-T MRI using contrast-enhanced Radial-VIBE, MPRAGE and 2D-TSE sequences. Two radiologists blinded to the sequence analyzed evaluated multiple parameters of image quality including motion artifact, degree of fat-suppression, clarity of choroidal enhancement, intraorbital vessels, extraocular muscles, optic nerves, brain parenchyma and evaluation of pathology. Each parameter was assessed on a 5-point scale, with a higher score indicating the more optimal exam. Mix-model analysis of variance and interobserver variability were assessed. RESULTS: Radial-VIBE demonstrated superior quality (p<0.001) for all orbit parameters when compared to MPRAGE and 2D-TSE. Interobserver agreement demonstrated average fair-to -good agreement for: degree of motion artifact (0.745), fat suppression (0.678), clarity of choroidal enhancement (0.688), vessels (0.655), extraocular muscles (0.675), optic nerves (0.518), brain parenchyma (0.710), and evaluation of pathology (0.590). CONCLUSION: Radial-VIBE sequence demonstrates superior image quality when evaluating the orbits as compared to conventional MPRAGE and 2D-TSE sequences. Advances in knowledge: Radial-VIBE employs unique non-Cartesian k-space sampling in a radial or spoke-wheel fashion which provides superior image quality improving diagnostic capability in evaluation of the orbits.

OBJECTIVE: Several criteria for time-consuming volumetric measurements of progressive supranuclear palsy Richardson syndrome subtype (PSP-RS) have been proposed. These often require image reconstruction in different planes for proper assessment. The purpose of this study was to evaluate the cerebral peduncle angle as a simple and reproducible measure of midbrain atrophy in patients with PSP-RS. MATERIALS AND METHODS: The records of 15 patients with PSP-RS were retrospectively identified. The records of 31 age-matched healthy control subjects, 15 patients with multiple-system atrophy, and 22 patients with Parkinson disease were included for comparison. Two neuroradiologists individually assessed these studies for midbrain atrophy by evaluating the cerebral peduncle angle, that is, the angle between the two cerebral peduncles. RESULTS: The cerebral peduncle angle measurements were 62.1 degrees (SD, 6.8 degrees ) in PSP-RS patients, 51.2 degrees (SD, 10.1 degrees ) in healthy control subjects, 55.7 degrees (SD, 11.6 degrees ) in patients with multiple-system atrophy, and 53.7 degrees (SD, 8.5 degrees ) in patients with Parkinson disease. A statistically significant difference was found in the cerebral peduncle angle measurements (observer 1, p = 0.015; observer 2, p = 0.004) between the PSP-RS patients and the other subgroups. Bland-Altman analysis showed a bias of 0.6 degrees (95% limits of agreement, 6.9 degrees , -5.8 degrees ), and intraobserver variability analysis showed a bias of 0.5 degrees (4.1 degrees , -3 degrees ). CONCLUSION: The cerebral peduncle angle is a simple, easy-to-calculate, and reproducible measure of midbrain atrophy. It is a useful criterion for differentiating patients with PSP-RS from healthy persons and from patients with multiple-system atrophy or Parkinson disease.

BACKGROUND: The use of minimally porous endoluminal devices (MPEDs) such as the Pipeline Embolization Device (PED) has been described for the treatment of brain aneurysms. The benefit of using MPEDs to assist embolization of a direct high-flow carotid cavernous fistula resulting from a ruptured cavernous carotid artery aneurysm is not well documented. METHODS: We describe our experience with deploying a tailored multidevice PED construct across the cavernous internal carotid artery (ICA) wall defect in combination with transarterial coil embolization using the "jailed microcatheter" technique. RESULTS: A 59-year-old woman presented with acute left-sided ophthalmoplegia. Diagnostic cerebral angiography demonstrated a ruptured giant cavernous carotid aneurysm with fistulous outflow via the ipsilateral left superior ophthalmic vein and into the pterygoid venous plexi bilaterally. Via the Marksman microcatheter, a total of three PEDs measuring 4.5 mm x 18 mm, 4.5 mm x 20 mm, and 4.75 mm x 16 mm were telescoped within the ICA across the aneurysm neck. Coiling of the aneurysm fundus and cavernous sinus via the "jailed" Rapidtransit microcatheter was subsequently achieved. A 2-year follow-up digital subtraction angiography (DSA) demonstrated stable obliteration of the aneurysm and the fistula, coincident with complete resolution of the patient's symptoms. CONCLUSIONS: Based on our long-term clinical and angiographic results, we advocate that the presented method be a valid treatment option for selected cases.

BACKGROUND AND PURPOSE: Treatment options for nonsaccular posterior cerebral artery aneurysms include a range of surgical and endovascular reconstructive and deconstructive methods. However, no truly satisfactory treatment option is available to date for lesions arising from the P1 and P2 segments. The purpose of the present case series is to investigate both the efficacy and safety of the Pipeline Embolization Device in treating these challenging aneurysms. MATERIALS AND METHODS: We present a series of 6 consecutive patients who underwent endoluminal reconstruction with the Pipeline Embolization Device for nonsaccular P1 or P2 segment aneurysms between January 2009 and June 2013. RESULTS: Aneurysm location included the P1 segment in 2 patients and the P2 segment in 4 patients. Mean aneurysm diameter was 23 mm (range, 5-44 mm). Mean length of the arterial segment involved was 10 mm (range, 6-19 mm). Clinical presentation included mass effect in 4 patients and perforator stroke and subacute aneurysmal subarachnoid hemorrhage in 1 patient each. Endovascular reconstruction was performed by using 1 Pipeline Embolization Device in 5 patients and 2 overlapping Pipeline Embolization Devices in the remaining patient. Angiographic aneurysm occlusion was immediate in 1 patient, within 6 months in 4 patients, and within 1 year in the remaining patient. Index symptoms resolved in 4 patients and stabilized in the remaining 2. No new permanent neurologic sequelae and no aneurysm recurrence were recorded during the mean follow-up period of 613 days (range, 540-725 days). CONCLUSIONS: Endovascular reconstruction with the Pipeline Embolization Device for nonsaccular aneurysms arising from the P1 and P2 segments compares favorably with historical treatment options in terms of occlusion rate, margin of safety, and neurologic outcome.

ABSTRACT Purpose: Previous publications demonstrated that multi-detector-row computed tomography Angiograpy (MDCTA) can evaluate the carotid artery wall thickness (CAWT). The purpose of this work was to compare the asymmetry of CAWT between carotids in symptomatic and asymptomatic patients. Material and Methods: Sixty consecutive symptomatic (males 44; median age 64) and sixty asymptomatic sex- and age-matched patients, were analyzed by using a 40-detector-row CT system. CAWT was calculated for both carotids in each patient and the ratio between the thicker CAWT and the contra-lateral was calculated to obtain the ACAWT index. Bland-Altman, logistic regression and Receiver Operating Characteristic (ROC) curve analysis were calculated. Results. The Bland-Altman plot demonstrates a very good agreement between measurements with a mean difference value of 3.4% and 95% CI from -8% to 14.8% The ACAWT was significantly different between symptomatic and asymptomatic patients (with a P value of 0.0001). The ROC area under the curve was 0.742 (P = 0.001). Logistic regression model indicated that ACAWT, CAWT, stenosis degree and fatty plaques were independent variables associated with cerebrovascular symptoms (P value respectively 0.0108, 0.0231, 0.0002 and 0.013). Conclusion: Results of our study indicated that the index of asymmetry in the CAWT might be used as a further parameter to stratify the risk of symptoms related to carotid artery.