Brain Computed Tomography Angiography Research Articles

Thromboembolic hazard in hereditary hemorrhagic telangiectasia.

A 23-year-old woman with hereditary hemorrhagic telangiectasia was found in her bedroom presenting right-side hemiparesis and aphasia. Brain computed tomography angiography (CTA) showed a complete occlusion of left-medium cerebral artery (Panel A) that required mechanical thrombectomy. CTA revealed the typical arteriovenous malformations in the lungs (Panel B) but not in the brain or liver. A bubble contrasted echocardiography ruled out intracardiacal shunts. Furthermore, repletion defects were found in subsegmentarial pulmonary arteries (Panel C, amplified in the inset). No thrombus was detected in lower extremity veins with Doppler-ecography, and thrombophilia screening was negative. Urgent thrombectomy, rehabilitation, and anticoagulation reduced neurological sequels to hand dizziness and mild concentration complaints. Arteriovenous malformations were embolized. Hereditary hemorrhagic telangiectasia, also known as Rendu–Osler–Weber disease, is an autosomical-dominant condition characterized by angiodysplastic lesions and arteriovenous malformations. Traditionally, the hemorrhagic manifestations have received all the attention. Nonetheless, arteriovenous malformations can bypass pulmonary circulation and permit paradoxical embolisms (see Figure 1). The authors declares they have no conflicts of interest. Patient gave informed consent for the publication of this case report.

Predictors and Outcomes of Salvaging the Corticospinal Tract After Thrombectomy in Basilar Artery Occlusion Stroke.

BackgroundRegional eloquence of brainstem structures may contribute to neurological status in basilar artery occlusion (BAO) stroke. The corticospinal tract (CST) which is vulnerable to BAO is important for motor activity. This study investigated the impact of CST salvage on outcomes and its associated factors in patients with BAO treated with thrombectomy.MethodsWe retrospectively investigated 88 patients with BAO admitted ≤24 h after onset and presented with motor deficits and who underwent thrombectomy. Patients with a pre-stroke modified Rankin Scale (mRS) score of 4–5 who did not undergo baseline brain computed tomography angiography were excluded. CST salvage was evaluated using follow-up imaging (magnetic resonance imaging [MRI] or computed tomography when MRI was not available) after thrombectomy. A good outcome was defined as a 3-month mRS score of ≤2 or 3 if a patient's pre-stroke mRS score was 3. The associations between CST salvage and outcomes and clinical parameters were analyzed using logistic regression analyses.ResultsThirty-nine (44.3%) patients had CST salvage and the same number of patients had good outcomes. CST salvage was independently associated with a good outcome [adjusted odds ratio (aOR): 18.52, 95% confidence interval (CI): 4.31–79.67, p < 0.001]. After adjusting for confounders, atrial fibrillation (aOR: 3.92, 95% CI: 1.18–13.00, p = 0.026), location of occlusion (mid-BAO; aOR: 0.21, 95% CI: 0.06–0.72, p = 0.013), length of occlusion (involved segment of BAO <2; aOR: 4.77, 95% CI: 1.30–17.59, p = 0.019), and onset-to-puncture-time ≤180 min (aOR: 4.84, 95% CI: 1.13–20.75, p = 0.034) were significantly associated with CST salvage.ConclusionCST salvage was associated with good functional outcomes in patients with BAO treated with thrombectomy. The presence of atrial fibrillation, location and length of BAO may predict CST salvage after thrombectomy, and rapid treatment with thrombectomy may protect this eloquent tract in these patients.

Trochlear Nerve Palsy Caused by a Superior Cerebellar Artery Aneurysm

Purpose: We report a case of trochlear nerve palsy caused by a superior cerebellar artery (SCA) aneurysm.Case summary: A 34-year-old woman visited our clinic complaining of distance diplopia and a temporal headache 7 days in duration. She had no previous relevant medical or trauma history. Her visual acuity; intraocular pressure; and pupil, anterior segment, and fundus evaluations were unremarkable. Extraocular muscle examination (EOM) revealed six prism diopters (PD) of right hypertropia in the primary gaze; this worsened when the head was tilted to the right. Brain magnetic resonance imaging revealed a round solid nodule between the temporal lobe and pons; we thus suspected a petrous ridge meningioma. She was referred to our neurosurgery department for meningioma treatment. However, 1 hour later, she visited our emergency room with severe headache and nausea. Brain computed tomography angiography revealed a subarachnoid hemorrhage and a ruptured SCA aneurysm. Emergency coil embolization was successfully performed. Four weeks after surgery, the right hypertropia was slightly decreased. Four months later, the diplopia had disappeared and EOM revealed orthotropia.Conclusions: SCA aneurysms are rare and can be misdiagnosed even after radiological examination. Our case emphasizes that an SCA aneurysm should be considered during the differential diagnosis of patients with diplopia and headache.

Abstract 130: Real World Experience With Viz.AI Automated Large Vessel Occlusion Detection

Introduction: Viz.AI LVO is an artificial-intelligence platform which analyzes brain computed tomography angiography (CTA) images in patients with suspected acute ischemic stroke (AIS) and sends an automated alert for suspected large vessel occlusions (LVO). The FDA cleared Viz.AI for LVO detection and Viz.AI reports high sensitivity and specificity (96.3% and 93.8%). We report our experience with Viz.AI LVO detection at our academic comprehensive stroke center (CSC). Methods: We performed a retrospective review of suspected stroke patients who had CTA ordered as a stroke code from September 2020 to December 2020. Data was collected on sex, age, Viz.AI LVO alert, and official Radiology review of CTA. Radiology read of CTA was considered gold standard. True negative was defined as Viz negative, Radiology negative. False positive was defined as Viz positive, Radiology negative. False negative was defined as Viz negative, Radiology positive. True positive was defined as Viz positive, Radiology positive. LVO was defined as occlusion of the intracranial carotid (ICAT) or MCA (M1 or M2 segment). Data was collected on performance of Viz.AI LVO alert, including sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Results: Among 282 consecutive suspected AIS patients with CTA analyzed by Viz.AI, the mean age was 61.9 years (range 19 to 96) and 152 (53.9%) were female. Viz LVO autodetection alerted for 60 patients (21.3%). Radiologist review reported 32 patients with LVO as follows: 12 (37.5%) M2, 16 (50%) M1, and 4 (12.5%) ICAT. The following were adjudicated: 219 true negatives, 31 false positive, 3 false negative, and 29 true positives. Sensitive was 90.6% and Specificity was 87.6%. PPV was 0.483 and NPV was 0.986. The 3 false negative patients all had M2 occlusions. The median time to alert was 10 min (range 7 to 656). Conclusions: In our series of AIS patients evaluated with CTA at an academic CSC, Viz.AI automated LVO detection performed well with a sensitivity of 90.6% and specificity of 87.5%, with a median time to alert of 10 minutes.

Improvement of depiction of the intracranial arteries on brain CT angiography using deep learning reconstruction.

To evaluate the ability of a commercialized deep learning reconstruction technique to depict intracranial vessels on the brain computed tomography angiography and compare the image quality with filtered-back-projection and hybrid iterative reconstruction in terms of objective and subjective measures. Forty-three patients underwent brain computed tomography angiography, and images were reconstructed using three algorithms: filtered-back-projection, hybrid iterative reconstruction, and deep learning reconstruction. The image noise, computed tomography attenuation value, signal-to-noise ratio, and contrast-to-noise ratio were measured in the bilateral cavernous segment of the internal carotid artery, vertebral artery, basilar apex, horizontal segment of the middle cerebral artery and used for the objective assessment of the image quality among the three different reconstructions. The subjective image quality score was significantly higher for the deep learning reconstruction than hybrid iterative reconstruction and filtered-back-projection images. The deep learning reconstruction markedly improved the reduction of blooming artifacts in surgical clips and coiled aneurysms. The deep learning reconstruction method generally improves the image quality of brain computed tomography angiography in terms of objective measurement and subjective grading compared with filtered-back-projection and hybrid iterative reconstruction. Especially, deep learning reconstruction is deemed advantageous for better depiction of small vessels compared to filtered-back projection and hybrid iterative reconstruction.

Bilateral Sudden Hearing Loss Caused by Basilar Artery Dissection: A Case Report

Bilateral sudden sensorineural hearing loss (SNHL) is rare, but a possible symptom of vertebrobasilar ischemia. A 69-year-old female patient with hypertension and atrial fibrillation presented with bilateral sudden hearing loss and vertigo without other neurological symptoms. On examination, she had left-beating horizontal nystagmus with positive head impulse on the left side. Pure tone audiometry revealed severe SNHL on both sides. Brain computed tomography angiography showed a dissection in the proximal portion of the basilar artery (BA) with occlusion of the mid-BA and bilateral anterior inferior cerebellar arteries (AICA), which confirmed on transfemoral cerebral angiography (TFCA). Left common carotid angiography demonstrated retrograde blood flow into the BA and right AICA via the left posterior communicating artery. During TFCA, her right hearing loss dramatically improved. Nine days later, follow-up TFCA showed an improvement of antegrade flow of the BA and AICA. We suggest that vertebrobasilar ischemia can be suspected in patients with bilateral sudden SNHL who present with risk factors for stroke.

Anatomic imaging study of luminal diameter of the circle of Willis in patients with ischemic stroke

Objectives: Stroke or cerebrovascular accident is associated with defects in the circle of Willis; the vascular network that supplies the brain. There is currently lack of literature on the involvement of the circle of Willis in patients with stroke or its association with impending stroke. The objective of the study was to evaluate luminal diameter of arteries that constitute the circle of Willis in patients with stroke using computed tomography angiography (CTA) and magnetic resonance imaging (MRI) scans. Material and Methods: Angiograms of 340 male and female patients aged 15–&gt;75 (40.18 ± 1.1 and 43.68 ± 1.18) years with suspected stroke, referred for either brain CTA or MRI in selected hospitals/diagnostic centers in Nigeria were evaluated using RadiAnt and the MicroDicom viewer software applications. A retrospective descriptive research design was adopted with approval from the federal health research ethics committee. Direct measurement of luminal diameter of major arteries of the circle of Willis was done using SPSS version 25 at P &lt; 0.05. Results: From the 340 images assessed, 256 (75.29%) patients had ischemic stroke with luminal diameter of arteries of the circle of Willis ranged from 1 mm to &gt;3 mm while 84 (24.71%) patients were without stroke with luminal diameter ranged from 1 mm to 2.11 mm (P &lt; 0.05). Conclusion: Patients with stroke have larger luminal diameter of arteries that form the circle of Willis when compared to patients without stroke. The study has established for the 1st time, luminal diameter of circle of Willis that may be an index in the sampled Nigerian population.

Analysis of posterior circulation diameters depending on age, sex and side by computed tomography angiography.

Posterior circulation of brain is important because of vital organs' blood supply provided by them. In this study, we evaluate the relationship of posterior circulation measurements with age, gender and side by using computed tomography angiography (CTA) images. A total 199 brain CTA examinations were retrospectively analysed for all posterior circulation arteries (vertebral artery, basilar artery, posterior cerebral artery [PCA], superior cerebellar artery [SCA], anterior inferior cerebellar artery, and posterior inferior cerebellar artery [PICA]) to compare the difference based on age, gender and side. There is no correlation between age and the mean diameters of all vessels (p > 0.05). The mean diameter of left vertebral artery was higher than right vertebral artery in all genders (p = 0.004 for males and p < 0.001 for females). The mean diameter of left SCA and PICA were higher than right SCA and PICA in females (p = 0.032 and p = 0.027, respectively). The mean diameters of basilar, left PCA, left SCA, left vertebral, right PCA, right SCA, right PICA and right vertebral artery were higher in males and that differences were statistically significant (p < 0.001, p = 0.002, p = 0.006, p = 0.004, p = 0.001, p = 0.003, p = 0.002, and p = 0.006, respectively). The posterior circulation vessel diameter is not affected by aging. The mean diameters of basilar artery, both PCAs, both SCAs, right PICA, both vertebral arteries were higher in males. The mean diameter of left vertebral artery is higher than that of right vertebral artery in all genders.

Cerebral aneurysm image segmentation based on multi-modal convolutional neural network

Background and Objective: Accurate segmentation of cerebral aneurysms in computed tomography angiography (CTA) can provide an essential reference for diagnosis and treatment. This study aimed to evaluate a more helpful image segmentation method for cerebral aneurysms.Methods: Firstly, the original CTA images were filtered by Gaussian and Laplace, and both the processed image and original image constitute multi-modal images as input. Then, through multiple parallel convolution neural networks to multi-modal image segmentation. Eventually, all of the segmentation results were fused by linear regression to extract cerebral aneurysm and adjacent vessels.Results: The cerebral aneurysm and adjacent vessels were extracted correctly. When the threshold value is about 0.95, the overall performance of the segmentation effect is the best. The dice, accuracy, and recall rate were different in various combinations of the three extraction methods.Conclusion: Multi-modal convolutional neural network can improve the segmentation accuracy by multi-modal processing of the original brain CTA image.

P-OT006. Vertebro-basilar dolichoectasia: A case report of recurrent stroke with treatment dilemma

Introduction. Vertebro-basilar dolichoectasia (VBD) has been associated with stroke and all- cause mortality. Subsequent stroke risk is also higher in patients with VBD. The incidence of the disease is low, and most patients are asymptomatic. Howbeit this disease carries significant mortality and disability rate in symptomatic patients. We report a case of recurrent ischemic stroke in a patient with VBD in Hospital Sultanah Maliha. Results. A 79-year-old man with underlying hypertension suffered from two strokes within six months duration. His first stroke was lacunar infarction with left hemiparesis and he was commenced on antiplatelet. He had modified Rankin Scale (mRS) score of 3 upon discharge. Six months later, he was readmitted for generalised tonic clonic seizure with worsening left hemiparesis. His computed tomography (CT) brain revealed hypodensity in right basal ganglia and right occipital, in line with recurrent ischemic stroke. His CT angiography of brain showed tortuous, elongated and dilated vertebral and basilar arteries with wall calcification which are consistent with VBD. Family members opted for conservative management and he was discharged with mRS score of 5. Discussion. VBD is recognized as an important independent risk factor for recurrent stroke. There are currently no effective measures to manage patients with VBD who present with ischemic symptoms. Dolichoectasia is an arteriopathy rather than an atherosclerosis; thus, the role of antiplatelet or anticoagulant therapy is unclear, but it may increase the risk of VBD rupture. Conclusion. VBD is considered a challenging lesion without an ideal treatment modality. Despite the unfavourable course of VBD, there is still uncertainty in the optimal treatment of VBD.

Transcavernous Approach for Microsurgical Clipping of Ruptured Right Superior Cerebellar Artery Aneurysm with Cadaveric Stepwise Video Illustration.

Superior cerebellar artery (SCA) aneurysms are rare. The management options are not well defined. There is increasing role of endovascular treatment for all aneurysms, especially for aneurysms of the posterior circulation. However in some situations (wide base, dysmorphic features) coiling is not feasible. The surgical management of these aneurysms has its own distinct complexity and requires careful planning. The classic pterional or subtemporal approaches had its own limitation in proper visualization of the neurovascular anatomy.In this video, we describe the technical nuances of transcavernous sinus approach for microsurgical clipping SCA and A-comm aneurysms. We present the case of a 67-year-old RHF who presented with ruptured right-sided SCA aneurysm. She complained of Headache, confusion, and double vision. On physical examination, she had no focal deficits and was Hunt and Hess grade 3. A brain computed tomography (CT) scan revealed a subarachnoid hemorrhage Fisher's grade 4. A brain CT angiography (CTA) demonstrated an aneurysm at the origin of right SCA. The patient had failed attempt of endovascular coiling and she underwent microsurgical clipping.Stepwise demonstration of the approach with cadaveric anatomical dissection is illustrated. The technique presented here allows for safe clipping of the aneurysm through the cavernous sinus. The approach allows for good exposure of the aneurysm and the surrounding structures. Care is taken to visualize the perforators to avoid any devastating brain stem infarction during the clipping.The transcavernous sinus is a robust approach with good visualization of the neurovascular structures allowing safe aneurysm clipping in this location. The link to the video can be found at: https://youtu.be/oE-HyDASiKM .

Evaluation of the Association between Paranasal Sinus Osteomas and Anatomic Variations Using Computed Tomography

Objective:The pathogenesis of paranasal sinus osteoma (PSO) has not been fully elucidated. It is thought that both embryological and developmental factors play a role in the etiology. The aim of the present study was to investigate the association of frequency and localization of PSOs detected on computed tomography (CT) examination with osteoma presence.Methods:In this retrospective study conducted in December 2017 through March 2020 in Gaziosmanpaşa University Faculty of Medicine, images of a total of 18,867 patients who underwent paranasal sinus, maxillofacial CT and brain CT angiography were reviewed for the presence of PSOs. Sizes of PSOs and accompanying mucosal pathologies were identified. Associations between PSOs and paranasal sinus variations were evaluated statistically compared to the control group (200 patients without PSO).Results:A total of 176 patients (0.92%) were found to have PSO. Average age of the patients with PSO was 59.9 years (range: 18–93). PSOs were unilateral in 152 patients while 24 patients had multiple osteomas. Female/male ratio was 1.1/1. PSOs were most commonly located in the frontal sinuses. Frequencies of vertical concha bullosa, secondary middle turbinate, twisted uncinate, supraorbital ethmoid cell, intersinus septal cell, ethmoidomaxillary cell, Haller’s cell, frontal sinus hypoplasia and sphenoid sinus hypoplasia were significantly higher in the patient group compared to the control group.Conclusion:Higher or lower incidence rates of some anatomic variations in the patients with PSO could be explained by the possible effects of genetic and/or environmental factor. Additional studies are needed to evaluate these possible associations.

Non-Pathological Opacification of the Cavernous Sinus on Brain CT Angiography: Comparison with Flow-Related Signal Intensity on Time-of-Flight MR Angiography.

Purpose: To investigate the non-pathological opacification of the cavernous sinus (CS) on brain computed tomography angiography (CTA) and compare it with flow-related signal intensity (FRSI) on time-of-flight magnetic resonance angiography (TOF-MRA). Methods: Opacification of the CS was observed in 355 participants who underwent CTA and an additional 77 participants who underwent examination with three diagnostic modalities: CTA, TOF-MRA, and digital subtraction angiography (DSA). Opacification of the CS, superior petrosal sinus (SPS), inferior petrosal sinus (IPS), and pterygoid plexus (PP) were also analyzed using a five-point scale. The Wilcoxon test was used to determine the frequencies of the findings on each side. Additionally, the findings on CTA images were compared with those on TOF-MRA images in an additional 77 participants without dural arteriovenous fistula (DAVF) using weighted kappa (κ) statistics. Results: Neuroradiologists identified non-pathological opacification of the CS (n = 100, 28.2%) on brain CTA in 355 participants. Asymmetry of opacification in the CS was significantly correlated with the grade difference between the right and left CS, SPS, IPS, and PP (p < 0.0001 for CS, p < 0.0001 for SPS, p < 0.0001 for IPS, and p < 0.05 for PP). Asymmetry of the opacification and FRSI in the CS was observed in 77 participants (CTA: n = 21, 27.3%; TOF-MRA: n = 22, 28.6%). However, there was almost no agreement between CTA and TOF-MRA (κ = 0.10, 95% confidence interval: −0.12–0.32). Conclusion: Asymmetry of non-pathological opacification and FRSI in the CS may be seen to some extent on CTA and TOF-MRA due to anatomical variance. However, it shows minimal reliable association with the FRSI on TOF-MRA.

Optimal placement of the region of interest for bolus tracking on brain computed tomography angiography in Beagle dogs.

This study aimed to determine the optimal placement of the region of interest (ROI) among four anatomical sites—pulmonary artery (PA), pulmonary vein (PV), aortic arch (AA), and carotid artery (CA)—in computed tomography (CT) brain angiography with automatic bolus tracking in healthy beagle dogs. Six beagles were included, and CT brain angiography was performed four times for each dog, to cover each ROI. The scan parameters, amount, and injection rate of the contrast medium were the same. The major intracranial arteries were selected for quantitative and qualitative evaluation: caudal cerebellar artery (CcA), basilar artery (BA), rostral cerebellar artery (RcA), caudal cerebral artery (CCA), middle cerebral artery (MCA), and rostral cerebral artery (RCA). Quantitative evaluation showed significantly higher CT attenuation values for the RcA, CCA, and MCA in the PA group and RcA and MCA in the PV group than in the CA group. Qualitative analysis revealed significantly higher scores for the BA, CCA, and MCA in the PA and PV groups than in the CA group. Venous contamination did not differ significantly among the ROIs, but the mean scores of the AA and CA groups were higher than those of the PA and PV groups. CT brain angiography using bolus tracking in the beagle dogs showed that the ROI should be placed at the PA or PV rather than at the CA for optimal images with strong contrast enhancement of the BA, RcA, CCA, and MCA and minimal venous contamination.

Aneurysmal subarachnoid hemorrhage accompanied by changes in the patterns of chronic migraine: a case report

Subarachnoid hemorrhage (SAH) has a high mortality rate, and cerebral aneurysm ruptures account for 80% of all cases. Although several previous case studies have reported a headache before aneurysmal SAH, no previous study has reported a case of SAH after a change in the existing migraine pattern without any other clinical signs. A 43-year-old male patient who had suffered chronic migraines for 10 years visited the emergency department due to migraine symptoms, which exacerbated 3 days before the visit. He was admitted for symptom management, and his condition improved after taking migraine-specific medication. However, his consciousness deteriorated, and he became drowsy 8 days from the onset of headache aggravation. Brain computed tomography angiography revealed SAH. A small ruptured aneurysm, which was not detected by brain magnetic resonance angiography performed a few days earlier, was found in the A1 segment of the right anterior cerebral artery. We performed emergency endovascular coil embolization in the right A1 without any other complications. After the procedure, his neurological symptoms no longer exacerbated during hospitalization. He showed only a mild headache after 2 weeks and was discharged. Aneurysmal SAH is one of the most devastating neurological diseases, but early detection and treatment of aneurysms before major rupture may facilitate a good prognosis. If the pattern of previously diagnosed chronic migraine changes suddenly, a minor leak before the major rupture of a cerebral aneurysm should be considered, even if a sentinel headache has not been suggested.

Brain Computed Tomography Angiography Maximum Intensity Projection Images for ASPECTS Derivation and Detection of Large Infarct Volumes: Preliminary Study

PurposeNon-contrast CT ASPECTS (NCCTasp) has an established role in determining eligibility for mechanical thrombectomy in centers without ready access to perfusion or DWI. Moreover, it has been suggested that CTA source ASPECTS (CTAasp) may be superior to NCCTasp in predicting final infarct volume (FIV). In this study, we hypothesized that CTA maximum intensity projection ASPECTS (MIPSasp) would be superior compared to both NCCTasp and CTAasp in predicting FIV as measured by DWI. Materials and MethodsIn 41 consecutive patients with MCA territory infarcts, NCCTasp, CTAasp and MIPSasp were visually assessed by 2 neuroradiologists. Disagreements were adjudicated by a third neuroradiologist, and the reconciled data used for all further analysis. MR-DWI was used as the standard for FIV determination. Receiver operating characteristic curve analysis was used to compare the area under the curve for all three CT-based methods in predicting FIV ≥70 ml. ResultsMIPSasp (AUC: 0.98, CI: 0.88–1.00) were statistically better than NCCTasp (AUC: 0.87, 95% CI: 0.72–0.95; p=0.01) in predicting FIV ≥70 ml. MIPSasp were also superior to CTAasp (AUC: 0.9, CI: 0.79–.98; p˂0.05). Optimal test performance for predicting FIV ≥70 ml for MIPSasp was ≤6 (sensitivity=100%, specificity=91.4%; Youden's J=0.98). ConclusionOur preliminary study suggests that a novel CTA-MIPS derived ASPECTS better predicts large MCA territory infarcts compared to CTA source and non-contrast ASPECTS. Thus, MIPSasp may be a promising technique for future studies aimed at improving ischemic stroke treatment in centers using ASPECTS for stroke management.

Clinical Implications of Preinterventional Thrombus Migration in Patients with Emergent Large Vessel Occlusion

In patients treated with thrombectomy, thrombus migration (TM) to distal arterial segments is occasionally observed. We investigated the incidence of TM, factors associated with TM, and association between TM and clinical outcomes. The study population consisted of 164 patients with anterior circulation stroke who underwent pretreatment brain computed tomography angiography and digital subtraction angiography before undergoing thrombectomy. TM was defined as a thrombus shift to a more distal arterial segment observed on digital subtraction angiography than that on computed tomography angiography. Successful and complete recanalization was defined as cerebral infarction perfusion scale scores of 2b-3 and 3, respectively. Good functional outcomes were defined as scores of ≤2 on the modified Rankin Scale at 3 months. The results are presented as adjusted odds ratios (ORs) and 95% confidence intervals (CIs). Thirty-two patients (19.5%) had TM. Intravenous thrombolysis (IVT) (OR, 5.238; 95% CI, 1.653-16.603) and female sex (OR, 2.874; 95% CI, 1.135-7.277) were associated with TM. IVT-related TM was not significantly associated with thrombus inaccessibility (P= 0.304). In addition, TM was not associated with successful (P= 0.960) or complete (P= 0.612) recanalization. However, TM (OR, 2.777; 95% CI, 1.019-7.569), together with IVT (OR, 2.982; 95% CI, 1.332-6.676), a low National Institutes of Health Stroke Scale score (OR, 0.906; 95% CI, 0.845-0.972), and successful recanalization (OR, 4.878; 95% CI, 1.940-12.266), were independently associated with good functional outcomes. TM is common, particularly after IVT. In addition, TM is associated with better functional outcomes, irrespective of the angiographic outcomes.

Intracranial aneurysm and coarctation of the aorta: prevalence in the current era.

A 10% prevalence of intracranial aneurysms in patients with coarctation of the aorta has been described in a few studies. Our objective is to describe the rate of intracranial aneurysm detection in patients with coarctation of the aorta in the current era. We hypothesise that, with earlier detection and coarctation of the aorta intervention, the rate of intracranial aneurysm is lower than previously reported and screening imaging may only be warranted in older patients or patients with certain risk factors. This is a retrospective study of 102 patients aged 13 years and older with coarctation who underwent brain computed tomography angiography, magnetic resonance imaging (MRI), or magnetic resonance angiography between January, 2000 and February, 2018. The median age of coarctation repair was 4.4 months (2 days-47 years) and the initial repair was primarily surgical (90.2%). There were 11 former smokers, 4 current smokers, and 13 patients with ongoing hypertension. Imaging modalities included computed tomography angiography (13.7%), MRI (41.2%), and magnetic resonance angiography (46.1%), performed at a median age of 33.3 years, 22.4 years, and 25 years, respectively. There were 42 studies performed for screening, 48 studies performed for neurologic symptoms, and 12 studies performed for both screening and symptoms. There were no intracranial aneurysms detected in this study. These results suggest that the rate of intracranial aneurysms may be lower than previously reported and larger studies should explore the risk of intracranial aneurysms in coarctation of the aorta in the current era.

Not aString, not aTangle, not an Aneurysm : Emerging Pattern of Large Parenchymal Bleeding in Younger Patients Associated with Abnormal Vessels on Imaging.

PurposeIntracerebral hemorrhage (ICH) accounts for up to 20% of all strokes, and there is a high rate of associated morbidity and mortality. Computed tomography (CT) findings, such as a spot sign have been shown to be an independent predictor of poor outcome. We have recently encountered a succession of ICH patients who presented with a peculiar imaging finding, which we term the spot on a string sign. This is a rare imaging finding, and interestingly, all these patients presented to our institution over the last few weeks.MethodsThis was a single high-volume center series of patients who presented to our institution between 1 April and 21 May 2020. All patients underwent initial non-contrast CT brain and subsequent CT angiography (CTA). We also present laboratory and clinical data. Our primary measure was the presence of the spot on a string sign on the CTA. We also report the clinical course of these patients.ResultsIn this study seven large-volume ICH patients with this imaging sign were identified, with a median age of 48 years (range 30–68 years). All had tested negative for coronavirus disease 19 (COVID-19).ConclusionWe have described an unusual imaging finding in a cohort of younger patients with large-volume ICH, all of whom presented in a 2-month period to a high-volume neurovascular unit. The cause of these ICH presentations and associated imaging findings are unclear, but we encourage other clinicians to be aware of and vigilant for this rare phenomenon, especially in younger patients with such a bleeding pattern.

Acute cerebral infarction with adenomyosis in a patient with fever: a case report

BackgroundIt is reported that acute cerebral infarction with adenomyosis is associated with elevated D-Dimer, elevated CA125, anemia and menstruation. However, previous reports did not notice infection known as fever, which may be a potential risk factor for developing acute cerebral infarction with adenomyosis.Case presentationWe describe a 34-year-old woman who presented headache and fever (38 °C) for 4 days and left limb weakness for 1 day during her menstrual phase. Laboratory test data showed: Hemoglobin (HGB) (112 g/L, normal: 120–150 g/L), Carcinoembryonic antigen 125 (CA125) (937.70 U/ml, normal: 0–35 U/ml), D-Dimer (27.4 mg/L, normal: 0–1.5 mg/L). Magnetic resonance imaging (MRI) indicated acute cerebral infarction in right basal ganglia and subcortical region of right frontotemporal lobe. Further, brain computed tomography angiography (CTA) showed that the M1 segment of right middle cerebral artery was strictured and the distal branches of right middle cerebral artery were significantly less than those on the opposite side. No obvious abnormality was found in cranial magnetic resonance venogram (MRV). She had a 5-year history of adenomyosis. No tumors were found by whole body positron emission tomography-computed tomography (PET-CT). We treated this patient by using anti-infective therapy for 1 week and using anticoagulant therapy with low molecular weight heparin for 2 weeks. Subsequently, the anticoagulant therapy was discontinued and replaced by antiplatelet therapy with clopidogrel. We followed up this patient for 4 months, and no recurrence of cerebral infarction was found.ConclusionsAcute cerebral infarction with adenomyosis may be related to elevated D-Dimer, elevated CA125, anemia and menstruation. Our report suggests that infection may be a potential risk factor for developing acute cerebral infarction with adenomyosis.