Intracranial Diseases Research Articles

A subject-specific assessment of measurement errors and their correction in cerebrospinal fluid velocity maps using 4D flow MRI.

Phase-contrast MRI (PC-MRI) of cerebrospinal fluid (CSF) velocity is used to evaluate the characteristics of intracranial diseases, such as normal-pressure hydrocephalus (NPH). Nevertheless, PC-MRI has several potential error sources, with eddy-current-based phase offset error being non-negligible in CSF measurement. In this study, we assess the measurement error of CSF velocity maps obtained using 4D flow MRI and evaluate correction methods. CSF velocity maps of 10 patients with NPH were acquired using 4D flow MRI (velocity-encoding = 5 cm/s). Distributed phase offset error was estimated for a whole 3D background field by polynomial fitting using robust regression analysis. This estimated phase offset error was then used to correct the CSF velocity maps. The estimated error profiles were compared with those obtained using an existing 2D correction approach involving local background information near the region of interest. The residual standard error of the polynomial fitting against the phase offset error extracted from the measured velocities was within 0.2 cm/s. The spatial dependencies of the phase offset errors showed similar tendencies in all cases, but sufficient differences in these values were found to indicate requirement of velocity correction. Differences of the estimated errors among other correction approaches were in the order of 10-2 cm/s, and the estimated errors were in good agreement with those obtained using existing approaches. Our method is capable of estimating the measurement error of CSF velocity maps obtained from 4D flow MRI and provides quantitatively reasonable characteristics for the main CSF profile in the cerebral aqueduct in patients with NPH.

EIF1A depletion restrains human pituitary adenoma progression

EIF1A encodes a translation initiation factor in eukaryocyte and aberrant expression of EIF1A is deemed to be associated with dysfunctions in intracranial diseases. The goal of this research was to explore the impacts of EIF1A on progression of human pituitary adenoma (PA). We employed immunohistochemistry to assess the expression of EIF1A in PA and para-carcinoma tissues. After constructing EIF1A-knockdown cell models via lentivirus infection, we examined cell proliferation through CCK-8 assay and Celigo cell counting assay. Flow cytometry was utilized to detect cell apoptosis and the migration ability of experimental cells was estimated using wound-healing assay and Transwell assay. The activity of the apoptosis-related factor, Caspase 3, was also examined via Caspase 3 activity assay. Lastly, in vivo xenograft mouse models were established to verify findings derived from in vitro cell models. Our results affirmed upregulation of EIF1A in PA cells and revealed that depletion of EIF1A could seriously limit cell proliferation and weaken the capacity of cell migration, and also enhance apoptosis of tumor cells. Mechanistically, degradation in cell growth mediated by EIF1A knockdown may involve in activation of MAPK signaling but inactivation of PI3K/AKT signaling pathway. This study indicates EIF1A plays a prominent role in facilitating tumor cell proliferation and migration which may further contribute to PA progression.

Retrospective Evaluation of Acute Headache in Pediatric Emergency Department: Etiologies, Red Flags, and Neuroimaging.

The aims of this study were to describe the etiologies of acute headache presenting to the pediatric emergency department, determine their clinical characteristics, the prevalence of red flag findings and neuroimaging and identify predictors of headaches because of serious intracranial diseases. Patients from 2 to 18 years of age who visited pediatric emergency department with a chief complaint of headache between January 1, 2016 and August 31, 2020 were retrospectively evaluated. The mean age of the 558 patients included in the study was 11.17±3.78 years, and 290 (52%) were female. The most common cause of acute headache was head and neck area infections (except central nervous system infections) in 355 (63.6%) patients. Forty patients (7.2%) had a headache because of serious intracranial diseases. According to binary logistic regression analysis, the findings that predicted a serious intracranial diseases were abnormal neurological physical examination [odds ratio (OR): 187.57; 95% confidence interval (CI): 32.67-1076.64], recent onset or suddenly severe headache (OR: 14.41; 95% CI: 3.14-65.91), and vomiting (OR: 9.42; 95% CI: 1.90-46.63). Neuroimaging was performed in 63 (11.3%) patients, and 7 (1.25%) had a pathology requiring emergency treatment. The majority of acute headaches were evaluated as secondary headache. The most common cause of acute headache was head and neck area infections. Abnormal neurological physical examination, recent onset or suddenly severe headache, and vomiting were the most useful red flags for predicting serious intracranial diseases. The requirement for neuroimaging should be evaluated individually for each patient.

Palinopsia as an initial symptom of cerebral amyloid angiopathy-related inflammation.

•We report the first case of cerebral amyloid angiopathy-related inflammation (CAA-RI) presenting palinopsia initially.•Palinopsia is generally caused by intracranial diseases involving the parietal and occipital areas.•CAA dominantly affects parietal and occipital lobes, therefore palinopsia could be an important phenomenon of the disease.

A Novel Method for Measuring the Pupil Diameter and Pupillary Light Reflex of Healthy Volunteers and Patients With Intracranial Lesions Using a Newly Developed Pupilometer.

Background: Physicians currently measure the pupil diameter and the pupillary light reflex with visual observations using a ruler and a traditional penlight, leading to possibly inaccurate and subjective assessments. Although a mobile pupillometer has been developed and is available in clinical settings, this device can only assess one pupil at a time. Hence, an indirect pupillary light reflex, including those under irradiation to the opposite side of pupil, cannot be evaluated. Consequently, we have developed a new automatic mobile pupilometer, the Hitomiru®, with Hitomiru Co., Ltd. (Tokyo, Japan). This device is a two-glass type pupilometer with a video recording system. The pupil diameter and light reflex of both pupils can be measured simultaneously; therefore, both indirect and direct light reflexes can be assessed.Purpose: To evaluate the clinical ability of the Hitomiru® pupilometer to assess the pupil diameter and the pupillary light reflex of healthy volunteers and patients with intracranial lesions in an intensive care unit (ICU).Methods: Twenty-five healthy volunteers and five ICU patients with intracranial lesions on only the left side were assessed using the Hitomiru® pupilometer. The protocol was as follows: infrared light was applied to both pupils, followed by visible light to the right pupil, infrared light to both pupils, visible light to the left pupil, and then infrared light to both pupils. All the intervals were 2 s, and the dynamics of pupil diameters on both sides were continuously recorded.Results: The healthy adults had approximately 0.5 mm anisocoria, miosis was harder, and mydriasis was less with increased age. There were several differences in miosis rates, miosis times, and mydriasis rates between the healthy adults and the patients with intracranial lesions with both direct irradiation and indirect irradiation.Conclusions: The initial trial estimated and digitally recorded direct and indirect light reflexes, including rapidity of miosis after direct and indirect lights on, and mydriasis after direct and indirect lights off. The Hitomiru® pupilometer was a useful device to digitally record and investigate the relationship between pupil reflexes and intracranial diseases.

Skull shape abnormalities in ischemic cerebrovascular and mental diseases in adults

Morphological changes in the child skull due to mechanical and metabolic stimulation and synostosis of the suture are well known. On the other hand, few studies have focused on clinical conditions relevant for adult skull deformity. We retrospectively reviewed computed tomography (CT) findings obtained from 365 cases that were treated for head injuries, moyamoya disease, cervical internal carotid artery stenosis, and mental diseases, and investigated the morphological changes in the skull associated with these diseases. The findings from head injuries were used not only for control subjects, but also for the analysis of generational changes in skull shape based on birth year. Head shape had a brachiocephalic tendency with occipital flattening in people born from the 1950s onwards. Cases of moyamoya disease, cervical internal carotid artery stenosis, and mental diseases showed significantly thicker frontal and occipital bone than those of control subjects. The skull thickening was especially noticeable in the frontal bone in moyamoya disease. Plagiocephaly was significantly frequent in moyamoya disease. These uncommon skull shapes are useful CT findings in screening subjects for early evidence of mental diseases and intracranial ischemic diseases with arterial stenosis.

Understand clearly about the intracranial vein diseases, prompt the clinical ability of diagnosis

Understand clearly about the intracranial vein diseases, prompt the clinical ability of diagnosis

A Case of Idiopathic Thoracic Spinal Subdural Hematoma With Bilateral Lower Limb Paralysis

Subdural hemorrhage is rare and is mostly triggered non-traumatically due to intracranial surgery, lumbar puncture, anticoagulant therapy, blood diseases, vascular malformations, and tumors. We experienced a case of idiopathic subdural hematoma with acute bilateral lower limb paralysis on postoperative day 4 after laparoscopic hysteromyomectomy.The patient was a 40-year-old woman with uterine myoma who took no medication nor had history of trauma or abnormalities such as vascular malformations. Four days after laparoscopic surgery, sudden chest and back pain and bilateral lower limb paralysis appeared. Muscle weakness was found predominantly on the left side. In manual muscle test (MMT), the quadriceps femoris was 5/5 on both sides, but the tibialis anterior, extensor pollicis longus and flexor pollicis longus were 5/5 only on the right, and 2/5 on the left side. Warm pain sensation was decreased below Th4 (Fourth thoracic vertebra), and the right side showed a greater decrease of deep sensation than the left. Excretion was difficult and dysuria was also apparent. There were no abnormalities in blood biochemical tests or in the blood coagulation system. Using the results of diagnostic imaging, as preoperative diagnosis of the patient, spinal subdural hematoma was suspected. Conservative treatment was initially conducted but the emergency surgery for hematoma removal was performed at 14 hours after the onset because of progression of paralysis. This resulted in improvement of neurological symptoms including lower limb paralysis, bladder-rectal disorder and hypoesthesia.If subdural hematoma is suspected regardless of the cause, it is important to observe neurological findings over time and make a quick decision to treat with surgery.

A study of clinical & angiographic profile of patients with young stroke in tertiary care center of Southern Rajasthan

: Understanding the exact etiology of stroke in the young has great relevance to its prevention and management. Recent development in the surgical and interventional therapy of extra cranial and intracranial vascular diseases have made it necessary to correctly identify the causative as well as contributory factors of stroke.This cross sectional observational study was done on patients admitted in the stroke unit of Geetanjali Medical College, Udaipur of aged 15 to 50 years with stroke and who have underwent at least one standard vessel imaging procedure within 2 weeks of stroke onset. Out of 310 patients, majority of the strokes occurred in the setting of a rheumatic valvular heart disease (63.6%), with mitral valve disease being the most frequent association. Almost 80% of patients had normal ECG whereas 20% of the patients had an ECG abnormality.70% of patients had normal ECHO and the most frequent etiologic abnormality detected was valvular heart disease. Scan and MRI was done in 180 patients. The most commonly performed angiographic procedure was CT angiogram. TOF MRA was the next most commonly performed angiographic procedure. The highest yield for picking up abnormalities was noted in the CT Angiography. The yield of CT angiography was 35.4% and 37.7% for extracranial and intracranial vasculature respectively.Arterial dissections are fairly common in young population and should be considered in appropriate clinical setting and all patients should have a good and timely angiographic assessment to rule out dissections. Thus, this study highlights the importance of risk factor evaluation, and control, complete etiological evaluation including angiographic assessment in the diagnosis, management and planning of secondary prevention strategies in young patients with stroke.

Development and Validation of a LASSO Prediction Model for Better Identification of Ischemic Stroke: A Case-Control Study in China.

BackgroundTimely diagnosis of ischemic stroke (IS) in the acute phase is extremely vital to achieve proper treatment and good prognosis. In this study, we developed a novel prediction model based on the easily obtained information at initial inspection to assist in the early identification of IS.MethodsA total of 627 patients with IS and other intracranial hemorrhagic diseases from March 2017 to June 2018 were retrospectively enrolled in the derivation cohort. Based on their demographic information and initial laboratory examination results, the prediction model was constructed. The least absolute shrinkage and selection operator algorithm was used to select the important variables to form a laboratory panel. Combined with the demographic variables, multivariate logistic regression was performed for modeling, and the model was encapsulated within a visual and operable smartphone application. The performance of the model was evaluated on an independent validation cohort, formed by 304 prospectively enrolled patients from June 2018 to May 2019, by means of the area under the curve (AUC) and calibration.ResultsThe prediction model showed good discrimination (AUC = 0.916, cut-off = 0.577), calibration, and clinical availability. The performance was reconfirmed in the more complex emergency department. It was encapsulated as the Stroke Diagnosis Aid app for smartphones. The user can obtain the identification result by entering the values of the variables in the graphical user interface of the application.ConclusionThe prediction model based on laboratory and demographic variables could serve as a favorable supplementary tool to facilitate complex, time-critical acute stroke identification.

A comparative analysis of the endoscopic endonasal and pterional approaches for clipping anterior communicating artery aneurysms on three-dimensional printed models.

A comparative analysis of the endoscopic endonasal and pterional approaches for clipping anterior communicating artery aneurysms on three-dimensional printed models.

T2-Weighted Whole-Brain Intracranial Vessel Wall Imaging at 3 Tesla With Cerebrospinal Fluid Suppression.

BackgroundT2-weighted (T2w) intracranial vessel wall imaging (IVWI) provides good contrast to differentiate intracranial vasculopathies and discriminate various important plaque components. However, the strong cerebrospinal fluid (CSF) signal in T2w images interferes with depicting the intracranial vessel wall. In this study, we propose a T2-prepared sequence for whole-brain IVWI at 3T with CSF suppression.MethodsA preparation module that combines T2 preparation and inversion recovery (T2IR) was used to suppress the CSF signal and was incorporated into the commercial three-dimensional (3D) turbo spin echo sequence-Sampling Perfection with Application optimized Contrast using different flip angle Evolution (SPACE). This new technique (hereafter called T2IR-SPACE) was evaluated on nine healthy volunteers and compared with two other commonly used 3D T2-weighted sequences: T2w-SPACE and FLAIR-SPACE (FLAIR: fluid-attenuated inversion recovery). The signal-to-noise ratios (SNRs) of the vessel wall (VW) and CSF and contrast-to-noise ratios (CNRs) between them were measured and compared among these three T2-weighted sequences. Subjective wall visualization of the three T2-weighted sequences was scored blindly and independently by two radiologists using a four-point scale followed by inter-rater reproducibility analysis. A pilot study of four stroke patients was performed to preliminarily evaluate the diagnostic value of this new sequence, which was compared with two conventional T2-weighted sequences.ResultsT2IR-SPACE had the highest CNR (11.01 ± 6.75) compared with FLAIR-SPACE (4.49 ± 3.15; p < 0.001) and T2w-SPACE (−56.16 ± 18.58; p < 0.001). The subjective wall visualization score of T2IR-SPACE was higher than those of FLAIR-SPACE and T2w-SPACE (T2IR-SPACE: 2.35 ± 0.59; FLAIR-SPACE: 0.52 ± 0.54; T2w-SPACE: 1.67 ± 0.58); the two radiologists’ scores showed excellent agreement (ICC = 0.883).ConclusionThe T2IR preparation module markedly suppressed the CSF signal without much SNR loss of the other tissues (i.e., vessel wall, white matter, and gray matter) compared with the IR pulse. Our results suggest that T2IR-SPACE is a potential alternative T2-weighted sequence for assessing intracranial vascular diseases.

Usefulness of black-blood magnetic resonance angiography generated from vessel wall imaging after the stent-assisted treatment of intracranial arterial diseases.

PurposeAfter stent-assisted treatment for intracranial diseases, three-dimensional time-of-flight magnetic resonance angiography is a noninvasive follow-up method, but susceptibility artifacts prevent accurate evaluations of stented arteries. Sampling perfection with application-optimized contrast using different flip angle evolution (SPACE) sequence often used for vessel wall imaging is less susceptible to susceptibility artifacts, since it is a spin-echo sequence. Hence, we evaluated the feasibility of black-blood magnetic resonance angiography generated from vessel wall imaging data obtained using the SPACE sequence in the depiction of stented arteries by comparing with three-dimensional time-of-flight magnetic resonance angiography and digital subtraction angiography.MethodsOur study group comprised 11 consecutive patients. For both three-dimensional time-of-flight magnetic resonance angiography and black-blood magnetic resonance angiography, the contrast ratio obtained from the stented artery and the normal artery proximal to the stent were calculated. And the depiction of stented arteries was visually evaluated. Additionally, the relative diameter index obtained from the stented artery and the normal artery proximal to the stent were calculated for three-dimensional time-of-flight magnetic resonance angiography, black-blood magnetic resonance angiography and digital subtraction angiography.ResultsThe contrast ratio of the stented artery was significantly lower than that of the normal artery on three-dimensional time-of-flight magnetic resonance angiography, but no significant difference was seen using black-blood magnetic resonance angiography. Regarding both the diameter index and the visual assessment score, black-blood magnetic resonance angiography was significantly better than three-dimensional time-of-flight magnetic resonance angiography. On black-blood magnetic resonance angiography, the diameter index was equal to that of digital subtraction angiography, and the flow signal was homogeneous and continuous in most the cases.

Can Hybrid Arterial Spin Labeling-Tagged Zero-Echo-Time Magnetic Resonance Angiography Be an Effective Candidate in the Evaluation of Intracranial Artery Diseases? A Clinical Feasibility Study.

Flow related artifacts in continuous arterial spin labeling (cASL) zero-echo-time (ZTE) magnetic resonance angiography (MRA) could influence the vasculature visualization. To investigate the clinical feasibility for the intracranial artery diseases assessment by utilizing hybrid ASL-ZTE-MRA (hASL-ZTE-MRA). Prospective, technical development. Sixty-seven subjects with known/suspected cerebrovascular diseases. Gradient echo based cASL-/hASL- ZTE-MRA at 3.0 T. Subjective/objective evaluation for sound-levels. Image quality (IQ), signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR) were analyzed within artery segments. Stenotic grading, aneurysm measurement, and signal intensity of lesions were further analyzed. Kolmogorov-Smirnov test for data normality check. Between two MRAs: Wilcoxon signed-rank test for sound experience/IQ ratings analysis; Paired t test for SNR/CNR comparison. One-way analysis of variance for sound intensity comparison. For stenosis grading/aneurysm measurement: Kendall's W test/intraclass correlation coefficient (ICC) for interobserver agreement test within each modality, weighted kappa statistics/ICC for intermodality agreement test between each MRA and computed tomography angiography. Sound-level perception/intensity was similar (P=0.86, P=0.55) between MRAs. The mean IQ score for hASL-ZTE-MRA was on diagnostic scale and slightly higher (P < 0.05) than that of cASL-ZTE-MRA. hASL-ZTE-MRA provided higher (P < 0.05) SNR/CNR than that of cASL-ZTE-MRA. Signal uniformity was improved on hASL-ZTE-MRA, particularly among the anterior circulation (P < 0.05). Comparing to cASL-ZTE-MRA, on hASL-ZTE-MRA, stenotic lesions were accurately assessed; flow in the stent or aneurysm remnant was better depicted (P < 0.05); AVM nidus was preferred with increased SNR (P < 0.05). No significant differences for the aneurysm measurement were found between MRAs (P=0.95), in addition to the slightly higher SNR (P < 0.05) on hASL-ZTE-MRA. Comparing to cASL-ZTE-MRA, hASL-ZTE-MRA is robust and feasible for the evaluation of intracranial artery diseases with diagnostic IQ, improved vessel contrast, and better signal heterogeneity. 2 TECHNICAL EFFICACY: 2.

Factors affecting in-stent restenosis after angioplasty with the Enterprise stent for intracranial atherosclerotic diseases

This study investigated factors affecting the safety and in-stent restenosis after intracranial stent angioplasty using the Enterprise stent for symptomatic intracranial atherosclerotic stenosis. Between January 2017 and March 2019, patients with intracranial atherosclerotic stenosis treated with Enterprise stent angioplasty were enrolled, including 400 patients in the modeling group and 89 patients in the validation group. The clinical factors affecting in-stent restenosis after Enterprise stent angioplasty in the modeling group were analyzed, and a logistic regression model of these factors was established and validated in the validation group. The receiver operating characteristic (ROC) curve and the area under the ROC curve (AUC) were analyzed. In the modeling group with 400 patients, there were 410 lesions, including 360 stenotic lesions and 50 occluded lesions, with 176 (42.9%) lesions in the anterior circulation and 234 (57.1%) in the posterior circulation. Successful stenting was performed in 398 patients (99.5%). Stenosis was significantly (P < 0.05) improved after stenting compared with before stenting (27.7% ± 2.9% vs. 77.9% ± 8.0%). Periprocedural complications included ischemic stroke (3.25%), hemorrhagic stroke (0.75%), and death (0.50%), with a total periprocedural complication rate of 4.0%. The first follow-up angiography was performed in 348 (87.0%) patients with 359 lesions 3.5–14 months (mean 5.7 months) after stenting. In-stent restenosis occurred in 62 (17.3%) lesions, while the other 295 (82.7%) had no restenosis. Lesion location, calcification degree, balloon expansion pressure, residual stenosis, intraprocedural dissection, and cerebral blood flow TICI grade were significant (P < 0.05) risk factors for in-stent restenosis. The in-stent restenosis prediction model was established as follows: P = 1/[1 + e−(−6.070–1.391 location + 2.745 calcification + 4.117 balloon inflation pressure + 2.195 intraprocedural dissection + 1.163 residual stenosis + 1.174 flow TC grade)]. In the validation group, the AUC in the ROC curve analysis was 0.902 (95% CI: 0.836–0.969), and when the cutoff value was 0.50, the sensitivity and specificity of this model were shown to be 76.92% and 80.26%, respectively, in predicting in-stent restenosis at angiographic follow-up, with a total coincidence rate of 79.78%. In conclusion, in-stent restenosis after intracranial Enterprise stenting is affected by stenosis location, calcification, balloon inflation pressure, intraprocedural arterial dissection, residual stenosis, and cerebral flow grade, and establishment of a logistic model with these factors can effectively predict in-stent restenosis.

Clinical characteristics and aetiology of acute acquired comitant esotropia

ABSTRACT Clinical relevance Acute acquired comitant esotropia (AACE) is characterised by the acute onset of diplopia which affects work and life. Background To describe the clinical characteristics and discuss the aetiology of acute acquired comitant esotropia. Methods The medical records of 51 patients with AACE were retrospectively analysed, and their age, occupation, daily average time spent on near work, angle of deviation, refractive error and aetiology were analysed. Results The age at onset of AACE was eight to 55 years. Thirty-nine patients were aged 12 to 36 years (76.5%), and 42 patients (82.4%) were myopic. The angle of deviation was 20Δ (12Δ to 35Δ) during near fixation and 25Δ (18Δ to 40Δ) during distance fixation. The deviation during distance fixation was larger than that during near fixation, the difference being statistically significant (p < 0.001). The daily average time of near work before onset was 9.0 h (8.0 h to 10.0 h); 35 patients (68.6%) spent more than 8 h performing near work. Their occupations included students, accountants, information technology staff, and those who required electronic use for a long time. There is no correlation between the angle of deviation and the time of near work (p > 0.05). Among the 51 patients, three had intracranial diseases. Diplopia resolved in 47 cases following treatment. The angle of deviation post-treatment was 0Δ (0Δ to 5Δ) during near and 0Δ (0Δ to 3Δ) during distance fixation. Conclusion AACE occurs mostly in myopic older children and adults. The onset of esotropia is related to long-term near work. AACE patients mostly present an angle of deviation that is larger during distance than near fixation. Intracranial disease is an infrequent but important cause of AACE that needs to be excluded in all cases.

Association between coexisting intracranial artery and extracranial carotid artery atherosclerotic diseases and ipsilateral cerebral infarction: a Chinese Atherosclerosis Risk Evaluation (CARE-II) study

BackgroundTo evaluate the association between coexisting intracranial and extracranial carotid artery atherosclerotic diseases and ipsilateral acute cerebral infarct (ACI) in symptomatic patients by using magnetic resonance (MR) vessel wall imaging.MethodsSymptomatic...

Clinical Classification of Acquired Concomitant Esotropia.

Classification and management of acquired concomitant esotropia is controversial. We sought to establish a simple clinical classification in order to determine in which cases further investigations in search of underlying pathologies are necessary. Observational retrospective study of the files of 175 consecutive patients examined in our unit between 2009 and 2018 for acute convergent strabismus. One hundred and nine patients were selected, after exclusion of infantile, incomitant, or mechanical esotropias, residual esotropias, and patients examined on a single occasion. All patients received a complete orthoptic and ophthalmological examination. We grouped the patients according to their common characteristics. We established the following categories: 1. Acute esotropia of large angle (20 to 45 prism diopters [PD]), accompanied by mild hyperopia (mean 1.2 D) in children (n = 16) and moderate myopia (mean 3.7 D) in adolescents and adults (n = 13). 2. Decompensated micro-esotropia, which is distinguished from the other categories by the presence of abnormal retinal correspondence (n = 33). 3. Decompensated esophoria, with intermittent deviations of 5 to 30 PD, esotropia being compensated part of the time (n = 25). 4. Esotropia present only at a distance in patients over 50 years of age (n = 20). 5. Small-angle esotropia (< 15 PD) greater at a distance, associated with oculomotor cerebellar syndrome (n = 2). Complementary examinations (MRI or CT scan) were performed on 21 patients, leading to the discovery of a posterior fossa astrocytoma in a 4-year-old boy. The recognition of decompensated micro-esotropia and esophoria, as well as distance esotropia of the elderly, avoids unnecessary additional investigations, which are indicated in any type of acute comitant strabismus if associated with any neurological sign or symptom (e.g., headaches, nausea, vertigo, imbalance, poor coordination, nystagmus, or papilledema). In the absence of neurological findings, there is no consensus about the indication of neuroimaging in large-angle acquired concomitant esotropia, but long-term follow-up of patients that do not undergo neuroimaging is strongly recommended in order to identify later occurring intracranial diseases. This is of particular importance with children.

The role of CE-MRA of the supraortic vessels in the detection of associated intracranial pathology.

Contrast-enhanced magnetic resonance angiography (CE-MRA) has become a very popular imaging technique in the evaluation of the extracranial vessels pathology, while it is not commonly used to rule out intracranial vascular pathology. On the contrary, 3D time of flight MRA (TOF-MRA) has a solid role in the study of intracranial arterial vessels disease. One hundred and eight patients were consecutively included in the study. All patients were submitted to a 3 Tesla 3D CE-MRA imaging to rule out extracranial vessels pathology. A comparison was made with a 3D-TOF sequence acquired at the same time in the assessment of intracranial vessels diseases such as steno-occlusion, dissection, and aneurysms. With regard to steno-occlusive disease, Spearman's rank correlation coefficient was of 0.56 for stenosis detection and of 0.57 for occlusive disease detection. The two techniques shared similar results in the evaluation of anterior circulation, while 3D-TOF found higher grades of stenosis for posterior circulation. With regard to dissection, Spearman's rank correlation coefficient was of 0.7. 3D-TOF depicted more intramural hematoma (Spearman's rank = 0.46), while CE-MRA showed more pseudo-aneurysms (Spearman's rank = 0.56). Both the technique equally evaluated the presence of intracranial aneurysms (Spearman's rank = 1). CE-MRA can be considered a reliable tool to rule out intracranial pathology associated to supraortic steno-occlusive disease, also allowing time reduction. In the suspicion of dissection a T1-weighted sequence has to be added to detect the presence of a subacute vessel wall hematoma.

Application of 3D printed model for planning the endoscopic endonasal transsphenoidal surgery

The application of 3D printing in planning endoscopic endonasal transsphenoidal surgery is illustrated based on the analysis of patients with intracranial skull base diseases who received treatment in our department. Cranial computed tomography/magnetic resonance imaging data are attained preoperatively, and three-dimensional reconstruction is performed using MIMICS (Materialise, Leuven, Belgium). Models of intracranial skull base diseases are printed using a 3D printer before surgery. The models clearly demonstrate the morphologies of the intracranial skull base diseases and the spatial relationship with adjacent large vessels and bones. The printing time of each model is 12.52–15.32 h, and the cost ranges from 900 to 1500 RMB. The operative approach was planned in vitro, and patients recovered postoperatively well without severe complications or death. In a questionnaire about the application of 3D printing, experienced neurosurgeons achieved scores of 7.8–8.8 out of 10, while unexperienced neurosurgeons achieved scores of 9.2–9.8. Resection of intracranial skull base lesions is demonstrated to be well assisted by 3D printing technique, which has great potential in disclosing adjacent anatomical relationships and providing the required help to clinical doctors in preoperative planning.