Intracranial Vascular Lesions Research Articles

Compromiso del sistema nervioso central en el lupus eritematoso sistémico

ObjectivesTo review the epidemiological, pathophysiological, and neurological manifestations, as well as the diagnosis and treatment of central nervous system involvement in systemic lupus erythematosus. MethodsA literature search was performed using PubMed database complemented by review of literature references listed in identified articles. There were no limits to publication date of the literature references. Only articles in English and Spanish were included. ResultsCentral nervous system involvement is one of the major causes of morbidity and mortality in systemic lupus erythematosus patients. Common disorders (cumulative incidence >5%) were cerebrovascular disease and seizures, and relatively uncommon (1-5%) were severe cognitive dysfunction, acute confusional state, psychosis, while the remaining neuropsychiatric disorders were unusual (less than 1%). Mechanisms that can lead to neuropsychiatric manifestations include intracranial vascular lesions (vasculitis and thrombosis), autoantibody production against neuronal antigens, ribosomes, and phospholipids, and inflammation related to local cytokine production. Serological tests, cerebrospinal fluid, and imaging investigations have been used to support the clinical diagnosis. Treatment is based on the use of corticosteroids, immunosuppressants, and symptomatic treatment. The use of antiplatelet and antithrombotic drugs was indicated when positive moderate-to-high titres of anti-phospholipid antibodies were present. ConclusionsThe involvement of vital organs and tissues, such as the brain, in patients with systemic lupus erythematosus, impels efforts to develop diagnostic tools for systemic lupus erythematosus associated neuropsychiatric disease to guide effective therapeutic decisions.

Relationship between cognitive impairment and cerebrovascular stenosis in patients with subcortical infarction

Objective To investigate the intracranial vascular lesions in patients with subcortical infarction-induced vascular cognitive impairment(VCI),and to investigate the etiology and mechanisms of VCI.Methods Inpatients with subcortical infarction in our hospital were enrolled in this study from Nov.2012 to Feb.2014,with those unable to complete the cognitive evaluation eliminated.According to the diagnostic criteria of VCI the patients were divided into two groups:49with cognitive impairment(VCI group)and 42 without cognitive impairment(NVCI group).The clinical data,physical examinations,laboratory tests,and the Montreal Cognitive Assessment(MoCA)scale scores were collected.Cerebral blood vessels were assessed by CT angiography or magnetic resonance angiography(MRA).Results The results showed that,according to TOAST classification,VCI group had 24(48.98%)patients with large artery atherosclerosis(LAA)and NVCI group had 22(52.38%),showing no significant difference between the two groups.CTA or MRA indicated that 37(75.51%)patients in VCI group had vascular stenosis,with 75.25% of the 37 patients having intracranial vascular stenosis and 28.71%with middle cerebral artery stenosis.Patients with single cerebral artery stenosis accounted for 18.37% and those with the multiple artery stenosis accounted for 57.14%.CTA or MRA indicated that 34(80.95%)patients in NVCI group had vascular stenosis,with 60% having intracranial vascular stenosis,including 32% with middle cerebral artery stenosis,26.19% with single cerebral artery stenosis,and 54.76% with the multiple artery stenosis,with the latter two data being significantly different from the VCI group(P0.05).In VCI group,the number of intracranial vascular stenosis branches ranged 0-6,with a mean of(1.51±1.67),and a negative relation was found between numbers of stenosis arteries and MoCA scores in patients of VCI group(rs=-0.283,P0.05).Conclusion Different from the common causes of small blood vessels,LAA is the most common etiology of subcortical VCI,which implied that exploring the LAA causes of small lesions is crucial for the prevention of VCI in Chinese patients.

Arterial fenestrations and their association with cerebral aneurysms

Fenestrations of intracranial arteries and associated aneurysms are rare. The significance of these fenestrations in relation to aneurysms remains unclear. We present four patients with fenestration-associated aneurysms and a comprehensive review of associations with aneurysms and other vascular lesions. A PubMed search of the literature was conducted from 1970–2012 reporting cases of intracranial aneurysms associated with arterial fenestration or duplications. Data were collected on patient presentation, sex, age, aneurysm and fenestration location, aneurysm treatment, and presence of other vascular lesions. We performed a retrospective review of four patients with intracranial fenestrations associated with aneurysms at our institution from 2012–2013. There were 59 cases of fenestrations and associated aneurysms in the literature. Aneurysms were reported as either arising from (n=50) or adjacent to but distinct from (n=13) fenestrations. The most common single fenestration location was at the basilar artery (n=23, 36.5%); however the majority of fenestrations were in the carotid circulation (n=34, 54.0%). The majority of patients with aneurysms and fenestrations at all locations except those at the anterior communicating artery (70.5%) presented with subarachnoid hemorrhage. Patients with aneurysms arising from a fenestration or adjacent to a fenestration presented with an additional intracranial vascular lesion in 38% and 31% of cases, respectively. The majority of all aneurysms were treated with microsurgical clipping. Aneurysms associated with cerebral arterial fenestrations are most commonly discovered after subarachnoid hemorrhage and are most often located in the carotid circulation. A high index of suspicion must be maintained for an associated vascular lesion if an intracranial fenestration is discovered.

Imaging intracranial vessel wall pathology with magnetic resonance imaging: current prospects and future directions.

To date, the probable cause of ischemic stroke is often inferred from the size and location of the infarct, in combination with an evaluation of the heart and the presence of extracranial arterial occlusion or high-grade stenosis.1 Currently used conventional lumenography-based methods such as digital subtraction angiography, computed tomography angiography, and magnetic resonance (MR) angiography are used to determine the presence of such an acute occlusion or high-grade arterial stenosis. From extracranial studies, it is known that luminal narrowing may be absent in patients with severe atherosclerosis owing to arterial remodeling.2–4 Therefore, these methods do not provide information about the underlying pathological processes, which most often involve the vessel wall.5 Vessel wall changes such as vessel wall thickening, enhancement, or the presence of vulnerable atherosclerotic plaques without luminal stenosis are therefore often missed but might be of importance for a better understanding of ischemic stroke.6 Furthermore, intracranial atherosclerosis is an important cause of ischemic stroke7 and often involves the vessel wall. Patients with intracranial atherosclerosis have high recurrent stroke rates,8 and increasingly more attention is being directed to the assessment of the intracranial vessel wall, necessitating an imaging technique directly assessing the intracranial vessel wall. MR imaging (MRI) seems the most promising technique to reliably image intracranial vessel wall pathologies because of its superior soft tissue contrast. Recent advances in MRI9 have made it possible to obtain information about these abnormalities within the intracranial vessel wall, which provides an imaging tool to investigate the role of intracranial vessel wall abnormalities in the diagnosis of stroke. In this review, we discuss the current status of intracranial vessel wall MRI and its potential to identify different intracranial vessel wall pathologies. First, we present the state-of-the-art MRI methods to visualize the intracranial vessel wall …

P-023 Transfontanelle and Transcardiac Veno-arterial Approaches for Embolization of Complex Pediatric Intra-cranial Vascular Malformations

IntroductionTrans-arterial endovascular embolization using liquid embolics for the treatment of intra-cranial vascular lesions can be challenging in neonates and infants due to difficulties with arterial access. This is particularly true...

What Are the Potential Implications of Identifying Intracranial Internal Carotid Artery Atherosclerotic Lesions on Cone-Beam Computed Tomography? A Systematic Review and Illustrative Case Studies

A systematic literature review was performed to examine the clinical implications of intracranial internal carotid artery calcific atherosclerotic lesions (IICACALs) detected at cone-beam computed tomographic (CBCT) examinations. The PubMed database was queried in 2 separate searches using the linked search terms non-contrast enhanced cone beam computed tomography and calcified intracranial vascular lesions and non-contrast enhanced computed tomography and calcified intracranial vascular lesions. Reviewed were all English-language articles using CBCT or CT imaging that enrolled neurologically asymptomatic and symptomatic patients. Excluded were studies describing patients with hemorrhagic stroke. Illustrative cases describing incidentally detected IICACALs on CBCT scans are provided. Three articles described identification of IICACALs on CBCT scans of almost 1,500 dental patients. Two of these fully addressed the subject, with 1 noting that IICACALs were benign and another urging patient referral for further workup. Five non-contrast-enhanced CT studies were evaluated in detail; all confirmed IICACALs as a substantive risk marker of advanced stenotic disease in the cerebral circulation, central brain atrophy, concomitant advanced atherosclerotic disease in the cardiovascular circulation, and an indicator of future ischemic events. Five CBCT examinations showing IICACALs in the cavernous and ophthalmic segments are presented. Few studies have denoted the importance of identifying IICACALs on CBCT scans. However, all non-contrast-enhanced CT studies emphasized the clinical significance of these lesions in relation to cerebral and cardiovascular disease. Therefore, IICACALs seen on CBCT and CT scans present the same risk and should prompt referral for further evaluation.

Microsurgery / Endovascular / Combined Treatment of Intracranial Vascular Lesions

Introduction: Intracranial vascular lesions treatment includes, nowadays, several options, and requires careful evaluation when deciding which modality to choose. The goals remain simple - permanent occlusion and optimal preservation or even restoration of patient’s neurological function. There are two main groups of treatment, microsurgery and endovascular. With development of multidisciplinary approach there are cases that require, and are eligible for combined treatment. Varieties of factors have to be considered when deciding on treatment modality. Those include whether vascular lesion has ruptured or not, it’s size and location, patient’s age and medical condition and associated factors such as intracerebral hemorrhage (ICH), intraventricular hemorrhage (IVH) or presence of vasospasm. Aim: We present several cases treated microsurgical, endovascular or with combined approach considering latest recommendations, multidisciplinary decisions making (neurologist, radiologist, neurosurgeon) and availability of an interventional option that had an acceptable risk. Material and Methods: The cases have been chosen regarding the presentation, treatment option and outcome. Results: On the basis on several cases presented, we have considered indications and so far published several studies results and recommendations regarding treatment options for intracranial vascular lesions, focusing on combined approach. Conclusion: With development of endovascular treatment techniques, which are approaching the phase of acceptance and appropriate use, the patients with intracranial vascular lesions have gained a therapy option that can be primary, secondary or combined with surgical treatment. The decision on treatment option has to be individually based considering patient/lesion factors and institutional availability of each technique experts.

Is Calcification of Intracranial Arteries Important and How?

Intracranial atherosclerosis is a well-recognized and common cause of stroke in Asian, black, and Hispanic individuals.1,2 Recent studies showed that intracranial occlusive disease is also a more common cause of stroke in white individuals than previously thought.3 In this issue of JAMA Neurology, Bos and colleagues4 provide evidence that intracranial carotid artery calcification is an important risk factor for stroke in an elderly white Dutch population. As part of the prospective, population-based Rotterdam study, the authors followed up 2323 individuals to determine the incidence of stroke (parenchymal brain hemorrhage or ischemic) after they had nonenhanced computed tomography (CT) scanning that imaged the coronary arteries, aortic arch, extracranial carotid arteries, and intracranial carotid arteries. The authors used calcification volume in these arteries as an indicator of atherosclerosis and correlated this with the risk for all stroke and ischemic stroke. They found that larger intracranial carotid calcification volume was independently associated with all stroke and that intracranial carotid calcification was a more important risk factor for stroke than aortic arch calcification or extracranial carotid calcification. The apparent discrepancy between the importance of intracranial carotid calcification as a major risk factor for stroke in this study and the low frequency of stroke caused by intracranial atherosclerosis in most studies of white patients is largely explained by the different design of these studies. Prior studies identified consecutive patients with stroke and determined the frequency of proximal intracranial atherosclerotic arterial stenosis. In the current study, intracranial carotid calcification (not stenosis) was measured and correlated with subsequent stroke regardless of the territory of the stroke. Data on the size, location (cortical or subcortical), and vascular territory of brain infarcts were not collected. While the current study suggests that intracranial carotid artery calcification is an important, previously seldom considered, risk factor for subsequent stroke in any vascular territory in white patients, the study did not show that the intracranial vascular lesions were the cause of the strokes. Many of the ischemic strokes in this study were almost surely not caused by intracranial carotid atherosclerosis because the strokes were either in a different vascular territory or were caused by other vascular diseases (eg, coexisting penetrating artery disease,5 a cardiac source of embolism). Moreover, at least 11% of the strokes in the study were hemorrhagic and no causal relationship has been established between intracranial arterial calcification and parenchymal brain hemorrhage. Recent interest in calcification of arteries has been spurred on by the strong association between coronary calcification detected by cardiac CT and the risk for future cardiac events.6 The situation appears to be different in relation to carotid artery disease in the neck where the presence of heavy calcification on spiral CT has been correlated with stable, noninflammatory, asymptomatic plaques.7 Whether intracranial arterial calcification is also associated with stable plaque that is unlikely to cause a distal stroke is unknown. What is known is that severe stenosis of an intracranial artery is strongly associated with a high risk for stroke distal to the stenosis in patients presenting with a transient ischemic attack or stroke.8 If the presence of severe intracranial carotid calcification implied coexistent severe arterial stenosis of the artery, that would provide some evidence of a potential causal link between calcification and risk for stroke attributable to the affected artery. However, the relationship between calcification of the intracranial carotid artery and coexistent stenosis is unsettled. Older pathological studies found that heavy calcification of the carotid siphon did not necessarily indicate stenosis of the lumen9; however, a more recent neuroimaging study showed that the positive predictive value of severe carotid siphon calcification on CT for a stenosis of greater than 50% on angiography was 86% using bone window measurements.10 It is also possible that intracranial carotid calcification may cause stroke without the presence of coexistent stenosis if calcification is associated with unstable plaque features that predispose to distal embolism. This study by Bos and colleagues4 raises important questions about the role of calcification in the pathophysiology of intracranial atherosclerosis and should reawaken interest in intracranial atherosclerosis as a cause of stroke inwhite individuals. The study indicates that intracranial carotidcalcification isamajor risk factor for stroke inwhite individuals but does not establish a pathophysiologic causal relationshipbetweenthe two.Establishing thatwill require further prospective studies that correlate the association between intracranial arterial calcification and stenosis more clearly, identifyatheroscleroticplaque featuresassociatedwith calcification thatmay be associatedwith a high risk for distal embolism, and classify ischemic strokes that occur in patientswith intracranial carotid calcification according to size, location (cortical or subcortical), vascular territory, and thecoexistenceofotherpotential causesof stroke.Muchworkneeds to be done. Related article page 405 Opinion

Treatment of Cerebral Aneurysms—Surgical Clipping or Endovascular Coiling: The Guiding Principles

Cerebral aneurysms represent common intracranial vascular lesions encountered in neurosurgical practice. The clinical presentation is varied, ranging from asymptomatic lesions to those presenting with catastrophic intracranial hemorrhage. Aneurysm treatment has been a rapidly evolving field with numerous technical innovations, especially in the last two decades. Selecting the appropriate treatment can be a complex process that involves integration of information regarding the patient's clinical presentation, associated comorbidities, the aneurysm's morphological characteristics, safety and efficacy of the treatment options and skill and experience of available practitioners, amongst others. In this article, we review each of these factors and appraise the available scientific evidence in an effort to facilitate decision making in the treatment of cerebral aneurysms. The treatment of intracranial aneurysms is best performed at high volume centers that utilize a multidisciplinary, team-based approach.

New and Emerging Interventional Neuroradiologic Techniques for Neuro-Opthalmologic Disorders

A number of cerebrovascular disorders produce manifestations of neuro-ophthalmologic significance. In many cases, these disorders can be treated using endovascular techniques. The material in this article was obtained from a combination of personal experience and review of the literature using PubMed. A variety of new equipment, materials, and techniques are available to the interventional neuro-radiologist dealing with intracranial vascular lesions such as aneurysms, arteriovenous fistulas, and arteriovenous malformations. Physicians whose patients have intracranial vascular lesions should be aware of the endovascular options available for their patients.

Intracranial Vasa Vasorum: Insights and Implications for Imaging

This review offers insight into the possible role of vasa vasorum in the development of intracranial vascular disease. Unique structural features of intracranial vessels and nourishment from the surrounding cerebrospinal fluid environment may account for the relative lack of intracranial vasa vasorum early in life. However, with advancing age and with the development of vascular disease, vasa vasorum are known to develop. Advanced contrast material-enhanced imaging techniques are capable of helping detect and even grade intracranial vasa vasorum, and this may provide new insights into our ability to diagnose and assess the risk of intracranial vascular lesions such as atherosclerosis, aneurysms, dissections, and vasculitis.

Fluorescein Fluorescence Use in the Management of Intracranial Neoplastic and Vascular Lesions: A Review and Report of a New Technique

The use of fluorescent technologies in neurosurgery has a substantial history with applications to vascular and tumor surgery dating back to the 1940s. This review focuses on the applications of fluorescence imaging to intracranial vascular and neoplastic lesions using sodium fluorescein. The authors performed a literature search for articles about the use of sodium fluorescein in neurosurgery. Fifty-five articles were initially retrieved, and 37 of these were appropriate for this review. The subcategorization of these articles revealed 2 describing the properties of fluorescein, 19 articles relating to applications of fluorescein to tumor, 11 relating to vascular applications, and 5 reporting side effects associated with fluorescein use. Articles related to use of this agent in evaluation of CSF leak were excluded. Sodium fluorescein has been reported to be a useful surgical adjunct in resection of neoplastic lesions based on differential fluorescence between normal and neoplastic tissue. There are many reports on the utility of fluorescein in vascular imaging relating to arteriovenous malformations, aneurysms, and vessel anastomosis; however, these reports do not examine primary outcomes. Sodium fluorescein has been judged as generally safe with few reports of severe complications. Sodium fluorescein has demonstrated promise as a useful surgical adjunct in neurosurgery for vascular and neoplastic lesions. It is well tolerated, but further study is required to determine its full utility. Finally, we will introduce a new practical technology that could potentially improve intraoperative application of sodium fluorescein by improving its fluorescence visualization while using substantially lower doses of this dye.

Management of vasospasm in ruptured unsecured intracranial vascular lesions: review of 10 cases

IntroductionRisks associated with endovascular management remain unaddressed for post-hemorrhagic cerebral vasospasm (PHCV) caused by pathologies that cannot be secured or identified before vasospasm treatment. This retrospective study reviews our 10...

Value of CT angiography for the detection of intracranial vascular lesions in patients with acute severe headache

To retrospectively investigate the prevalence and characteristics of intracranial vascular lesions in patients with acute severe headache with the use of CT angiography (CTA). We systematically searched for neurologically intact patients with acute severe headache and normal unenhanced head CT. The study group consisted of 512 patients; 251 male; mean age 46.2 ± 12.4 years. All patients underwent CTA between 1 day and 2 months after the headache attack. CTA images were interpreted by two experienced neuroradiologists for the presence of vascular lesions. Thirty-four (6.6 %) of the 512 patients had intracranial vascular lesions on CTA, including 33 aneurysms (2 patients had 2 aneurysms each), 2 moyamoya disease and 1 arterial dissection. No gender- or age-related differences were found. Aneurysms arose most commonly on the internal carotid artery (n = 12), followed by the anterior communicating artery (n = 7), and the middle cerebral artery (n = 7). Maximal diameters ranged from 2.0 to 13.1 mm (mean, 3.9 ± 2.6 mm). CTA is a feasible tool for diagnosing intracranial vascular lesions in patients with acute severe headache. The prevalence of vascular lesions in our series was 6.6 %, which is higher than that predicted in the general population. • Unruptured cerebral aneurysms may be a cause of acute severe headache • CTA assesses intracranial vascular lesions in patients with acute severe headache • The prevalence of vascular lesions in our series of patients was 6.6 %

Correlation of single small vessels infarction in carotid territory with large arterial lesion

Whether small vessel infarction (SVI) correlates with large arterial lesion is under debate. The aim of the present study was to analyze the relationship between the single SVI in carotid territory by diffusion weight imaging (DWI) and arterial lesion by contrast enhanced magnetic resonance angiography (CEMRA). Sixty patients with acute cerebral infarction underwent DWI within 7 days and CEMRA within 2 weeks after onset. They were divided into 2 groups of patients with and without single SVI. The clinical and magnetic resonance image features were compared between two groups. Lesions of ipsilateral extracranial carotid artery were detected in 10 patients of SVI groups (36%) versus 8 patients (25%) of non-SVI group (P = 0.54). Incidence of intracranial vascular lesion in single SVI group (32%) was slightly lower than that of non-SVI group (47%) (P = 0.52). And 46 patients (77%) were assessed on plaque of carotid artery. Incidence of ipsilateral carotid artery plaque (44%) was higher in single SVI group than that of non-SVI group (35%) (P = 0.76). And the incidence of vulnerable plaque in single SVI group (26%) was similar to that of non-SVI group (22%) (P = 0.73). SVI has not a single underlying mechanism of stroke. However, further studies with a large number of patients are warranted.

Do Lacunar Strokes Benefit from Thrombolysis? Evidence from the Registry of the Canadian Stroke Network

Lacunar infarcts constitute up to 25% of all ischaemic strokes. As acute intracranial vascular imaging has become widely available with computed tomographic angiography, thrombolysis of lacunar strokes has become contentious because an intracranial vascular lesion cannot be visualized. We studied the effect of thrombolysis on lacunar strokes compared to other clinical ischaemic stroke sub-types. Ischaemic stroke patients from phase 3 of the Registry of the Canadian Stroke Network data (July 2003-March 2008) were included. Lacunar stroke was defined as a lacunar syndrome supported by computed tomography brain showing a subcortical hypodense lesion with a diameter <20 mm. Clinical syndromes were used to define other stroke sub-types. The outcomes were mortality at 90 days, modified Rankin Scale score 0-2 at discharge, occurrence of intracranial haemorrhage as a complication of stroke in-hospital, and discharge disposition to home. A total of 11,503 patients of ischaemic stroke were included from the Registry of the Canadian Stroke Network 3 between July 2003 and March 2008. Lacunar strokes formed 19.1% of the total strokes. The total number of patients who received tissue plasminogen activator was 1630 (14.2%). A significant association was found between tissue plasminogen activator treatment and outcomes after controlling Oxfordshire Community Stroke Project types--for modified Rankin Scale at discharge and discharge to home, but not for mortality. A thrombolysis-by-Oxfordshire Community Stroke Project stroke sub-type interaction was observed due to lack of benefit among the posterior circulation stroke sub-types. Patients with lacunar strokes, partial anterior circulation stroke, and total anterior circulation strokes all benefited approximately equally from thrombolysis. Thrombolysis is associated with clinically improved outcome among patients with lacunar stroke syndromes.

Predictors of in-stent stenosis and occlusion after endovascular treatment of intracranial vascular disease with the Willis covered stent

Covered stent placement has emerged as a promising therapeutic option for intracranial vascular lesions. However, in-stent stenosis and occlusion continue to be important concerns with the use of a covered stent, which is more thrombogenic than other types of stents. The purpose of this study was to determine predictors of in-stent stenosis and occlusion for covered stents used in the treatment of intracranial vascular diseases. Clinical, procedural and angiographic data of 46 patients with 49 intracranial vascular lesions treated with the Willis covered stent (Micro-Port, Shanghai, China) between April 2005 and October 2010 were collected and analyzed retrospectively. Univariate analysis and multivariate logistic regression analysis were performed to determine the factors predictive of in-stent stenosis and/or occlusion of the stents. In-stent stenosis and/or occlusion were documented at angiography in six patients with six lesions, and no stenoses or occlusions were seen at angiography in the remaining 40 patients with 43 lesions. Univariate analysis revealed that hypertension, post-procedure irregular antiplatelet therapy and cerebrovascular arteriosclerosis were associated with in-stent stenosis and/or occlusion. By multivariate logistic regression analysis, post-procedure irregular antiplatelet therapy (odds ratio [OR]=15; 95% confidence interval [CI], 1.172–192.004; p=0.037) and cerebrovascular arteriosclerosis (OR=19; 95% CI, 1.374–262.659; p=0.028) were independent predictors of in-stent stenosis and/or occlusion. Thus, post-procedure irregular antiplatelet therapy and coexistent cerebrovascular arteriosclerosis appear to increase the risk of in-stent stenosis and/or occlusion of covered stents in the treatment of intracranial vascular disease.

Susceptibility-weighted angiography for the detection of high-flow intracranial vascular lesions: preliminary study

Susceptibility-weighted magnetic resonance imaging (MRI) sequences may demonstrate various signal intensities of draining veins in cases of high-flow vascular malformation (HFVM), including arteriovenous malformation (AVM) and dural arteriovenous fistula (dAVF). Our objective was to evaluate susceptibility-weighted angiography (SWAN) for the detection of HFVM. Fifty-eight consecutive patients with a suspected intracranial vascular malformation were explored with SWAN and post-contrast MRI sequences at 3 T. The diagnosis of slow-flow vascular malformation (SFVM), including developmental venous anomaly (DVA) or brain capillary telangiectasia (BCT), was based on MRI. Patients with suspected HFVM underwent digital subtraction angiography (DSA). SWAN images were analysed by three blinded readers according to a three-point scale of the venous signal. Thirty-one patients presented 35 SFVM (26 DVA and 9 BCT) that systematically appeared hypointense on SWAN images. In patients with atypical MRI findings, DSA revealed one patient with an atypical DVA and 26 patients with HFVM (22 AVM and 4 dAVF). SWAN revealed at least one venous hyperintensity in all patients with HFVM. Agreement between readers was excellent. SWAN appears reliable for characterising blood flow dynamics in brain veins. In clinical practice, SWAN can routinely rule out HFVM in patients with atypical brain veins.

Pitfalls in the Detection of Intracranial Aneurysms With 3-Dimensional 64-Multidetector CT Angiography

CME Category: Neuroradiology Modality: CT Diagnosing intracranial aneurysms is a challenging task for radiologists. Currently, rotational cerebral angiography is the “gold standard” for detecting intracranial aneurysms.1 But because rotational cerebral angiography is an invasive procedure with potential complications, CT angiography (CTA) with volume-rendered 3-dimensional (3D) reconstruction has been suggested as a promising alternative for the initial evaluation of the intracranial circulation. However, even this latter modality is less than perfect, and the radiologist can benefit from the information provided in this CME activity by realizing the limitations when interpreting images based on CTA/3D reconstruction. The limitations are outlined in Table 1. By addressing these limitations, the radiologist potentially can avoid pitfalls that would otherwise cause misdiagnosis of intracranial vascular lesions.

Pediatric Intracranial Nongalenic Pial Arteriovenous Fistulas: Clinical Features, Angioarchitecture, and Outcomes

NGAVFs are rare vascular malformations usually presenting in infancy or childhood. We sought to identify clinical and angiographic predictors of clinical outcome for these lesions. Retrospective review of a neurointerventional data base identified 386 pediatric patients with intracranial AVFs and AVMs, from which a cohort of 25 patients with NGAVF were selected for medical record and imaging analysis. NGAVFs constituted 7.3% of pediatric intracranial vascular lesions with a nondural arteriovenous shunt. Seven of 8 patients who presented in the first month of life had CHF and harbored large, complex fistulas with multiple sites of arteriovenous shunting. Single-hole fistulas predominated later in childhood and more frequently presented with seizures, hemorrhage, or focal neurologic deficits. More treatment procedures were performed in subjects presenting at ≤ 2 years of age compared with older children (median = 3 versus 2, P = .041), and in those harboring a multi-hole fistula versus those with a single-hole fistula (median = 3 versus 2, P = .003). Eighteen patients (72%) had complete posttreatment elimination of NGAVF shunting. Compared with patients presenting at >2 years of age, patients presenting in the first 2 years of life were more likely to have a multi-hole fistula (100% versus 25%, P = .0001) and to have a poor clinical outcome (54% versus 0%, P = .0052), defined as a pediatric mRS of ≥ 3. The morbidity of NGAVF appears higher than previously reported despite a somewhat higher rate of angiographic cure. Poor clinical outcome occurred primarily in patients with multi-hole NGAVFs presenting at ≤ 2 years of age.