AJNR. American journal of neuroradiology最新文献

Background and purpose: In patients with large-core infarcts, the risk and clinical implications of post-treatment intracranial hemorrhage (ICH) remain poorly understood. We aimed to characterize the frequency, patterns, predictors, and prognostic relevance of post-treatment ICH in patients with large-core infarcts treated in the TENSION trial.

Methods: We performed a post hoc analysis of 253 patients with anterior circulation stroke and an Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of 3-5 randomized to either mechanical thrombectomy (MT) plus best medical treatment (BMT) or BMT alone. Hemorrhages were categorized both clinically (symptomatic vs. asymptomatic) and radiologically using the Heidelberg Bleeding Classification. Predictors of parenchymal hematoma (PH) and symptomatic ICH (sICH) were identified using logistic regression. The association between bleeding severity and 90-day outcome was evaluated using multivariable models.

Results: Any ICH occurred in 45.1% of patients, more frequently after MT compared with BMT (54.4% vs. 35.9%, p=0.004), mostly asymptomatic. Among patients with any ICH, hemorrhagic infarction was associated with the highest rate of favorable outcome (34.0%) and was equally distributed across treatment arms. PH were more common after MT (23.2% vs. 9.4%, p=0.004). Predictors of PH included MT itself (aOR 2.11, CI 1.11-3.99), higher NIHSS (aOR 1.13, CI 1.04-1.23), and larger core volume (aOR 1.003, CI 1.000-1.005). No independent predictors of sICH were identified. In adjusted models, bleeding severity was not associated with poor outcome, whereas age, NIHSS, and core volume were. Importantly, MT remained independently associated with better functional outcomes, even when adjusting for hemorrhagic events. However, the benefit of MT appeared attenuated in patients who developed PH, as shown by a significant treatment interaction.

Conclusions: ICH is common in large-core stroke, particularly after MT, but is often asymptomatic and not independently linked to poor outcome. PH may reduce the benefit of MT, but overall, MT remains associated with improved functional outcomes. Distinguishing hemorrhage types is crucial in assessing post-treatment risk in this vulnerable population.

Background and purpose: Normative linear measurements of inner ear structures may enhance diagnostic accuracy in detecting subtle congenital abnormalities. This study aimed to establish Cone-Beam Computed Tomography (CBCT)-based normative reference values for temporal bone anatomy.

Materials and methods: We retrospectively reviewed consecutive CBCT scans of normal temporal bones acquired between June 2022 and June 2024. Scans were classified as normal based on the absence of pathological findings and no history of otologic disorders. Eleven linear measurements of inner ear structures were independently performed by two radiologists, and interobserver agreement was assessed. Reference centiles were generated for each parameter.

Results: A total of 319 patients (135 men, 184 women; mean age, 50.03 years; range, 3 months-91 years) were included. Interobserver reliability was high across all measurements. Age and sex showed a small effect on any measurement. Normative centile distributions for all eleven structures were established.

Conclusions: This study provides robust CBCT-derived normative linear measurements of inner ear structures. These reference values may improve radiologic assessment of congenital hearing loss, particularly in patients with normal-appearing CT examinations.

Background and purpose: Complications of aneurysmal subarachnoid hemorrhage (aSAH), including vasospasm and delayed cerebral ischemia (DCI) substantially contribute to morbidity and mortality. We investigated the correlation between quantitative measurements on MRA performed immediately post-endovascular embolization and subsequent development of DCI or vasospasm.

Materials and methods: We included consecutive patients scanned between 9/1/2016 and 1/14/2022 with ruptured intracranial aneurysms (IAs) after endovascular treatment. We recorded clinical data including sex, age, BMI, smoking history, vascular risk factors, baseline CTA/CT features, modified Fisher score, and Glasgow Coma Score. We extracted quantitative MRA features, including total arterial length, total branch number, and average tortuosity, using a custom semi-automated software (VesselVoyager). Correlations between baseline quantitative MRA, other imaging and clinical features with DCI and vasospasm were determined using logistic regression analysis. Receiver operating characteristic (ROC) curves were calculated for clinical-only models and for models augmented with quantitative MRA features.

Results: 78 patients with ruptured IAs were included, of whom 48 developed vasospasm and 24 developed DCI. Multivariable logistic regression analysis showed that only average tortuosity was significantly and independently associated with subsequent DCI (OR 0.62, 95% CI 0.39-0.91, p=0.02). For vasospasm, total arterial length (0.87, 0.78-0.95, p=0.005), average tortuosity (0.37, 0.18-0.62, p=0.001), and age (0.92, 0.86-0.98, p=0.02) were independently associated with vasospasm incidence on multivariable regression. Adding quantitative MRA features improved ROC performance for both DCI (AUC 0.63 [95% CI 0.51-0.75])vs 0.75 [0.64-0.87]) and vasospasm (0.67 [0.54-0.79] vs 0.85 [0.77-0.94]).

Conclusion: In patients with aSAH, average tortuosity is independently inversely associated with future development of DCI. Total branch number and average tortuosity are independently inversely associated with future vasospasm. With further validation, quantitative MRA features may serve as predictive markers for DCI and vasospasm after aSAH.

Background and purpose: Multi-echo (ME) functional MRI (fMRI) acquisition improves separation of signal from noise relative to single-echo (SE). We tested whether this enhances reliability of functional connectivity (FC), with a focus on personalizing transcranial magnetic stimulation (TMS) targets in the dorsolateral prefrontal cortex (DLPFC) in patients with depression.

Materials and methods: Resting-state fMRI scans were acquired from adult patients with major depression (20 female, 15 male) presenting for clinical TMS using either SE (n=21) or ME (n=31). Each subject's fMRI timeseries was split in half, and voxel-wise seed-based FC was computed for 100 general regions of interest (ROIs) and for two TMS-specific ROIs: subgenual cingulate cortex (SGC) and a previously published depression circuit (DEP). Reliability was assessed using (1) spatial correlation between split-half connectivity maps and (2) intraclass correlation coefficient (ICC) for each ROI's connectivity to the DLPFC.

Results: In general ROI analysis, ME showed significantly higher whole-brain split-half correlations than SE (p = 0.006) and higher ICC (ΔICC = 0.16; p = 0.03). In TMS-specific ROI analysis, ME showed higher split-half correlations for both the SGC-DLPFC (p = 0.04) and DEP-DLPFC (p = 0.01). TMS-specific ICC values were numerically higher for ME (SGC-DLPFC: 0.47; DEP-DLPFC: 0.75) than for SE (0.02 and 0.40, respectively), although these differences were not statistically significant.

Conclusion: ME fMRI improves general FC reliability over SE, with suggested advantages for TMS-specific measures. Future work is needed to determine whether these gains meaningfully improve TMS targeting.

Background and purpose: Ventral dural tears (Type 1) are a major cause of spontaneous intracranial hypotension (SIH) and require precise localization for targeted treatment. Although prone digital subtraction myelography (DSM) and dynamic CT myelography (dCTM) are standard diagnostic modalities, their diagnostic performance has not been directly compared. We aimed to evaluate the diagnostic yield and radiation exposure of prone DSM compared with dCTM in a paired cohort.

Materials and methods: In this ambispective study, we analyzed 39 patients with Type 1 leaks who underwent both prone DSM and dCTM at a single tertiary center between July 2024 and September 2025. All images were independently re-evaluated by a blinded neurointerventionist using the SIH-RADS scoring system. The primary outcome was the rate of successful localization, defined as SIH-RADS Category 5. Secondary outcomes included the effective radiation dose and inter-rater reliability.

Results: Successful localization was achieved in 31 patients (79.5%) using prone DSM and in 33 patients (84.6%) using dCTM, with no statistically significant difference between the two modalities (P = .72). Concordant localization was observed in 28 patients (71.8%). The median effective radiation dose of prone DSM was approximately half that of dCTM (P < .001). Diagnostic failures in DSM were primarily attributed to artifacts at the cervicothoracic junction, which were avoidable using the swimmer's position in the majority of the patients, whereas failures in dCTM were associated with temporal limitations or technical failures.

Conclusions: Prone DSM and dCTM demonstrated comparably high diagnostic yields for localizing Type 1 leaks. However, DSM offered a significant advantage in radiation safety. When available and supported by appropriate expertise, prone DSM may be considered as a preferred first-line modality, with dCTM serving as a complementary option.

Vertebral augmentation using the SpineJack implant system (Stryker) is a minimally invasive spine procedure for treatment of patients with vertebral compression fractures.¹ Careful procedural planning and imaging guidance allow safe and effective management of these patients. This management implies preprocedural imaging with measurement of the vertebral body length and pedicle width, which are essential for selection of the appropriate implant size.^2,3 Implant kyphoplasty has been shown to significantly reduce pain, restore the vertebral height, and improve the local kyphotic angle, without major adverse events.^3,4 It also offers the advantages of functional recovery and decreasing the refracture rates with overall an improved quality of life.^5,6 This video article gives an overview of the indications, procedural considerations, and technical approach, as well as postprocedural care and patient outcomes with representative clinical images obtained from our experience.

Background and purpose: CSF-venous fistulas (CVFs) are an increasingly recognized cause of spontaneous intracranial hypotension and require invasive myelography for localization. Whether spine MRI can noninvasively predict CVF origin remains unclear. The purpose of our study was to determine if spine MRI features, particularly the size and location of spinal meningeal diverticula, are predictive of the CVF location identified on myelography.

Materials and methods: Retrospective review was conducted of 100 patients with a CVF confirmed on decubitus CT myelography who underwent preprocedural spine MRI. The primary outcome was whether the CVF arose at or adjacent to the largest diverticulum. Secondary outcomes included distribution patterns of the largest adjacent-level diverticula and their spatial relationship to the CVF (cranial, caudal, ipsilateral, contralateral). χ² tests, 1-sided binomial tests, and t tests were used to assess statistical significance.

Results: CVFs originated at or adjacent to the largest diverticulum in 77% of patients, significantly more than expected by chance (P < .001); 71.7% of CVFs were within one level of the adjacent largest diverticulum on spine MRI. Among adjacent-level cases of the largest diverticula, there was a significant directional preference for the adjacent largest diverticulum to occur caudal to the CVF compared with a uniform distribution (P = .001). Three specific diverticular patterns were statistically significant: caudal and ipsilateral 1 level below the CVF (P < .001), contralateral same level (P < .001), and caudal and contralateral one level (P = .002). There was no significant correlation between the laterality of the largest diverticulum size nor the laterality of most of the diverticula compared with the laterality of the CVF.

Conclusions: Spinal CVFs most commonly arise at or adjacent to the largest meningeal diverticulum. The adjacent largest diverticulum was commonly within 1 level to the CVF and most commonly caudal 1 level to the CVF or at the same level contralateral side to the CVF. These MRI-based predictors may help guide myelography.

Background and purpose: We investigated patient-reported symptom relief from percutaneous ultrasound-guided radiofrequency ablation (RFA) of benign thyroid nodules in routine clinical care, given that prior studies have reported efficacy based on size reduction and specific symptom scores but not patient-reported effectiveness.

Materials and methods: This retrospective cohort study included all consecutive adults treated between May 12, 2021 and August 7, 2024 with ultrasound-guided RFA for symptomatic benign thyroid nodules at a quaternary care hospital. Procedures were performed by a single board-certified neuroradiologist utilizing a trans-isthmus moving shot technique. Patient-reported symptom relief (symptoms resolved yes/no) was assessed at 6-month routine clinical follow-up. Descriptive statistics were performed. Preablation nodule size associations with symptom resolution were assessed with Wilcoxon tests.

Results: Forty-nine patients (mean age, 56.6 ± 13.1 years; 45 women) had average preablation nodule volume of 30.6 ± 31.0 mL, higher than the 20.1 ± 22.4 mL reported in a recent meta-analysis of efficacy studies. Common preablation symptoms were cosmetic deformity (37/49, 77.1%), dysphagia (28/49, 58.3%), and dysphonia (15/49, 30.6%). Thirty-six patients (73.0%) completed at least 1 follow-up visit. Postablation symptom resolution was 78.0% (28/36, 95% CI, 61.9%-88.3%) among those with follow-up, higher than the 64.4% reported in the single study included in the meta-analysis that assessed subjective symptom relief. Relative mean volume reduction was 52.3% ± 27% in those with follow-up and was associated with symptom resolution (59% reduction with symptom resolution versus 30% without; P = .035). One patient experienced a minor bleeding complication.

Conclusions: Patient-reported symptom relief from percutaneous ultrasound-guided thermal ablation of benign thyroid nodules in our clinic has resulted in approximately 80% clinically relevant effectiveness based on patient-reported symptom relief, with a slightly lower volume reduction rate compared with those reported in efficacy studies. Our clinic patients had larger nodule volumes than typical in published studies and many patients opted to forgo posttreatment follow-up. This likely led to underestimation of our effectiveness and volume reduction measurements.

A subset of postdural puncture headaches (PDPH) persist despite conventional epidural blood patches (EPDs), leading to chronic symptoms and substantial disability. Dural punctures may involve not only the dorsal dural surface, which is covered by a standard interlaminar EBP but also in some instances the ventral dural surface, which may not be covered by standard EBPs. This report describes the CT fluoroscopy-guided circumferential EBP, a technique that achieves 360° coverage of patching material around the thecal sac using combined ventral transforaminal and dorsal interlaminar injections. The procedural details for this technique are described, and the technical success and clinical results are reported for 6 patients with PDPH, 4 of whom had failed prior dorsal-only EBPs. Intraprocedural imaging confirmed complete circumferential patch coverage in all cases, and all 6 patients reported substantial or complete symptomatic resolution. These results establish the feasibility of CT fluoroscopy-guided circumferential EBP for PDPH.

Background and purpose: Type 2 leaks occur in up to 20% of spontaneous intracranial hypotension (SIH) due to a spinal lateral dural tear, typically accompanied by an arachnoid hernia. Their CSF-outflow dynamics are unclear, but could have implications for performing myelography for the best possible detection. This cross-sectional study analyzed temporal characteristics of type 2 leaks using digital subtraction myelography (DSM).

Materials and methods: Between February 2020 and April 2025, 63 consecutive patients with type 2 leaks were retrospectively identified. Patients undergoing sufficient decubitus DSM (comprising additional fluoroscopy and x-ray images) were included. We assessed the time for the contrast agent to first appear in the epidural space after reaching the level of the leak intrathecally at 1-2 frames-per-second (fps) and categorized them as fast (0-9 seconds), medium (10-90 seconds), and slow (>90 seconds) leaks. Furthermore, effects of intrathecal pressurization, arachnoid hernia size, opening pressure, and symptom duration on CSF-outflow were studied.

Results: Forty-five patients (36 women) were included. Mean age was 39.0 years (SD ±11.4 years), mean body mass index 23.2 (SD ±3.9), and median Bern score 6 (interquartile range 5). Type 2 leaks most commonly occurred at the T10/11 level (12/45; 26.7%), ranging between T7/8-L1/2. During DSM, contrast appeared in the epidural space within 0-9 seconds in 3 of 45 (6.7%), 10-90 seconds in 24/45 (53.3%), and >90 seconds in 5 of 45 (11.1%) of cases (range: 4 to 473 seconds). If DSM (or fluoroscopy/x-ray) missed the leak, subsequent conebeam or CT myelography detected it (13/45; 28.9%); total slow leaks were 18 of 45 (40%). All patients undergoing surgery (40/45) had the leak confirmed intraoperatively. In a subgroup of patients undergoing pressurization during DSM (12/45), there were significantly more leaks detected within 90 seconds (P = .22), while arachnoid hernia size, opening pressure, and symptom duration did not affect CSF-outflow significantly.

Conclusions: Type 2 leaks show a wide range of CSF-outflow characteristics, with most being medium and slow. For DSM, we propose using a 90-second run with intrathecal pressurization and conebeam CT standby for effective leak detection, whereas less than 1 fps (eg, 0.5 fps) seems feasible to minimize radiation. Alternatively, dynamic CT myelography can be considered, though the timing of CT scans has yet to be evaluated.