AJNR. American journal of neuroradiology最新文献

Background and purpose: The safety and efficacy of intravenous tenecteplase in acute ischemic stroke patients with primary medium and distal vessel occlusions (MDVO) selected for mechanical thrombectomy remain an area of active investigation. This observational study aimed to compare tenecteplase and alteplase in MDVO patients treated with mechanical thrombectomy (MT).

Methods: A retrospective, propensity score-weighted analysis of two cohorts: patients with patients with primary MDVO who received bridging intravenous thrombolysis prior to MT, from the multicenter TETRIS registry treated with tenecteplase, and patients from a tertiary center cohort treated with alteplase. The primary outcome was a modified Rankin Scale (mRS) score of 0-2 at 90 days. Secondary outcomes included mortality, symptomatic intracranial hemorrhage (sICH), and early and final successful reperfusion rates, assessed using the extended Thrombolysis in Cerebral Infarction (eTICI) 2b-3 scale.

Results: We included 110 patients, 65 receiving tenecteplase and 45 receiving alteplase. mRS 0-2 at 90 days was achieved in 53.8% of tenecteplase-treated patients versus 48.9% of alteplase-treated patients (p = 0.41). Mortality and sICH rates were similar between groups (12.3% vs. 13.3%, p=0.68; 3.1% vs. 0%, p = 0.51, respectively). There was no significant difference in early reperfusion between tenecteplase and alteplase (40.2% vs. 31.1%; p = 0.53). Final successful reperfusion did not significantly differ (80.4% vs. 88.9%; p = 0.28).

Discussion and conclusion: In MDVO, tenecteplase yielded comparable safety and functional outcomes to alteplase, without statistically significant differences in early or final reperfusion. In light of recent trials questioning the benefit of MT in MDVO, these data suggest comparable safety and functional outcomes between tenecteplase and alteplase as bridging thrombolysis prior to mechanical thrombectomy, within the limits of this observational study.

Background and purpose: Idiopathic intracranial hypertension (IIH) is a condition marked by elevated intracranial pressure, often leading to vision loss if untreated. While cerebrospinal fluid (CSF) opening pressure is a primary diagnostic criterion, it lacks sensitivity in normotensive cases. This study aimed to develop a non-invasive, imaging-based diagnostic model integrating a novel MRI-Rigidity Index (MRI-RI) and a conventional MRI-derived IIH-MR Score to assess intracranial rigidity and improve diagnostic accuracy across the IIH spectrum.

Materials and methods: Sixty-one participants were prospectively analyzed and divided into three groups: confirmed IIH (n=23), normotensive with IIH-compatible imaging (n=18), and healthy controls (n=20). The male-to-female distribution was 7/16 in Group 1, 5/13 in Group 2, and 8/12 in Group 3. All subjects underwent 1.5T MRI, including structural sequences and phase-contrast (PC) CSF flow imaging. The MRI-RI was calculated as Vmax² × |NFV|/Vmean, where Vmax reflects peak CSF flow velocity, Vmean represents mean flow velocity, and |NFV| denotes the net cerebrospinal fluid displacement per cardiac cycle, calculated as a magnitude-based volumetric measure independent of flow direction. A six-parameter IIH-MR Score (range: 0-10) quantified perioptic CSF distension, Meckel's cave size, sella morphology, optic disc protrusion, optic nerve tortuosity, and posterior scleral flattening. Interobserver agreement, intergroup comparisons, ROC analysis, and correlation with CSF pressure were performed.

Results: MRI-RI and IIH-MR Scores differed significantly across groups (p<0.001), with the highest values in confirmed IIH and the lowest in controls. A total MRI score ≥6 yielded 100% sensitivity and 92% specificity for detecting elevated CSF pressure; ≥7 provided 100% specificity. MRI-RI was notably elevated in normotensive patients with IIH-compatible features. Strong correlations were found between total MRI score and CSF pressure (r=0.85), and MRI-RI (r=0.66). Interobserver agreement was excellent (ICC=0.88-0.96; kappa=0.76-0.91).

Conclusion: The combined use of MRI-RI and IIH-MR Score allows comprehensive, non-invasive evaluation of intracranial rigidity in IIH. MRI-RI may detect early mechanical alterations even in normotensive patients, while IIH-MR Score offers structurally grounded diagnostic support. These tools may enhance early diagnosis and reduce the need for lumbar puncture in selected cases.

Background and purpose: Moyamoya disease (MMD) is characterized by chronic progressive stenosis of intracranial vessels and subsequent formation of abnormal collateral vessel networks. Indirect revascularization techniques, such as encephalo-duro-arterio-synangiosis (EDAS), promote angiogenesis to restore perfusion but have variable success rates. This study aimed to identify clinical and radiographic predictors of successful collateral vessel ingrowth after EDAS, emphasizing the role of contralateral interhemispheric collaterals.

Materials and methods: We conducted a single-center retrospective analysis of cerebral hemispheres from adult MMD patients who underwent EDAS. We assessed demographic characteristics, clinical presentation, procedural details, clinical and radiographic outcomes. Angiographic outcomes were assessed using the Orbital Grading System. Univariate analysis was performed to identify factors associated with favorable postoperative collateral development. Consequently, preoperative contralateral interhemispheric collateralization was quantitatively evaluated through pixel density analysis on digital subtraction angiography (DSA), comparing the moyamoya-affected hemisphere to the contralateral hemisphere.

Results: 61 MMD hemispheres of 43 adult patients were included in the study. Median times to last clinical and angiographic follow up were 29.9 months and 13.6 months, respectively. Higher Suzuki-stages (V and VI; p=<0.01), occlusions of the anterior cerebral artery (ACA; p=0.03) and internal carotid artery (ICA; p=0.048) were associated with superior postoperative collateralization. The presence of robust contralateral collaterals on preoperative angiography significantly predicted poor postoperative neovascularization (p=0.01). Pixel density analysis showed that increased pixel density ratios of moyamoya-affected hemisphere to contralateral hemisphere significantly correlated with reduced postoperative collateral vessel formation (Orbital Grading System, OR=130.94, p=0.008; Matsushima grading system, OR=52.09, p=0.018).

Conclusion: Higher Suzuki-stages, ACA and ICA occlusion predict successful neovascularization after EDAS. The presence of robust preoperative contralateral interhemispheric collaterals is an important predictor of poor collateral vessel ingrowth following EDAS. This finding suggests that such collateralization might reduce the local ischemic stimulus required for effective indirect revascularization. These findings could refine surgical decision-making by identifying patients who may be less likely to benefit from EDAS.

Introduction: Middle meningeal artery (MMA) embolization is increasingly used to treat chronic subdural hematoma (cSDH) following surgical evacuation. However, no standardized system exists to assess angiographic embolization extent or its clinical impact. This study introduces a novel grading system for evaluating liquid embolic penetration and its association with outcomes.

Methods: Consecutive patients who underwent MMA embolization using n-BCA between 2019 and 2023 were included. Data were prospectively collected and retrospectively analyzed, including demographics, hematoma characteristics, and follow-up imaging up to 12 months. Embolization was graded on a four-point angiographic scale: 1-proximal ligation, 2-branch penetration without midline reach, 3-penetration to midline, and 4-crossing midline. Postoperative CT was used to evaluate hematoma volume and recurrence. Linear and logistic regression analyses were performed to correlate angiographic grade with time to resolution and recurrence, with significance at p < 0.05.

Results: Seventy-thee patients met inclusion criteria. Embolization was grade 2 in 43.8%, grade 3 in 46.6%, and grade 4 in 5.5%. Complete cSDH resolution within 3 months occurred in 19% of patients, with a mean resolution time of 6.60 ± 4.07 months. Each grade increase correlated with a 1.61-month faster resolution (p = 0.048) and a significantly higher likelihood of 3-month resolution (OR 4.86, 95% CI 1.36-23.9, p = 0.027).

Conclusion: Deeper liquid embolic penetration on angiography is associated with faster and more complete cSDH resolution. This novel grading scale may serve as a useful intra-procedural tool, pending further validation in larger prospective studies.

We evaluated the safety and efficacy of CT-guided intracystic fibrin glue injection for cerebrospinal fluid-venous fistulas (CVFs) causing spontaneous intracranial hypotension. In this 2-center retrospective series, 16 patients underwent fibrin injection directly into the diverticular cyst, with additional epidural or paravertebral injection as needed. Median intracystic fibrin volume was 1.0 mL; thecal sac extension was present in 44% of cases. No serious or permanent complications, arachnoiditis, or neurologic deficits were observed. Transient rebound intracranial hypertension occurred in 31% and transient radicular pain in 6%, both resolving spontaneously. Clinical outcomes were favorable, with 88% of patients reporting complete and 12% partial symptom improvement. The median Bern score decreased from 6.0 pretreatment to 0 posttreatment, and CT myelography in a subset confirmed fistula closure. CT-guided intracystic fibrin glue injection appears to be a safe, effective, and targeted option for CVF treatment, meriting further prospective evaluation.

Background and purpose: Photon-counting CT (PCCT) offers several advantages over conventional CT for cochlear implant (CI) imaging, including improved spatial resolution, and both signal-to-noise and contrast-to-noise ratios. However, the optimal PCCT reconstruction parameters for CI imaging has not been established. This study compared six PCCT reconstruction approaches for temporal bone CI imaging in a multi-reader design.

Materials and methods: 20 patients with CIs (24 implants) underwent temporal bone PCCT on a NAEOTOM Alpha scanner. Raw data was reconstructed using six different algorithms, as follows: Hr84 0.2mm T3D (head-regular, sharpness level 84, polyenergetic), Hr84 0.4mm T3D, Qr56 0.4mm iMAR T3D (quantitative-regular, sharpness level 56, iterative metal artifact reduction), Qr76 0.4mm M_140 (virtual monoenergetic 140 keV), Qr76 0.4mm M_70 (virtual monoenergetic 70 keV), and Qr76 0.4mm T3D.Two fellowship-trained neuroradiologists independently rated electrode visibility and overall image quality for all implants, and wire visibility for implants with visible wires, on 0-2 Likert scales. Inter-reader agreement was assessed with quadratic weighted Cohen's kappa. A mixed effects model was used to evaluate reconstruction differences for each metric.

Results: Mean patient age was 50.9 ± 26 years; 8 were women. Inter-reader agreement was substantial for electrode visibility (κ = 0.66) and overall image quality (κ = 0.79), and moderate for wire visibility (κ = 0.52). Reconstruction type significantly affected all three metrics. The sharp kernel reconstructions (Hr84 0.2mm T3D and Hr84 0.4mm T3D) consistently ranked highest, with significantly greater scores than most other reconstructions. Qr56 0.4mm iMAR T3D was the lowest rated in every category, significantly worse than all other reconstructions.

Conclusions: PCCT reconstruction parameters substantially influence postoperative CI image quality. Ultra-high-resolution reconstructions provided the best combination of artifact suppression and fine structural detail, while iterative MAR and high-keV monoenergetic reconstructions performed the worst. These findings can guide reconstruction selection to optimize PCCT protocols for CI evaluation.

Background and purpose: Coronal clival cleft is a congenital corticated defect traversing the basioccipital portion of the clivus, beneath the spheno-occipital synchondrosis. It has been reported in cases of CHARGE syndrome, Cornelia de Lange syndrome, anencephaly, hemifacial microsomia, Chiari deformities, and in asymptomatic patients, but it may be underdiagnosed and underestimated on imaging. This study aims to estimate the prevalence of coronal clival cleft and expand its genetic and clinical associations.

Materials and methods: In this retrospective study, the imaging report database from a single children's hospital was queried for the terms "clival cleft", "clivus cleft", "clefts of the clivus", and "cleft of the clivus". The search was restricted to head and neck, brain, and cervical spine CTs and MRIs. reports from a consecutive 2-year period (May 2022 to June 2024) authored by either of two neuroradiologists with expertise in the diagnosis of clival clefts. Electronic medical records were reviewed for demographics and to confirm final diagnosis and genetic disorders. Descriptive statistics were used to calculate frequency, demographic characteristics, and percentage distribution.

Results: The search yielded 13 patients with coronal clival cleft (estimated prevalence: 4.2/1,000; 95% CI 1.67-10.52 per 1,000). The distribution between the sexes was 7 females and 6 males. Partial coronal clival cleft (n=9) was more frequent than complete coronal clival cleft (n=4). Clival clefts were associated with 9 different disorders, including CHARGE syndrome (n=4), Chiari I deformities (n=2), Cornelia de Lange (n=1), and others (n=6).

Conclusion: Coronal clival clefts are potentially more common than previously anticipated. Radiologists should be able to recognize and differentiate coronal clival clefts from anatomic variants in the skull base and, when a coronal clival cleft is found, must actively search for additional cerebral and craniovertebral junction abnormalities, often found in combination.

Background and purpose: Gadopiclenol is a next-generation macrocyclic gadolinium-based contrast agent (GBCA) distinguished by its high T1 relaxivity and kinetic stability. It was developed to address the clinical need for reduced gadolinium dosing while maintaining high diagnostic accuracy, thereby minimizing potential long-term risks associated with gadolinium retention. Although various neuroradiology applications have been explored, the potential benefits of gadopiclenol's increased T1 relaxivity have not been investigated for the purpose of evaluating endolymphatic hydrops (EH) using delayed contrast-enhanced inner ear imaging.

Materials and methods: We prospectively enrolled 26 consecutive patients at our institution's Otology clinic based on the 2015 American Academy of Otolaryngology-Head and Neck Surgery criteria for Ménière disease (MD), including acute or fluctuating symptoms of vertigo, hearing loss, tinnitus, or aural fullness. Each patient underwent 4-hour delayed contrast-enhanced inner ear imaging at 3T with half-dose (0.05 mmol/kg) GBCA administration using gadopiclenol. The contrast-to-noise ratio (CNR) and signal-to-noise ratio (SNR) were determined. Assessment of blood-labyrinthine barrier (BLB) permeability, utricle-saccule discrimination, and endolymphatic hydrops was performed by two head and neck neuroradiologists. Image quality, SNR, and CNR was compared to previously published data that utilized the same technical parameters with a contrast dose of 0.1 mmol/kg.

Results: Fifty-one ears were analyzed. One ear was excluded based on a prior history of left labyrinthectomy after failed medical management of MD. There were 31 symptomatic and 20 asymptomatic ears determined by clinical and hearing evaluation. Delayed contrast-enhanced inner ear imaging with gadopiclenol at 0.05 mmol/kg provided comparable CNR and SNR to gadobenate dimeglumine at 0.1 mmol/kg, with no statistically significant difference (P > 0.05). There was excellent interobserver agreement for the grading EH (κ>0.80).

Conclusions: Our study demonstrates that 3D-FLAIR inner ear imaging using gadopiclenol at 0.05 mmol/kg is a reliable method for detecting clinically concordant EH and that image quality, based on qualitative and quantitative metrics, is comparable to a previously published study using gadobenate dimeglumine at a single-dose of 0.1 mmol/kg.