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BACKGROUND AND PURPOSE Vessel recanalization after cerebral venous thrombosis (CVT) is associated with favorable outcomes and lower mortality. Several studies examined the timing and predictors of recanalization after CVT with mixed results. We aimed to investigate predictors and timing of recanalization after CVT. METHODS We used data from the multicenter, international AntiCoagulaTION in the Treatment of Cerebral Venous Thrombosis (ACTION-CVT) study of consecutive patients with CVT from January 2015 to December 2020. Our analysis included patients that had undergone repeat venous neuroimaging more than 30 days after initiation of anticoagulation treatment. Prespecified variables were included in univariate and multivariable analyses to identify independent predictors of failure to recanalize. RESULTS Among the 551 patients (mean age, 44.4±16.2 years, 66.2% women) that met inclusion criteria, 486 (88.2%) had complete or partial, and 65 (11.8%) had no recanalization. The median time to first follow-up imaging study was 110 days (interquartile range, 60-187). In multivariable analysis, older age (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.03-1.07), male sex (OR, 0.44; 95% CI, 0.24-0.80), and lack of parenchymal changes on baseline imaging (OR, 0.53; 95% CI, 0.29-0.96) were associated with no recanalization. The majority of improvement in recanalization (71.1%) occurred before 3 months from initial diagnosis. A high percentage of complete recanalization (59.0%) took place within the first 3 months after CVT diagnosis. CONCLUSION Older age, male sex, and lack of parenchymal changes were associated with no recanalization after CVT. The majority recanalization occurred early in the disease course suggesting limited further recanalization with anticoagulation beyond 3 months. Large prospective studies are needed to confirm our findings.

BACKGROUND Lacunes, microbleeds, enlarged perivascular spaces (EPVS), and white matter hyperintensities (WMH) are brain imaging features of cerebral small vessel disease (SVD). Based on these imaging markers, we aimed to identify subtypes of SVD and to evaluate the validity of these markers as part of clinical ratings and as biomarkers for stroke outcome. METHODS In a cross-sectional study, we examined 1207 first-ever anterior circulation ischemic stroke patients (mean age 69.1 ± 15.4 years; mean NIHSS 5.3 ± 6.8). On acute stroke MRI, we assessed the numbers of lacunes and microbleeds and rated EPVS and deep and periventricular WMH. We used unsupervised learning to cluster patients based on these variables. RESULTS We identified five clusters, of which the last three appeared to represent distinct late stages of SVD. The two largest clusters had no to only mild or moderate WMH and EPVS, respectively, and favorable stroke outcome. The third cluster was characterized by the largest number of lacunes and a likewise favorable outcome. The fourth cluster had the highest age, most pronounced WMH, and poor outcome. Showing the worst outcome, the fifth cluster presented pronounced microbleeds and the most severe SVD burden. CONCLUSION The study confirmed the existence of different SVD types with different relationships to stroke outcome. EPVS and WMH were identified as imaging features of presumably early progression. The number of microbleeds and WMH severity appear to be promising biomarkers for distinguishing clinical subgroups. Further understanding of SVD progression might require consideration of refined SVD features, e.g., for EPVS and type of lacunes.

Purpose This study aimed to investigate the variability of the retrotympanum in patients undergoing surgical treatment for cholesteatoma. Methods We included 59 ears of patients undergoing middle ear surgery for cholesteatoma who had preoperative computed tomography scans. A retrospective analysis of the medical records was conducted. The sinus tympani (ST), subtympanic sinus (STS) and facial recess (FR) were classified into types A–C based on the relationship of their extension to the facial nerve. The mastoid and petrous apex were assessed and categorized as normal pneumatized or sclerotic. Results Type A extension was the most frequently found in all sinuses (ST 64%, FR 77%, STS 69%), Type B extension was found more often in ST (34%) and STS (24%) than in FR (15%). A very deep extension was found only rarely (ST 2%, FR 8%, STS 7%). A sclerotic mastoid was found in 67% of cases. Those cases showed a statistically significant difference regarding retrotympanum pneumatization when compared with normal mastoid. Conclusion The most frequent variant of retrotympanic pneumatization in relation to the facial nerve was type A in all subsites in cholesteatoma patients. The variability among patients with cholesteatoma is different to previously published results in healthy subjects. Moreover, the pneumatization of the retrotympanum is associated with mastoid pneumatization.

OBJECTIVE To correlate radiographic evidence of cholesteatoma in the retrotympanum with intraoperative endoscopic findings in cholesteatoma patients and to evaluate the clinical relevance of radiographic evidence of cholesteatoma in the retrotympanum. STUDY DESIGN Case series with chart review. SETTING Tertiary referral center. METHODS Seventy-six consecutive cases undergoing surgical cholesteatoma removal with preoperative high-resolution computed tomography (HRCT) were enrolled in this study. A retrospective analysis of the medical records was conducted. The extension of cholesteatoma regarding different middle ear subspaces, into the antrum and mastoid were reviewed radiologically in preoperative HRCT and endoscopically from surgical videos. Additionally, facial nerve canal dehiscence, infiltration of the middle cranial fossa, and inner ear involvement were documented. RESULTS Comparison of radiological and endoscopic cholesteatoma extension revealed statistically highly significant overestimation of radiological cholesteatoma extension for all retrotympanic regions (sinus tympani 61.8% vs 19.7%, facial recess 69.7% vs 43.4%, subtympanic sinus 59.2% vs 7.9%, and posterior sinus 72.4% vs 4.0%) and statistically significant overestimation for mesotympanum (82.9% vs 56.6%), hypotympanum (39.5% vs 9.2%), and protympanum (23.7% vs 6.6%). No statistically significant differences were found for epitympanum (98.7% vs 90.8%), antrum (64.5% vs 52.6%), and mastoid (26.3% vs 32.9%). Statistically significant radiological overestimation of facial nerve canal dehiscence (54.0% vs 25.0%) and invasion of tegmen tympani (39.5% vs 19.7%) is reported. CONCLUSION Radiologic cholesteatoma extension in different middle ear subspaces is overestimated compared to the intraoperative extension. The preoperative relevance of radiological retrotympanic extension might be limited in the choice of approach and transcanal endoscopic approach is always recommended first.

BACKGROUND The effect of early as compared with later initiation of direct oral anticoagulants (DOACs) in persons with atrial fibrillation who have had an acute ischemic stroke is unclear. METHODS We performed an investigator-initiated, open-label trial at 103 sites in 15 countries. Participants were randomly assigned in a 1:1 ratio to early anticoagulation (within 48 hours after a minor or moderate stroke or on day 6 or 7 after a major stroke) or later anticoagulation (day 3 or 4 after a minor stroke, day 6 or 7 after a moderate stroke, or day 12, 13, or 14 after a major stroke). Assessors were unaware of the trial-group assignments. The primary outcome was a composite of recurrent ischemic stroke, systemic embolism, major extracranial bleeding, symptomatic intracranial hemorrhage, or vascular death within 30 days after randomization. Secondary outcomes included the components of the composite primary outcome at 30 and 90 days. RESULTS Of 2013 participants (37% with minor stroke, 40% with moderate stroke, and 23% with major stroke), 1006 were assigned to early anticoagulation and 1007 to later anticoagulation. A primary-outcome event occurred in 29 participants (2.9%) in the early-treatment group and 41 participants (4.1%) in the later-treatment group (risk difference, -1.18 percentage points; 95% confidence interval [CI], -2.84 to 0.47) by 30 days. Recurrent ischemic stroke occurred in 14 participants (1.4%) in the early-treatment group and 25 participants (2.5%) in the later-treatment group (odds ratio, 0.57; 95% CI, 0.29 to 1.07) by 30 days and in 18 participants (1.9%) and 30 participants (3.1%), respectively, by 90 days (odds ratio, 0.60; 95% CI, 0.33 to 1.06). Symptomatic intracranial hemorrhage occurred in 2 participants (0.2%) in both groups by 30 days. CONCLUSIONS In this trial, the incidence of recurrent ischemic stroke, systemic embolism, major extracranial bleeding, symptomatic intracranial hemorrhage, or vascular death at 30 days was estimated to range from 2.8 percentage points lower to 0.5 percentage points higher (based on the 95% confidence interval) with early than with later use of DOACs. (Funded by the Swiss National Science Foundation and others; ELAN ClinicalTrials.gov number, NCT03148457.).

Herpes simplex virus (HSV) and varicella zoster virus (VZV) are among the most commonly diagnosed infectious causes of sporadic encephalitis worldwide. Despite treatment, mortality and morbidity rates remain high, especially for HSV encephalitis. This review is intended to provide an overview of the existing scientific literature on this topic from the perspective of a clinician who is confronted with serious decisions about continuation or withdrawal of therapeutic interventions. We performed a literature review searching two databases and included 55 studies in the review. These studies documented or investigated specifically outcome and predictive parameters of outcome of HSV and/or VZV encephalitis. Two reviewers independently screened and reviewed full-text articles meeting the inclusion criteria. Key data were extracted and presented as a narrative summary. Both, HSV and VZV encephalitis have mortality rates between 5 and 20% and complete recovery rates range from 14 to 43% for HSV and 33 to 49% for VZV encephalitis. Prognostic factors for both VZV and HSV encephalitis are older age and comorbidity, as well as severity of disease and extent of magnetic resonance imaging (MRI) lesions on admission, and delay in treatment initiation for HSV encephalitis. Although numerous studies are available, the main limiting factors are the inconsistent patient selection and case definitions as well as the non-standardised outcome measures, which hampers the comparability of the studies. Therefore, larger and standardised observational studies applying validated case definitions and outcome measures including quality of life assessment are required to provide solid evidence to answer the research question.

Objective: Over the recent decades, the number of different manufacturers and models of cerebrospinal fluid shunt valves constantly increased. Proper identification of shunt valves on x-ray images is crucial to neurosurgeons and radiologists to derive further details of a specific shunt valve, such [for full text, please go to the a.m. URL]

Background and objectives In general, suddenly occurring neurological deficits, i.e., negative neurological symptoms, are considered symptoms of focal cerebral ischemia, while positive irritative symptoms with gradual onset are viewed as the characteristics of migraine aura. Nevertheless, cortical spreading depolarization, the pathophysiological basis of migraine aura, has also been observed in acute ischemic stroke. The aim of our study was to determine the frequency of migraine aura-like symptoms at ischemic stroke onset and stroke-like symptoms in migraine with aura. Methods We interviewed 350 consecutive patients with ischemic stroke and 343 with migraine with aura using a structured questionnaire. Stroke diagnosis was confirmed by imaging, and migraine with aura was diagnosed according to the current criteria of the International Headache Society. Patients with wake-up strokes or severe cognitive deficits that precluded a useful interview were excluded from the study. Results Seventy-eight patients with stroke (22.3%) reported visual symptoms, 145 (41.4%) sensory symptoms, 197 (56.3%) a paresis, and 201 patients (57.4%) more than one symptom, compared to 326 migraine patients with aura (95%) with visual symptoms (P < 0.001), 175 (51%) with sensory symptoms (p = 0.011), 50 (14.6%) with paresis (P < 0.001), and 211 (61.5%) with more than one symptom (p = 0.27). Among patients with stroke, migraine-like symptoms were frequent: 36 patients (46.2%) with visual disturbance and 78 (53.8%) with sensory symptoms experienced irritative sensations. Paresis-onset in stroke lasted longer than 5 min in 43 patients (21.8%). Spreading of sensory and motor symptoms occurred in 37 (25.5%) and 37 (18.8%) patients, respectively. Stroke-like negative symptoms in migraine with aura occurred in 39 patients (12%) with visual symptoms, in 55 (31.4%) with sensory symptoms, and paresis appeared suddenly in 14 patients (28%). More than one symptom in succession occurred in 117 patients with stroke (58.2%) and in 201 migraine with aura patients (95.3%; P < 0.001). Conclusion Many patients with stroke experience migraine-like symptoms at stroke onset, and many migraine with aura patients have stroke-like symptoms. Though overall the symptom frequencies of the two groups are significantly different, clarifying the differential diagnosis in an individual patient requires additional history elements, physical findings, or results of ancillary investigations.

Diabetic ketoacidosis is a severe complication of diabetes mellitus. We report a case of global hypoperfusion in an elderly patient on CT, with complete resolution shown on early MRI follow-up. Metabolic causes have always to be included in the differential diagnosis of diffuse hypoperfusion in the appropriate clinical setting.

Background: Blood-brain barrier dysfunction in active multiple sclerosis (MS) lesions leads to pathological changes of cerebrospinal fluid (CSF). Theoretically, CSF analyses could help to predict relapse recovery and the course of disability. In this monocentric study, we investigated the impact of CSF findings assessed during the first relapse of MS on the short-term course of disability. Methods: We performed a retrospective observational study including MS patients with available CSF data after onset of first MS relapse. Clinical symptoms had to be accompanied by gadolinium-enhanced lesion on magnetic resonance imaging. Expanded Disability Status Scale (EDSS) assessments at timepoint of relapse and after relapse recovery were studied to analyze disability. A two-step multivariate linear regression analysis adjusted for EDSS at spinal tab, duration of symptoms, sex, time until post relapse EDSS assessment, immunotherapy post relapse, and relapse treatment with glucocorticoids/plasma exchange to predict relapse associated disability was run. Results: In the first step of the regression model, pathological albumin quotient (QAlb) [regression coefficient 0.50, 95% confidence interval (CI) (0.07-0.92), p = 0.02, n = 99] and CSF protein concentration [regression coefficient 0.84, 95% CI (0.33-1.35), p = 0.001, n = 99] predicted EDSS after relapse recovery. In the second step, the sum score of both predictors [range 0-2; n per value: 0 (n = 73), 1 (n = 10), 2 (n = 15)] confirmed the negative impact on course of disability after relapse [regression coefficient 0.38, 95% CI (0.13-0.62), p = 0.003, n = 98]. In this final multivariate linear regression model (p < 0.001; R-2 0.34), also EDSS at lumbar puncture [regression coefficient 0.58, 95% CI (0.35-0.81), p < 0.001, n = 98] and time between symptom onset and CSF evaluation [regression coefficient 0.03, 95% CI (0.006-0.048), p = 0.01, n = 98] forecast subsequent disability Discussion: Our study conducted in MS patients during first relapse confirmed that both increased CSF protein concentration and pathological QAlb have a negative impact on EDSS after relapse. As secondary finding, we identified time from symptom onset to lumbar puncture as predictor of disability recovery after relapse.

Background and Purpose- The brush sign (BS) is an abnormally accentuated signal drop of the subependymal and deep medullary veins in paramagnetic-sensitive magnetic resonance sequences, previously described in acute ischemic stroke. We aimed to describe the BS in patients with thrombosis of the cerebral veins and sinuses and explore its association with clinical severity, thrombosis extent, parenchymal brain lesion, and clinical prognosis. Methods- We assessed consecutive adult patients admitted to 2 university hospitals with diagnosis of acute thrombosis of the cerebral veins and sinuses and imaging assessment with magnetic resonance imaging, including paramagnetic-sensitive sequences. Demographics, imaging findings, clinical presentation, and functional outcome at 3 months were analyzed according to the presence of BS. Results- In 118 patients included, BS was observed in gradient-echo T2*weighted (T2*WI) in 16% and susceptibility-weighted imaging in 13% of cases. All patients with BS had thrombosis of the superior sagittal sinus, straight sinus, or deep venous system. BS was associated with ipsilateral parenchymal lesion (odds ratio, 6.4; 95% CI, 1.9-21.1; P=0.002) and higher thrombus load (median [interquartile range] 5 [4-6] versus 2 [2-4]); P

Learning objectives Background Findings and procedure details Conclusion Personal information References, Learning objectives: To understand the technical background and mathematical models of CT perfusion. To understand the value of different perfusion parameters. To identify the various clinical situations that may cause perfusion changes. To understand the potential and...

Performance of models highly depend not only on the used algorithm but also the data set it was applied to. This makes the comparison of newly developed tools to previously published approaches difficult. Either researchers need to implement others' algorithms first, to establish an adequate benchmark on their data, or a direct comparison of new and old techniques is infeasible. The Ischemic Stroke Lesion Segmentation (ISLES) challenge, which has ran now consecutively for 3 years, aims to address this problem of comparability. ISLES 2016 and 2017 focused on lesion outcome prediction after ischemic stroke: By providing a uniformly pre-processed data set, researchers from all over the world could apply their algorithm directly. A total of nine teams participated in ISLES 2015, and 15 teams participated in ISLES 2016. Their performance was evaluated in a fair and transparent way to identify the state-of-the-art among all submissions. Top ranked teams almost always employed deep learning tools, which were predominately convolutional neural networks (CNNs). Despite the great efforts, lesion outcome prediction persists challenging. The annotated data set remains publicly available and new approaches can be compared directly via the online evaluation system, serving as a continuing benchmark (www.isles-challenge.org)., Fundacao para a Ciencia e Tecnologia (FCT), Portugal (scholarship number PD/BD/113968/2015). FCT with the UID/EEA/04436/2013, by FEDER funds through COMPETE 2020, POCI-01-0145-FEDER-006941. NIH Blueprint for Neuroscience Research (T90DA022759/R90DA023427) and the National Institute of Biomedical Imaging and Bioengineering (NIBIB) of the National Institutes of Health under award number 5T32EB1680. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. PAC-PRECISE-LISBOA-01-0145-FEDER-016394. FEDER-POR Lisboa 2020-Programa Operacional Regional de Lisboa PORTUGAL 2020 and Fundacao para a Ciencia e a Tecnologia. GPU computing resources provided by the MGH and BWH Center for Clinical Data Science Graduate School for Computing in Medicine and Life Sciences funded by Germany's Excellence Initiative [DFG GSC 235/2]. National Research National Research Foundation of Korea (NRF) MSIT, NRF-2016R1C1B1012002, MSIT, No. 2014R1A4A1007895, NRF-2017R1A2B4008956 Swiss National Science Foundation-DACH 320030L_163363.

A 90-year-old woman developed a severe stroke (National Institutes of Health Stroke Scale Score (NIHSS) 24) due to an occlusion of the left carotid T. Computed tomography 60 min after symptom onset showed a large area of tissue at risk with a relatively large area of reduced cerebral blood volume indicating a relative large infarct core. After successful reperfusion, she recovered very well with only residual facial asymmetry (NIHSS 1). Up to now, therapeutic decisions for intravenous thrombolysis and endovascular treatment were mainly based on these time windows, although it was well known that the individual time window may vary widely due to a large variability of the quality of collateral circulation. The recently presented results of the DAWN trial have demonstrated that patients can be successfully treated in a time window up to 24 h when selected by imaging and clinical criteria. The described case impressively demonstrates that this positive selection of patients beyond established treatment time windows does not implicate in reverse that patient selection for therapy within the established time windows can be based on the same imaging criteria. In conclusion, patient selection beyond the established time windows may be based on the available techniques, but imaging-based decisions against therapy in patients within the established time windows should be made only with extreme caution.

Cerebral arteries may exhibit a wide range of variation from normal anatomy, which can be incidentally discovered during imaging. Knowledge of such variants is crucial to differentiate them from pathologies, to understand the etiology of certain pathologies directly related to a vascular variant, and to depict the changes in collateral circulation in patients with certain variants. Detection of particular variants may lead to the discovery of other nonvascular or vascular anomalies, especially aneurysms, and may also affect planning of endovascular or neurosurgical interventions. In this review, we summarize the variants and anomalies of cerebral arteries seen on cross-sectional imaging classified by a morphological approach and categorize their significance from a clinical perspective. This structured review is intended to serve as a guide for daily use in clinical practice.

Learning objectives Background Findings and procedure details Conclusion Personal information References, Learning objectives: To illustrate the different variants of the cerebral arteries. To summarize their incidence according to the reviewed literature. To classify these variants in a proposed structured morphological approach. To summarize their clinical...

Clinical History Image Findings Discussion Find Diagnosis Differential Diagnosis, male, 71 years, Clinical History: A 71-year old patient, complaining of epigastric pain was referred to our radiology department. A diagnosis of acute pancreatitis was made due to the elevated levels of serum amylase and lipase. There was a past history of a similar episode two years prio... Final Diagnosis: Acute oedematous pancreatitis with pancreas divisum.

Clinical History Image Findings Discussion Find Diagnosis Differential Diagnosis, male, 77 years, Clinical History: A patient with embolic infarction was referred for CTA, due to a suspected stenosis of the ICA.Regarding the found anomaly the patient was asymptomatic and no further treatment was required. Due to the symptomatic stenosis of the ICA, the patient wa... Final Diagnosis: Type II right aortic arch with aortic diverticulum.

Clinical History Image Findings Discussion Find Diagnosis Differential Diagnosis, male, 65 years, Clinical History: A patient complaining of right-sided hemianopsia. Final Diagnosis: Paradoxical posterior infarction associated with PAVM and concurrent pulmonary embolism.

Clinical History Image Findings Discussion Find Diagnosis Differential Diagnosis, male, 62 years, Clinical History: A 62-year-old male patient, complaining of chest pain, was referred to our radiology department to exclude pulmonary embolism. Final Diagnosis: Partial anomalous left upper pulmonary venous return.

Performance of models highly depend not only on the used algorithm but also the data set it was applied to. This makes the comparison of newly developed tools to previously published approaches difficult. Either researchers need to implement others' algorithms first, to establish an adequate benchmark on their data, or a direct comparison of new and old techniques is infeasible. The Ischemic Stroke Lesion Segmentation (ISLES) challenge, which has ran now consecutively for 3 years, aims to address this problem of comparability. ISLES 2016 and 2017 focused on lesion outcome prediction after ischemic stroke: By providing a uniformly pre-processed data set, researchers from all over the world could apply their algorithm directly. A total of nine teams participated in ISLES 2015, and 15 teams participated in ISLES 2016. Their performance was evaluated in a fair and transparent way to identify the state-of-the-art among all submissions. Top ranked teams almost always employed deep learning tools, which were predominately convolutional neural networks (CNNs). Despite the great efforts, lesion outcome prediction persists challenging. The annotated data set remains publicly available and new approaches can be compared directly via the online evaluation system, serving as a continuing benchmark (www.isles-challenge.org).

Differentiation between infectious and neoplastic brain processes is crucial for treatment planning. Advanced magnetic resonance imaging techniques, such as diffusion, perfusion, susceptibility weighted imaging, and magnetic resonance spectroscopy, enhance the imaging differences between these two pathologies. However, despite the utilization of these advanced techniques, the pathologic process may be confound by atypical findings. Here, we report a case of an autistic patient with multiple brain lesions with diffusion weighted imaging, susceptibility weighted imaging, and perfusion patterns resembling features of a multicentric glioblastoma, which were confirmed surgically, neuropathologically, and bacteriologically as brain abscesses. We discuss the differentiation of these different entities in the light of advanced magnetic resonance imaging techniques.