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Background Primary angiitis of the central nervous system (CNS) is a rare vasculitic disorder that typically involves the brain and, less frequently, the spinal cord without involvement of the blood vessels outside the CNS. Case Description We present a case of a 52-year-old woman who developed a conus syndrome linked to an enhancing mass of her lower thoracic spinal cord, lumbar cord, and conus. Spinal cord biopsy performed for diagnostic purposes in the setting of progressive neurological deficit confirmed angiitis of the spinal cord. Therapy with steroid and cyclophosphamide was associated with long-term (3 years) clinical and imaging remission of the lesion. Conclusions The prognosis of primary CNS angiitis is dismal with most cases progressing to death. Long-term remission is unusual. Aggressive therapy with steroid and cytotoxic agents may improve survival.

Ischemic stroke is a major public health problem worldwide. The potential to cure stroke patients with intravenous thrombolytic therapy has evolved to the use of intra-arterial thrombolytic agents. Fewer than 200 patients have been enrolled in randomized trials of intra-arterial therapy. In this article the authors have reviewed the literature listed in MEDLINE and EMBase, and searched relevant articles to examine the role of fibrinolytic agents in acute interventional stroke therapy. Only English language articles reporting five or more patients were included. Outcomes were defined at 90 days. Good outcome was defined on the modified Rankin Scale. Symtpomatic hemorrhage was defined as hemorrhage in the setting of clinical deterioration in the first 24 to 48 h. The search identified 57 studies of which 44 reported usable data. Only three randomized trials were reported. Of a total of 1140 patients, most (73%) were treated open-label with urokinase (Abbokinase, Abbott Laboratories). The best outcomes were reported in case series and slightly worse outcomes were reported in clinical trials. Overall, it was not possible to distinguish whether one agent was superior to the others. There is a paucity of published evidence on intra-arterial therapy for acute ischemic stroke. Alteplase (Activase, Genentech Inc.) is currently the drug of choice simply because it is available and it is the current intravenous standard. Further trials and developments are anticipated.

We describe a case of asymptomatic extravasation of iodinated contrast material into the sulci on digital subtraction angiography following carotid angioplasty and stenting resulting in sulcal hyperdensity on computed tomography (CT). We believe the mechanism for this observation is hyperperfusion injury and that in the absence of any associated clinical signs, it should not be considered alarming for subarachnoid hemorrhage.

✓ To the authors' knowledge, only 1 case of communicating hydrocephalus after endovascular coiling of unruptured brain aneurysms has been reported previously. Here, they report on 2 such cases of delayed communicating hydrocephalus after treatment with hydrogel-coated coils and offer the first histopathological evidence of foreign material, presumably related to the coils, as the cause of hydrocephalus.

Object Digital subtraction (DS) angiography is the current gold standard of assessing intracranial aneurysms after coil placement. Magnetic resonance (MR) angiography offers a noninvasive, low-risk alternative, but its accuracy in delineating coil-treated aneurysms remains uncertain. The objective of this study, therefore, is to compare a high-resolution MR angiography protocol relative to DS angiography for the evaluation of coil-treated aneurysms. Methods In 2003, the authors initiated a prospective protocol of following up patients with coil-treated brain aneurysms using both 1.5-tesla gadolinium-enhanced MR angiography and biplanar DS angiography. Using acquired images, the subject aneurysm was independently scored for degree of remnant identified (complete obliteration, residual neck, or residual aneurysm) and the surgeon's ability to visualize the parent vessel (excellent, fair, or poor). Results Thirty-seven patients with 42 coil-treated aneurysms were enrolled for a total of 44 paired MR angiography–DS angiography tests (median 9 days between tests). An excellent correlation was found between DS and MR angiography for assessing any residual aneurysm, but not for visualizing the parent vessel (κ = 0.86 for residual aneurysm and 0.10 for parent vessel visualization). Paramagnetic artifact from the coil mass was minimal, and in some cases MR angiography identified contrast permeation into the coil mass not revealed by DS angiography. An intravascular microstent typically impeded proper visualization of the parent vessel on MR angiography. Conclusions Magnetic resonance angiography is a noninvasive and safe means of follow-up review for patients with coil-treated brain aneurysms. Compared with DS angiography, MR angiography accurately delineates residual aneurysm necks and parent vessel patency (in the absence of a stent), and offers superior visualization of contrast filling within the coil mass. Use of MR angiography may obviate the need for routine diagnostic DS angiography in select patients.

We discuss a case report from a patient who had symptoms of transient neurological deficits in the presence of a chronic subdural hematoma and severe carotid stenosis. Multi-modality imaging was used to guide management.The symptoms settled without carotid intervention and were presumed due to the subdural hematoma.Severe symptomatic carotid stenosis is treated with carotid endarterectomy. In some patients with transient neurological deficits, the diagnosis is not as simple as first thought. Multi-modality imaging (MRI, TCD and CT) can help differentiate the causative lesion.

Background The Penumbra system is a newly approved mechanical device for the treatment of acute stroke designed for better and faster recanalization. We describe our initial experience with the use of this device. Methods We studied 27 consecutive patients with acute ischemic stroke from January 2009 to October 2009 at our stroke centre. The primary outcome was the degree of reperfusion (TIMI grade 2/3) at end of the procedure. Secondary end points were the proportion of patients who achieved a modified Rankin Scale (mRS) ≤2 at 3 months, all cause mortality and intracerebral hemorrhage (ICH) on non-contrast CT at 24 h. Procedural complications such as vascular perforations, vasospasm, dissection, distal embolization and groin complications were recorded. Results 27 patients (13 men, mean age 61 years) were treated during the period January–October 2009. Median National Institutes of Health Stroke Scale on admission was 18 (range 3–32), median Alberta Stroke Program Early CT Score on non-contrast CT at admission was 8 (range 5–10) and median onset to intra-arterial treatment time was 192 min. 22 (81%) patients had anterior circulation strokes. 17 (63%) had intravenous tissue plasminogen activator initiated prior to angiography. 85% (23/27) patients achieved TIMI 2/3 grade reperfusion at completion of the procedure. 48% (13/27) patients had mRS ≤2 at the 3 month follow-up. Procedural complications included vasospasm (1/27), distal emboli (13/27) and ICH (seven HI1, one PH1 and one PH2). All cause mortality was 19% (5/27). Conclusions High reperfusion rates and good clinical outcomes are achievable with the Penumbra system. Complication rates are comparable with the previously published literature.

A 63-year-old woman presented with progressive dementia over 2 years. Plain head CT demonstrated dilated parenchymal vessels and vascular channels in the left occipital bone (figure 1, A and B). Angiography confirmed a dural arteriovenous malformation (dAVM) centered on the left …