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OBJECTIVEPrimary intraosseous meningioma (PIM) is a rare manifestation of meningioma, a benign, neoplastic lesion of the meninges. Its characteristic appearance is hyperostosis, while no or only minimal dural changes can be observed. This study aims to characterize this rare entity from both a clinical and histopathological point of view in order to improve clinical management.METHODSIn the years 2009–2017, 26 cases of PIM were diagnosed using MRI and CT scans. In 16 cases the indication for resection was given, and specimens were further examined using a multilevel approach, including histological and immunohistochemical analyses. Additionally, the local database was searched for all cases of meningiomas, as well as osteosclerotic differential diagnoses—i.e., fibrous dysplasia, Paget’s disease of bone, and other benign osteosclerotic lesions.RESULTSIn this study, PIM represented 2.4% of all meningiomas with a predominant occurrence in females (85%). Regarding the initial manifestation, PIMs show a slightly earlier onset than meningiomas. While most PIMs are located in the sphenoid bone, associated calcifications were visible in 58% of the cases on CT scans. Most of the cases were classified as WHO grade I (93%) and meningotheliomatous meningiomas (91%). Tumor growth was associated with an increased bone resorption followed by massive osteoid deposition and consecutive sclerosis. The frequently observed frayed appearance results from multiple bony canals, which contain blood vessels for the blood supply of the highly vascularized tumor tissue.CONCLUSIONSPIM is a rare but important differential diagnosis for osteosclerotic lesions of the skull, especially in women. Tumor-induced, cellular-mediated bone resorption and formation may play a central role in the underlying pathogenesis.

Background and aim To analyze the incidence of peripheral emboli after successful mechanical thrombectomy (MT) of intracranial large vessel occlusions (LVO). Methods We performed a prospective analysis of patients with intracranial LVO who underwent successful MT and received a 1.5 T MRI including diffusion-weighted imaging (DWI) in standard- and high-resolution as well as susceptibility-weighted imaging (SWI) on the day following the intervention. Reperfusion grade was assessed on post-thrombectomy digital subtraction angiography (DSA) using the expanded thrombolysis in cerebral infarction (eTICI) scale. Punctuate DWI lesions distal to the DWI core lesion were classified as peripheral emboli. DWI lesions outside the primary affected vascular territory were classified as emboli into new territories. Additionally, SWI and post-thrombectomy DSA were analyzed and correlated to findings on DWI. Results Twenty-eight patients undergoing successful MT met the inclusion criteria. In 26/28 patients (93%), a total of 324 embolic lesions were detected in DWI representing 2.1% of the cumulated ischemic core volume. 151 peripheral emboli were detected in standard-resolution DWI, 173 additional emboli were uncovered in high-resolution DWI. Eight out of nine patients with an eTICI 3 reperfusion had embolic lesions (29 DWI lesions). 9.6% (31/324) of peripheral emboli were observed in vascular territories not affected by the LVO. SWI lesions were observed in close proximity to 10.2% (33/324) of DWI lesions. Conclusions Peripheral emboli are frequent after MT even after complete reperfusion. These emboli occur rather in the vascular territory of the occluded vessel than in other territories. A large proportion of peripheral emboli is only detected by high-resolution DWI.

To determine the accuracy of the recently proposed landmark-method 'nostril-to-tragus minus 10 mm' and compare with ERC-recommended distances for nasopharyngeal airway length sizing in children.We conducted a prospective observational study in sedated children 12 years. Nasopharyngeal airways were inserted following 'nostril-to-tragus minus 10 mm'. Primary outcome was the rate of nasopharyngeal airway tips between soft palate and epiglottis on magnetic resonance imaging (MRI) indicated for medical reasons. An optimal placement was defined when the tip lied within 25-75% of the total soft palate-to-epiglottis distance. Between 0-100% of this distance, placement was still considered acceptable, below 0% too proximal or above 100% too distal. Secondary outcomes were the rate of adverse events, the qualitative positions of airway tips, and the comparison of ́nostril-to-tragus minus 10 mḿ with the ERC-recommended distances 'nostril-to-angle of the mandible' and 'nostril-to-tragus' with objective MRI measurements.We analysed 92 patients with a mean age of 4.3 years. Nasopharyngeal airways were optimally placed in 37.0% (8.7% too proximal-77.2% acceptable-14.1% too distal). Three qualitative malpositions, but no airway-associated adverse event occurred. Objective measurements on MRI revealed the probability of 40.2% optimally placed nasopharyngeal airways (5.4%-67.4%-27.2%) for 'nostril-to-tragus minus 10 mm', 38.0% (17.4%-58.7%-23.9%) for 'nostril-to-mandible' and 13.0% (0%-28.3%-71.7%) for 'nostril-to-tragus', respectively.No landmark-method predicted nasopharyngeal airway position reliably. 'Nostril-to-tragus minus 10 mm' seems the least inaccurate one and could be a valuable approximation until another estimation-formula proves more accurate. During insertion, careful clinical evaluation of airway patency is crucial.German Clinical Trials Register; DRKS00021007.

Purpose Use of automated perfusion software has gained importance for imaging of stroke patients for mechanical thrombectomy (MT). We aim to compare four perfusion software packages: 1) with respect to their association with 3‑month functional outcome after successful reperfusion with MT in comparison to visual Cerebral Blood Volume - Alberta Stroke Program Early CT Score (CBV-ASPECTS) and collateral scoring and 2) with respect to their agreement in estimation of core and penumbra volume. Methods This retrospective, multicenter cohort study (2015–2019) analyzed data from 8 centers. We included patients who were functionally independent before and underwent successful MT of the middle cerebral artery. Primary outcome measurements were the relationship of core and penumbra volume calculated by each software, qualitative assessment of collaterals and CBV-APECTS with 3‑month functional outcome and disability (modified Rankin scale >2). Quantitative differences between perfusion software measurements were also assessed. Results A total of 215 patients (57% women, median age 77 years) from 8 centers fulfilled the inclusion criteria. Multivariable analyses showed a significant association of RAPID core (common odds ratio, cOR 1.02; p = 0.015), CBV-ASPECTS (cOR 0.78; p = 0.007) and collaterals (cOR 0.78; p = 0.001) with 3‑month functional outcome (shift analysis), while RAPID core (OR 1.02; p = 0.018), CBV-ASPECTS (OR 0.77; p = 0.024), collaterals (OR 0.78; p = 0.007) and OLEA core (OR 1.02; p = 0.029) were significantly associated with 3‑month functional disability. Mean differences on core estimates between VEOcore and RAPID were 13.4 ml, between syngo.via and RAPID 30.0 ml and between OLEA and RAPID −3.2 ml. Conclusion Collateral scoring, CBV-ASPECTS and RAPID were independently associated with functional outcome at 90 days. Core and Penumbra estimates using automated software packages varied significantly and should therefore be used with caution.

Background and purposeTo evaluate factors influencing the confidence of management recommendation for unruptured intracranial aneurysms (UIAs) and to assess the ability of neurointerventionalists to predict procedure-related neurological complications compared with a 3-point risk score.Materials and methodsTwenty-eight neurointerventionalists were asked to evaluate digital subtraction angiographies examinations of patients with UIAs by determining the best management approach, their level of confidence in their management recommendation, and estimating the risk of procedure-related neurological complications. Knowledge and experience in interventional neuroradiology (INR) of each participant were assessed.ResultsReliability was moderate regarding any treatment recommendation (ICC=0.49) and low regarding the estimation of risk of complications (ICC=0.38). The recommendation of clipping was less likely with more experience in INR (OR=0.6) and more likely with increasing knowledge (OR=1.7). Odds of recommending WEB device were lower with more experience in INR (OR=0.6), higher in patients with multiple aneurysms (OR=3.6) and increasing neck width (OR=2.7). The recommendation of stent-assisted coiling was more likely with increasing neck width (OR=2.4) and when cerebral ischemic comorbidities were present (OR=2.9). The participants were significantly worse than the risk score (mean area under the curve of 0.53) and not better than random guess in predicting complications. Neither knowledge nor experience in INR was significantly associated with the participants’ ability to predict neurological complications.ConclusionsOur study shows a moderate interrater reliability of treatment recommendations of UIAs. Confidence in treatment recommendation varied significantly according to recommended treatments. Overall performance in predicting neurological complications was worse than the risk score and not better than random guess.

Purpose Follow-up infarct volume (FIV) is moderately associated with functional outcome. We hypothesized that accounting for infarct location would strengthen the association of FIV with functional outcome. Methods We included 252 patients from the HERMES collaboration with follow-up diffusion weighted imaging. Patients received endovascular treatment combined with best medical management (n = 52%) versus best medical management alone (n = 48%). FIV was quantified in low, moderate and high modified Rankin Scale (mRS)-relevant regions. We used binary logistic regression to study the relation between the total, high, moderate or low mRS-relevant FIVs and favorable outcome (mRS Results Small lesions only occupied high mRS-relevant brain regions. Lesions additionally occupied lower mRS-relevant brain regions if FIV expanded. Higher FIV was associated with a higher risk of unfavorable outcome, as were volumes of tissue with low, moderate and high mRS relevance. In multivariable modeling, only the volume of high mRS-relevant infarct was significantly associated with favorable outcome. The c-statistic was highest (0.76) for the models that included high mRS-relevant FIV or the combination of high, moderate and low mRS-relevant FIV but was not significantly different from the model that included only total FIV (0.75). Conclusion This study confirms the association of FIV and unfavorable functional outcome but showed no strengthened association if lesion location was taken into account.

Background: Thrombus fragmentation causing distal emboli is a feared complication during mechanical thrombectomy (MT). We aimed to investigate the impact of procedural parameters and thrombus properties on the incidence of peripheral emboli after MT for large vessel occlusions (LVO). Methods: We performed a prospective analysis of patients with LVO stroke successfully treated with MT, defined as a score of 2b, 2c, or 3 on the thrombolysis in cerebral infarction (TICI) scale. A follow-up MRI including high-resolution diffusion-weighted imaging (DWI) was performed within 24 h following MT. The primary endpoint was the number and volume of peripheral emboli, classified as punctuate DWI lesions distant to the diffusion-restricted core lesion. Further analysis included the influence of baseline characteristics, procedural and outcome parameters, and thrombus properties on peripheral emboli. Results: Thirty-seven patients with successful MT met the inclusion criteria. Use of a balloon guide catheter (BGC) and TICI were the only independent predictors for a reduced number of peripheral emboli. The use of a BGC led to a significant reduction in the number and volume of peripheral emboli, with a median number/volume of peripheral emboli of 4.5/287 μl (IQR 1.25–8.25/76–569 μl) vs. 12/938 μl (IQR 4–19/242–1,836 μl). In cases where BGC was not employed, the number of peripheral emboli increased with decreasing TICI scores. Conclusions: BGC-aided MT reduces the number of peripheral emboli in successful but incomplete reperfusion (TICI 2b and 2c). The effectiveness of this strategy therefore goes above and beyond that which can be demonstrated by the TICI score alone.

Background and purpose: While computer-aided diagnosis (CAD) tools are widely used in stroke imaging routines already, their influence on actual decision-making is still underexplored. We analyzed the effect of a simulated CAD tool on ASPECT-Scoring on acute-stroke CT-scans with respect to experience level. Materials and methods: Baseline CT scans of 100 stroke patients from the MR CLEAN trial with consensus-ASPECTS as ground truth were independently ASPECTS graded by three readers with different levels of experience. Weeks later the same CTs were re-analyzed with additional displaying of simulated ASPECTS (s-ASPECTS, by adding or subtracting 2 points from the ground truth). Readers were told that the score was generated by an automatic ASPECT-Scoring algorithm. The influence of the displayed s-ASPECTS on the readers’ second ASPECT-Scoring was analyzed by using a linear mixed model and the reliability was assessed. Performance was measured as the absolute difference between readers ASPECTS and consensus-ASPECTS. Results: The influence of the s-ASPECTS on the second ASPECT-Scoring was the lowest for the reader with the most experience in neuroradiology, while the other readers were significantly more influenced. All readers veered further away from the ground truth in their second ASPECT-Scoring with the s-ASPECTS, though not significantly. Overall interrater reliability was excellent (ICC = 0.94 [0.92–0.96]). Conclusions: ASPECT-Scoring may be significantly influenced by simulated ASPECTS displayed by a suboptimal CAD tool, especially in readers with less experience, and performance tends to decrease. Keywords: Computed tomography, Ischemic stroke, Diagnostic method, Alberta stroke program early CT score, Machine learning

Background IgLON5 disease is an autoimmune disorder that shares neuropathological aspects with a tauopathy. Its clinical spectrum is heterogeneous, and figural memory impairment as an initial phenomenon of IgLON5 syndrome has not yet been described. The rationale of this report is to highlight symptoms related to IgLON5 disease that have not been reported to date. This case report will thereby emphasize how important it is to initiate thorough diagnostic methods including cerebrospinal fluid analysis (CSF) before starting early immunotherapy. Methods We examined a 65-year-old Caucasian male via neuropsychological tests, magnetic resonance imaging (MRI), electroencephalography (EEG), neurography and polysomnography. He also underwent two lumbar punctures from which we determined specific autoantibodies in cerebrospinal (CSF) and peripheral blood (PB). Results The patient presented initially complaining of memory loss, gradual dysphagia and sleeping dysfunction. Neuropsychological testing at first presentation and follow-up revealed subtle figural and working memory impairment. At onset and at his 6-month follow-up, we detected IgLON5 antibodies in CSF and PB. Furthermore, we identified in the CSF a blood-brain barrier disturbance at disease onset and follow-up, and markers of neuroaxonal damage such as mildly elevated phosphorylated Tau-181 protein with 86 pg/ml (normal range ≤ 61 pg/ml) at onset. Three months after his initial presentation, he was suffering from axonal neuropathy and transient ataxia in the extremities. Assuming a definitive autoimmune encephalitis-associated with anti-IgLON5 antibodies, we applied high-dose steroids monthly (1g methylprednisolone i.v. for five consecutive days) and his memory complaints, ataxia of extremities and peripheral neuropathy as well as sleeping dysfunction decreased. Conclusions Our findings broaden IgLON5 disease's clinical spectrum to include predominant and discrete figural memory impairment together with sleeping dysfunction at disease onset. In addition, our report illustrates how important taking an elaborated diagnostic approach is to assuring an accurate diagnosis and the appropriate therapy if a patient presents with a persisting figural memory impairment and sleeping abnormalities so as to avoid overlooking IgLON5 disease and a potentially poor outcome.

The number of patients above 40 years suffering an anterior shoulder dislocation for the first time has recently increased. This study investigated the role of glenoid version, inclination and rotator interval dimension in patients older than 40 years with an anterior shoulder dislocation. We hypothesize that the rotator interval plays a more important role than the osseus alignment in older patients. Patients aged older than 40 years with a traumatic shoulder dislocation were compared with patients who had undergone magnetic resonance imaging (MRI) for a different reason. The MRIs of 61 dislocation group patients were compared with MRIs of 73 comparison group patients. Two shoulder surgeons measured glenoid version, inclination, height and width, rotator interval (RI) height, base (width) and area. The study and comparison group consisted of 61 patients with a mean age of 59 ± 9 years and 73 patients with a mean age of 57 ± 12, respectively. The mean glenoid version of the dislocation group was − 4.9° ± 4.4° (retroversion) and mean inclination was 9.8° ± 8° (reclination). Mean rotator interval base, height and the rotator interval area was 46 ± 6 mm, 14 ± 5 mm and 33 ± 14 mm2, respectively. The comparison group had a mean glenoid version of − 5.4° ± 5.4° and a mean inclination of 10.8° ± 6.2°. The rotator interval base was 41 ± 6 mm, the height was 16 ± 4 mm and the area was 34 ± 11 mm2. The between-group differences were statistically significant for rotator interval height and base (p

To compare the learning benefit of three different teaching strategies on the interpretation of emergency cerebral computed tomography (CT) pathologies by medical students. Three groups of students with different types of teaching (e-learning, interactive teaching, and standard curricular education in neuroradiology) were tested with respect to the detection of seven CT pathologies. The test results of each group were compared for each CT pathology using the chi-square test. A p-value ≤ 0.05 was considered to be significant. Opposed to the results of the comparison group (curricular education), the e-learning group and interactive teaching tutorial group both showed a significantly better performance in detecting hyperdense middle cerebral artery sign (p = 0.001 and p 0.0001) as well as subarachnoid hemorrhage (p = 0.03 and p = 0.001) on CT. Moreover, an increase in performance for the detection of subdural hematoma and skull fracture could be observed for both the interactive teaching group and the e-learning group, with statistical significance in the latter (p = 0.03 and p 0.0001, respectively). No statistically significant differences were found for the detection of intracranial and epidural hemorrhage, as well as midline shift, among the groups studied. Our study demonstrates potential learning benefits for both the interactive teaching tutorial and e-learning module group with respect to reading CT scans with slightly different advantages. Thus, the introduction of new learning methods in radiological education might be reasonable at an undergraduate stage but requires learning content-based considerations. · E-learning can offer benefits regarding the reading of cerebral CT scans by students. · Interactive tutorial can offer benefits regarding the reading of cerebral CT scans by students. · E-learning and interactive tutorial feature different strengths for student learning in radiology. · Application of interactive teaching methods in radiology requires learning content-based considerations.· Groth M, Barthe KG, Riemer M et al. Critical Analysis of an e-Learning and Interactive Teaching Module with Respect to the Interpretation of Emergency Computed Tomography of the Brain. Fortschr Röntgenstr 2017; 190: 334 - 340.ZIEL: Vergleich von drei verschiedenen Lehrmethoden zur Interpretation von Notfall-Pathologien mit der zerebralen Computertomografie (CT) durch Medizinstudenten. Drei Studentengruppen wurden bzgl. der Detektion von sieben CT-Pathologien getestet, nachdem sie verschiedene Lehrmethoden absolviert hatten (e-Learning, interaktives Seminar, curriculäre Lehre). Die Testergebnisse der drei Gruppen wurde für jede Pathologie mit einem Chi-Quadrat-Test verglichen. Das Signifikanzniveau wurde ≤ 0,05 gewählt. Im Gegensatz zur Vergleichsgruppe (curriculäre Lehre) zeigten die e-Learning- und Interaktivseminar-Gruppe signifikant bessere Ergebnisse bei der Detektion des „hyperdensen Mediazeichens“ (p = 0,001 und p 0,0001) sowie der Subarachnoidalblutung (p = 0,03 und p = 0,001). Darüber hinaus zeigten sowohl die Interaktivseminar- als auch die e-Learning-Gruppe bessere Ergebnisse für die Detektion eines subduralen Hämatoms und einer Kalottenfraktur, wobei nur die letzte Gruppe hier eine statistische Signifikanz aufwies (p = 0,03 und p 0,0001). Keine signifikanten Unterschiede zeigten sich für Pathologien wie intrakranielle Blutung, epidurales Hämatom und Mittellinienverlagerung. Unsere Studie zeigt jeweils unterschiedliche potentielle Vorteile der Interaktivseminar- sowie der e-Learning-Gruppe bei der Interpretation von CTs. Daher können interaktive Lehrmethoden das Potenzial besitzen, die studentisch-radiologische Ausbildung zu verbessern, die passende Lehrform muss jedoch dem jeweiligen Lerninhalt angepasst werden. · E-Learning kann die studentische Beurteilungfähigkeit zerebraler CTs verbessern. · Ein interaktives Seminar kann die studentische Beurteilungfähigkeit zerebraler CTs verbessern. · E-Learning und Interaktivseminare besitzen unterschiedliche Stärken in der studentischen Radiologieausbildung. · Die Anwendung neuer Lehrmethoden in der Radiologie erfordert eine Lerninhalt spezifisch Anpassung.

The aim of the study was to evaluate the B‑flow sonography (BFS) to image the basal cerebral arteries in newborn infants. For this purpose 34 newborns, who underwent standardized ultrasound of the brain including BFS, color Doppler (CDS) and power Doppler (PDS) techniques were retrospectively assessed. Delineation of the anterior communicating (Acom), the posterior communicating (Pcom), the middle cerebral (M1 and M2 segments), the anterior cerebral (A1 and A2 segments), and the posterior cerebral artery (P1 and P2 segments) were visually scored. Vessel delineation was better with BFS compared with CDS and PDS for the M2 segment (p = 0.0006 and p = 0.0136) and P2 segment (p = 0.0021 and p = 0.0014). Superior detectability was also noted for the Pcom with BFS compared with PDS (p = 0.0062). For all other vessel segments no significant differences were found. In conclusion BFS is feasible to image the basal cerebral arteries in newborns with an equal or better vessel delineation compared with standard vascular ultrasound methods.

The aim was to evaluate a novel method of threshold-free prediction of brain infarct from computed tomography perfusion (CTP) imaging in comparison to conventional ischemic thresholds. In a multicenter cohort of 161 patients with acute large vessel occlusion who received endovascular therapy, brain infarction was predicted by CTP using (1) optimized parameter cut-off values determined by ROC curve analysis and (2) probabilistic logistic regression threshold-free analysis. Predicted infarct volumes and prediction errors based on four perfusion parameter maps were compared against observed infarcts. In 93 patients with successful recanalization, the mean observed infarct volume was 35.7 ± 61.9 ml (the reference for core infarct not savable by reperfusion). Optimal parameter thresholds predicted mean infarct volumes between 53.2 ± 44.4 and 125.0 ± 95.4 ml whereas threshold-free analysis predicted mean volumes between 35.9 ± 28.5 and 36.1 ± 29.0 ml. In 68 patients with persistent occlusion, the mean observed infarct volume was 113.4 ± 138.3 ml (the reference to define penumbral infarct savable by reperfusion). Predicted mean infarct volumes by parameter thresholds ranged from 91.4 ± 81.5 to 163.8 ± 135.7 ml, by threshold-free analysis from 113.2 ± 89.9 to 113.5 ± 89.0 ml. Threshold-free prediction of infarct volumes had a higher precision and lower patient-specific prediction error than conventional thresholding. Penumbra to core lesion mismatch estimate may therefore benefit from threshold-free CTP analysis.

Background and Purpose— Ischemic lesion volume (ILV) assessed by follow-up noncontrast computed tomography correlates only moderately with clinical end points, such as the modified Rankin Scale (mRS). We hypothesized that the association between follow-up noncontrast computed tomography ILV and outcome as assessed with mRS 3 months after stroke is strengthened when taking the mRS relevance of the infarct location into account. Methods— An anatomic atlas with 66 areas was registered to the follow-up noncontrast computed tomographic images of 254 patients from the MR CLEAN trial (Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands). The anatomic brain areas were divided into brain areas of high, moderate, and low mRS relevance as reported in the literature. Based on this distinction, the ILV in brain areas of high, moderate, and low mRS relevance was assessed for each patient. Binary and ordinal logistic regression analyses with and without adjustment for known confounders were performed to assess the association between the ILVs of different mRS relevance and outcome. Results— The odds for a worse outcome (higher mRS) were markedly higher given an increase of ILV in brain areas of high mRS relevance (odds ratio, 1.42; 95% confidence interval, 1.31–1.55 per 10 mL) compared with an increase in total ILV (odds ratios, 1.16; 95% confidence interval, 1.12–1.19 per 10 mL). Regression models using ILV in brain areas of high mRS relevance instead of total ILV showed a higher quality. Conclusions— The association between follow-up noncontrast computed tomography ILV and outcome as assessed with mRS 3 months after stroke is strengthened by accounting for the mRS relevance of the affected brain areas. Future prediction models should account for the ILV in brain areas of high mRS relevance.

BACKGROUND AND PURPOSE: Previous studies indicated that ischemic lesion volume might be a useful surrogate marker for functional outcome in ischemic stroke but should be considered in the context of lesion location. In contrast to previous studies using the ROI approach, which has several drawbacks, the present study aimed to measure the impact of ischemic lesion location on functional outcome using a more precise voxelwise approach.MATERIALS AND METHODS: Datasets of patients with acute ischemic strokes from the Multicenter Randomized Clinical Trial of Endovascular Therapy for Acute Ischemic Stroke in the Netherlands (MR CLEAN) were used. Primary outcome was functional outcome as assessed by the modified Rankin Scale 3 months after stroke. Ischemic lesion volume was determined on CT scans 3-9 days after stroke. Voxel-based lesion-symptom mapping techniques, including covariates that are known to be associated with functional outcome, were used to determine the impact of ischemic lesion location for outcome.RESULTS: Of the 500 patients in the MR CLEAN trial, 216 were included for analysis. The mean age was 63 years. Lesion-symptom mapping with inclusion of covariates revealed that especially left-hemispheric lesions in the deep periventricular white matter and adjacent internal capsule showed a great influence on functional outcome.CONCLUSIONS: Our study confirms that infarct location has an important impact on functional outcome of patients with stroke and should be considered in prediction models. After we adjusted for covariates, the left-hemispheric corticosubcortical fiber tracts seemed to be of higher functional importance compared with cortical lesions.

BACKGROUND AND PURPOSE: Angiographic occlusion and retreatment of coiled aneurysms are commonly used as surrogate end points in clinical trials. We aimed to evaluate the influence of aneurysm, patient, and rater characteristics on the confidence of visual evaluation of aneurysm coiling and retreatment decisions. MATERIALS AND METHODS: Twenty-six participants of the Advanced Course in Endovascular Interventional Neuroradiology of the European Society of Neuroradiology were asked to evaluate digital subtraction angiography examinations of patients who had undergone endovascular coiling, by determining the grade of aneurysm occlusion, the change between immediate postprocedural and follow-up angiograms, their level of confidence, the technical difficulty of retreatment, and the best therapeutic approach. The experience, knowledge, and skills of each participant were assessed. The influence of rater and case characteristics on indicated confidence in diagnostic ratings and retreatment recommendations was analyzed. RESULTS: Interrater reliability was moderate regarding the assessment of aneurysm occlusion grade (intraclass correlation coefficient = 0.581) and substantial regarding change (intraclass correlation coefficient = 0.776). Overall confidence in the diagnostic rating was high (median, “very certain”). Confidence was statistically significantly higher in cases that were generally rated as “worse.” The odds of recommending retreatment were significantly higher in cases that were generally rated with higher mean confidence. CONCLUSIONS: Although overall confidence in the diagnostic rating was high, our study confirms the suboptimal interrater reliability of visual assessment of aneurysm occlusion as well as retreatment recommendations, rendering both questionable as primary outcome measures. Besides recurrence status, recommendation of retreatment is significantly influenced by patient age, aneurysm neck width, and characteristics of the therapist.

Background and purpose Most false negative findings in DWI of ischemic stroke are in patients with minor deficits clinically localized to the brainstem. Our goal was to evaluate the benefit of a thin-sliced sagittal DWI in addition to conventional axial DWI at 1.5T for the detection of brainstem infarctions. Methods Data of patients with symptoms consistent with acute and subacute brainstem infarction and an MRI examination including standard axial DWI and thin-sliced sagittal DWI were retrospectively analyzed. Patients with the later diagnosis of a TIA, an inflammation or a tumor of the brainstem were excluded from analysis. Diffusion restrictions were identified by two independent raters blinded for the final clinical diagnosis in three separate reading steps: First, only axial DWI, secondly only sagittal DWI, and lastly both DWIs together. Presence and size of DWI-lesions were documented for each plane. Differences between the observers were settled in consensus in a separate joint reading. Results Of 73 included patients, 46 patients were clinically diagnosed with brainstem infarction. Inter-observer agreement was excellent for the detection of brainstem lesions in axial and sagittal DWI (kappa = 0.94 and 0.97). In 28/46 patients (60.9%) lesions were detected in the axial plane alone, whereas in 6 more patients (73.9%) lesions were detected in the review of both sequences together. All lesions undetectable in the axial plane were smaller than 5 mm in cranio-caudal direction. Conclusions Thin-sliced sagittal DWI in addition to axial DWI improves the detection rate of brainstem infarction with little additional expenditure of time.

OBJECTIVES Net water uptake per volume of brain tissue may be calculated by computed tomography (CT) density, and this imaging biomarker has recently been investigated as a predictor of lesion age in acute stroke. However, the hypothesis that measurements of CT density may be used to quantify net water uptake per volume of infarct lesion has not been validated by direct volumetric measurements so far. The purpose of this study was to (1) develop a theoretical relationship between CT density reduction and net water uptake per volume of ischemic lesions and (2) confirm this relationship by quantitative in vitro and in vivo CT image analysis using direct volumetric measurements. MATERIALS AND METHODS We developed a theoretical rationale for a linear relationship between net water uptake per volume of ischemic lesions and CT attenuation. The derived relationship between water uptake and CT density was tested in vitro in a set of increasingly diluted iodine solutions with successive CT measurements. Furthermore, the consistency of this relationship was evaluated using human in vivo CT images in a retrospective multicentric cohort. In 50 edematous infarct lesions, net water uptake was determined by direct measurement of the volumetric difference between the ischemic and normal hemisphere and was correlated with net water uptake calculated by ischemic density measurements. RESULTS With regard to in vitro data, water uptake by density measurement was equivalent to direct volumetric measurement (r = 0.99, P < 0.0001; mean ± SD difference, -0.29% ± 0.39%, not different from 0, P < 0.0001). In the study cohort, the mean ± SD uptake of water within infarct measured by volumetry was 44.7 ± 26.8 mL and the mean percent water uptake per lesion volume was 22.7% ± 7.4%. This was equivalent to percent water uptake obtained from density measurements: 21.4% ± 6.4%. The mean difference between percent water uptake by direct volumetry and percent water uptake by CT density was -1.79% ± 3.40%, which was not significantly different from 0 (P < 0.0001). CONCLUSIONS Volume of water uptake in infarct lesions can be calculated quantitatively by relative CT density measurements. Voxel-wise imaging of water uptake depicts lesion pathophysiology and could serve as a quantitative imaging biomarker of acute infarct lesions.

Background and Purpose— Angiographic occlusion as a surrogate marker of satisfactory aneurysm treatment is commonly used in clinical trials although some pitfalls have to be considered. To investigate the inter-rater reliability of visual rating of aneurysm occlusion as study end point, we performed a systematic review and meta-analysis. Methods— Electronic databases (MEDLINE, EMBASE, PubMed, and the Cochrane Library) were searched up to June 2014. Assessment of risk for bias was based on the Quality Appraisal Tool for Studies of Diagnostic Reliability and the Guidelines for Reporting Reliability and Agreement studies. Inter-rater reliability estimates were pooled across studies using meta-analysis, and the influence of several factors (eg, imaging methods, grading scales, and occlusion rate) was tested with meta-regression. Results— From 1193 titles, 644 abstracts and 87 full-text versions were reviewed. Twenty-six articles met the inclusion criteria and provided 77 reliability estimates. Twenty-one different rating scales were used, and statistical analysis varied. Mean inter-rater agreement of the pooled studies was substantial (κ=0.65; 95% confidence interval, 0.60–0.69). Reliability varied significantly as a function of imaging methods, grading scales, occlusion rates, and their interaction. Observer agreement substantially increased with increasing occlusion rate in digital subtraction angiography but not in MR angiography. Reliability was higher in studies using 2- or 3-value grading scales than in studies with 4-value grading scales. Conclusions— There is significant heterogeneity between studies evaluating the reliability of visual evaluation of aneurysm coiling. On the basis of our analysis, we found that the combination of magnetic resonance angiography, 3-value grading scale, and 2 trained raters seems most promising for usage as surrogate study end points.

ZIEL: Evaluation von Femoralarterien (FA) bei Neugeborenen im Rahmen einer Herzkatheteruntersuchung mittels B-Mode (BMS) und B-Flow Sonographie (BFS) und Vergleich beider Methoden bzgl. Bildqualität und Reliabilität von Diametermessungen. Das Studienkollektiv bestand aus 21 konsekutiven Säuglingen, welche einen Ultraschall zur Evalation der FA vor oder nach Herzkatheteruntersuchung erhielten. Die Ultraschalldatensätze wurden von zwei Radiologen ausgewertet. Es wurden Gefäßdiameter sowie die maximal auf einem Ultraschallbild darstellbare Gefäßlänge mittels BMS und BFS vermessen. Zusätzlich wurde die Bildqualiät von einem Radiologen bewertet. Die Statistik umfasste den Intra-Klassen-Korrelationskoeffizient, eine Bland-Altman Analyse, Fisher´s exakten Test sowie einen t-Test. Die Intra- und Interobserverkorrelation war exzellent für BMS (0,7922 and 0,6521) sowie BFS (0,8094 and 0,7637). Eine Bland-Altman Analyse zeigte mittlere Abweichungen zwischen +/–0,73 mm (intraobserver) und für BMS +/–0,55 mm (interobserver) sowie +/–0,83 mm (intraobserver) und +/–0,7 mm (interobserver) für BFS. BFS ermöglicht eine signifikant längere Gefäßabbildung auf einem Ultraschallbild (3,54 +/–0,85 vs. 2,21 +/–0,9 cm, p 0,0001). Darüber hinaus war die Bildqualität mit BFS signifikant besser als mit BMS (p = 0,0043). Da BFS eine exzellente Reproduzierbarkeit bei Gefäßdiametermessungen sowie eine der BMS überlegende Bildqualität zeigt, sollte BFS, falls vorhanden, standardmäßig in Untersuchungsprotokolle integriert werden, wenn realistische Gefäßmessungen und -abbildungen erforderlich sind. · Die B-Flow Sonographie bietet eine hohe Bildqualität für die Evaluation von Femoralarterien. · Gefäßdiametermessungen können mit der B-Flow Sonographie mit exzellenter Reproduzierbarkeit durchgeführt werden. · Eine ergänzende B-Flow Sonographie der Femoralarterien von Säuglingen wird empfohlen, falls vorhanden.

BackgroundUnderstanding aneurysm growth is critical for the appropriate follow-up of patients after coil embolization and the need for retreatment. The purpose of the study was to stratify the growth dynamics of aneurysm recurrences after coiling by volumetric analysis and to determine predictive factors for aneurysm recurrences.MethodsSource images of follow-up three-dimensional time of flight MR angiography (ToF-MRA) scans were compared with the first post-interventional ToF-MRA scan and analyzed for residual flow after co-registration using ANALYZE-software. In the event of incomplete occlusion, the residual volume was segmented and calculated. Growth dynamic was determined for each aneurysm after embolization.ResultsWe analyzed 326 patients with 345 aneurysms from two centers. Each case had at least two ToF-MRA examinations after endovascular therapy. The mean observation interval was 59 months. Volumetric analysis of 1139 follow-up MRAs revealed that 218/345 aneurysms (63.2%) showed complete occlusion on initial follow-up imaging, and of these 95.0% remained stable. A steady increase in intra-aneurysmal flow was observed in 83/345 (24.1%). Less frequent observations were a steep increase (21/345; 6.1%) and a decrease (27/345; 7.8%). Independent predictors of increasing residual flow were greatest aneurysm diameter, total coil length, and incomplete occlusion.ConclusionsVolumetric analysis of registered three-dimensional ToF-MRA follow-up datasets allows the detection of different growth patterns with high precision, avoids the low inter-rater reliability, and represents a promising approach for future studies that include analysis of more complex predictors of residual flow. In cases of aneurysm recurrence after coiling, the major pattern seems to be a steady increase in intra-aneurysmal flow over several months.

This study aims to investigate diagnostic sensitivity and reliability for the detection of middle cerebral artery occlusion (MCAO) on non-contrast-enhanced computed tomography (NECT) by visual assessment (VA), Hounsfield unit (HU) measurement, calculation of the Hounsfield unit/hematocrit (HU/Hct) ratio, and combination of visual assessment and attenuation measurement (VA + HU). NECT of 18 patients with angiographically proven MCAO and 18 patients without MCAO were reviewed by two blinded observers. Visual assessment of presence or absence of a hyperdense sign was followed by HU measurement of both middle cerebral arteries (MCA). Sensitivity, specificity, positive predictive value, and negative predictive value were calculated for VA, HU measurement, HU/Hct ratio, and VA + HU measurement. Receiver operating characteristic curve analysis (ROC) was performed to determine the optimal cut-off values for MCAO using attenuation measurements or HU/Hct ratio. Diagnostic sensitivity/specificity was 63 %/91 % for VA, 56 %/88 % for attenuation measurement, 68 %/81 % for HU/Hct ratio, and 75 %/78 % for VA + HU. ROC curve analysis revealed cut-off values of >42.5 HU for attenuation measurements and >1.12 HU/Hct for HU/Hct ratio. Combination of visual assessment with additional attenuation measurement with a cut-off value of 42.5 HU is recommended for most sensitive and reliable detection of MCAO on NECT.

The treatment mode in acute vertebrobasilar occlusion (VBO) remains uncertain. We analyzed efficacy and safety of intravenous glycoprotein IIb/IIIa inhibitor (IV GPI) plus subsequent intra-arterial thrombolysis with or without additional endovascular mechanical therapy (percutaneous transluminal angioplasty/stenting or thrombus aspiration) and sought treatment factors that predict good clinical outcome.We retrospectively analyzed 120 cases of patients with angiographically proven acute VBO. Multivariate logistic regression was used to identify independent predictors for clinical outcome and included level of consciousness, age, sex, time to angiography, GPI agent, admission mode, occlusion type, recanalization success, and endovascular treatment mode. Clinical follow-up was dichotomized in no to moderate disability (modified Rankin scale (mRS) 0-3) vs. severe disability or death (mRS 4-6).Median National Institutes of Health stroke scale (NIHSS) score on admission was 32, and mean NIHSS score was 24. A total of 49 patients (41 %) developed no to moderate disability (mRS 0-3), and 39 patients (33 %) died. Thrombolysis in myocardial infarction 2/3 recanalization success was achieved in 97 patients (80.8 %). Symptomatic intracerebral hemorrhages occurred in 11 patients (9 %). Mild impairment of consciousness (p 0.001) and embolic occlusion type (p = 0.01) were significant predictors of favorable outcome. Clinical outcome in recanalized patients was better, but not statistically significant (p = 0.055).Our results indicate that combined therapy with IV GPI and subsequent endovascular therapy may be a valid treatment strategy in acute VBO. With this treatment approach, a preserved vigilance before treatment and an embolic occlusion type are associated with no to moderate disability.

Intracerebral hemorrhage (ICH) is one of the most devastating and costly diagnoses in the USA. ICH is a common diagnosis, accounting for 10–15 % of all strokes and affecting 20 out of 100,000 people. The CT angiography (CTA) spot sign, or contrast extravasation into the hematoma, is a reliable predictor of hematoma expansion, clinical deterioration, and increased mortality. Multiple studies have demonstrated a high negative predictive value (NPV) for ICH expansion in patients without spot sign. Our aim is to determine the absolute NPV of the spot sign and clinical characteristics of patients who had ICH expansion despite the absence of a spot sign. This information may be helpful in the development of a cost effective imaging protocol of patients with ICH. During a 3-year period, 204 patients with a CTA with primary intracerebral hemorrhage were evaluated for subsequent hematoma expansion during their hospitalization. Patients with intraventricular hemorrhage were excluded. Clinical characteristics and antithrombotic treatment on admission were noted. The number of follow-up NCCT was recorded. Of the resulting 123 patients, 108 had a negative spot sign and 7 of those patients subsequently had significant hematoma expansion, 6 of which were on antithrombotic therapy. The NPV of the CTA spot sign was calculated at 0.93. In patients without antithrombotic therapy, the NPV was 0.98. In summary, the negative predictive value of the CTA spot sign for expansion of ICH, in the absence of antithrombotic therapy and intraventricular hemorrhage (IVH) on admission, is very high. These results have the potential to redirect follow-up imaging protocols and reduce cost.

Purpose We sought to develop a standardized curriculum capable of assessing key competencies in Interventional Neuroradiology by the use of models and simulators in an objective, quantitative, and efficient way. In this evaluation we analyzed the associations between the practical experience, theoretical knowledge, and the skills lab performance of interventionalists. Materials and methods We evaluated the endovascular skills of 26 participants of the Advanced Course in Endovascular Interventional Neuroradiology of the European Society of Neuroradiology with a set of three tasks (aneurysm coiling and thrombectomy in a virtual simulator and placement of an intra-aneurysmal flow disruptor in a flow model). Practical experience was assessed by a survey. Participants completed a written and oral examination to evaluate theoretical knowledge. Bivariate and multivariate analyses were performed. Results In multivariate analysis knowledge of materials and techniques in Interventional Neuroradiology was moderately associated with skills in aneurysm coiling and thrombectomy. Experience in mechanical thrombectomy was moderately associated with thrombectomy skills, while age was negatively associated with thrombectomy skills. We found no significant association between age, sex, or work experience and skills in aneurysm coiling. Conclusion Our study gives an example of how an integrated curriculum for reasonable and cost-effective assessment of key competences of an interventional neuroradiologist could look. In addition to traditional assessment of theoretical knowledge practical skills are measured by the use of endovascular simulators yielding objective, quantitative, and constructive data for the evaluation of the current performance status of participants as well as the evolution of their technical competency over time.

BACKGROUND AND PURPOSE: In proximal anterior circulation occlusive strokes, collateral flow is essential for good outcome. Collateralized vessel intensity in TOF- and contrast-enhanced MRA is variable due to different acquisition methods. Our purpose was to quantify collateral supply by using flow-weighted signal in TOF-MRA and blood volume–weighted signal in contrast-enhanced MRA to determine each predictive contribution to tissue infarction and reperfusion. MATERIALS AND METHODS: Consecutively (2009–2013), 44 stroke patients with acute proximal anterior circulation occlusion met the inclusion criteria with TOF- and contrast-enhanced MRA and penumbral imaging. Collateralized vessels in the ischemic hemisphere were assessed by TOF- and contrast-enhanced MRA using 2 methods: 1) visual 3-point collateral scoring, and 2) collateral signal quantification by an arterial atlas-based collateral index. Collateral measures were tested by receiver operating characteristic curve and logistic regression against 2 imaging end points of tissue-outcome: final infarct volume and percentage of penumbra saved. RESULTS: Visual collateral scores on contrast-enhanced MRA but not TOF were significantly higher in patients with good outcome. Visual collateral scoring on contrast-enhanced MRA was the best rater-based discriminator for final infarct volume < 90 mL (area under the curve, 0.81; P < .01) and percentage of penumbra saved >50% (area under the curve, 0.67; P = .04). Atlas-based collateral index of contrast-enhanced MRA was the overall best independent discriminator for final infarct volume of 50%; area under the curve, 0.89; P < .001). CONCLUSIONS: Visual scoring of contrast-enhanced but not TOF-MRA is a reliable predictor of infarct outcome in stroke patients with proximal arterial occlusion. By atlas-based collateral assessment, TOF- and contrast-enhanced MRA both contain predictive signal information for penumbral reperfusion. This could improve risk stratification in further studies.

Background Training by the use of simulators and flow models is increasingly integrated into training of young interventionalists and into the launch of new materials in Neurointerventions. There seems general agreement that such an artificial environment is useful but not all aspects of a given intervention can be trained there. We aimed at comparing the practical experience of a given interventionalist and the performance in the skills lab. We hypothesized that there is a strong positive correlation. Methods We enrolled 26 volunteers with different training background and 2–14 years of experience in Neurointerventions. The subjects were subdivided regarding experiences in thrombectomy, aneurysm coiling, flow diverter and flow disruptor placement as first operator as well as their overall years of practical experience in Neurointerventions. The maximum experience score was 28. We evaluated the skills of the volunteers with a set of four tasks (aneurysm coiling and thrombectomy in a virtual simulator, placement of an intra-aneurysmal flow disruptor and aneurysm coiling in a flow model). The respective procedural times and fluoroscopy times were subdivided in quartiles. The maximum score (procedural times within the lowest quartile in all four procedures) was 100. Results The median of the practical results was 75% (range 33–100) while the median score of practical experience was 18 (range 7–28). There was no correlation between practical experience and practical results in the simulator/flow model scores (R = 0.03, p > 0.1). Six out of the ten participants with the minimal practical experience had had scores in practical skills better than the median of the entire group. Three of them had perfect practical skill scores (100%). There was no equal score in the more experienced participants. Discussion This preliminary analysis of our training data reveals surprising insight into the relation between the measured performance in an artificial training environment and actual experience in neurointerventions. The missing correlation between the real-world-practical experience of a given interventionalist and the performance in the skills lab might suggest either a subchallenge or an excessive challenge by the training technologies. The high scores in the less experienced (younger) participants may be explained by influence of genuine computer skills on procedure duration. A subgroup analysis comparing the different procedures and their relation to the required practical experience is currently ongoing and will be presented during the meeting. Disclosures M. Ernst: None. J. Buhk: 2; C; Codman, Acandis, Sequent. 3; C; Codman, Acandis. A. Froelich: None. J. Fiehler: 1; C; Microvention. 2; C; Acandis, Microvention, Stryker, Codman, Sequent. 3; C; Covidien, Penumbra, Philips.