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Pilocytic astrocytoma is a WHO grade I tumor usually diagnosed in pediatric patients, and rarely encountered in the adult population. Therefore, available information about the magnetic resonance imaging characteristics of adult pilocytic astrocytoma is scarce. We report on the MRI features and corresponding histopathologic findings of six consecutive aPA cases diagnosed. The tumors were encountered in both infra- and supratentorial compartments, and their MRI characteristics were quite heterogeneous. Features included the typical solid-cystic appearance located in the cerebellum as well as the relatively unusual multifocal and/or hemorrhagic features located intra-ventricularly. The aPA MRI characteristics are remarkably variable, and might mimic those of higher grade tumors in adult patients.

Background Whether thrombectomy alone is equally as effective as intravenous alteplase plus thrombectomy remains controversial. We aimed to determine whether thrombectomy alone would be non-inferior to intravenous alteplase plus thrombectomy in patients presenting with acute ischaemic stroke. Methods In this multicentre, randomised, open-label, blinded-outcome trial in Europe and Canada, we recruited patients with stroke due to large vessel occlusion confirmed with CT or magnetic resonance angiography admitted to endovascular centres. Patients were randomly assigned (1:1) via a centralised web server using a deterministic minimisation method to receive stent-retriever thrombectomy alone or intravenous alteplase plus stent-retriever thrombectomy. In both groups, thrombectomy was initiated as fast as possible with any commercially available Solitaire stent-retriever revascularisation device (Medtronic, Irvine, CA, USA). In the combined treatment group, intravenous alteplase (0.9 mg/kg bodyweight, maximum dose 90 mg per patient) was administered as early as possible after randomisation for 60 min with 10% of the calculated dose given as an initial bolus. Personnel assessing the primary outcome were masked to group allocation; patients and treating physicians were not. The primary binary outcome was a score of 2 or less on the modified Rankin scale at 90 days. We assessed the non-inferiority of thrombectomy alone versus intravenous alteplase plus thrombectomy in all randomly assigned and consenting patients using the one-sided lower 95% confidence limit of the Mantel-Haenszel risk difference, with a prespecified non-inferiority margin of 12%. The main safety endpoint was symptomatic intracranial haemorrhage assessed in all randomly assigned and consenting participants. This trial is registered with ClinicalTrials.gov, NCT03192332, and is closed to new participants. Findings Between Nov 29, 2017, and May 7, 2021, 5215 patients were screened and 423 were randomly assigned, of whom 408 (201 thrombectomy alone, 207 intravenous alteplase plus thrombectomy) were included in the primary efficacy analysis. A modified Rankin scale score of 0-2 at 90 days was reached by 114 (57%) of 201 patients assigned to thrombectomy alone and 135 (65%) of 207 patients assigned to intravenous alteplase plus thrombectomy (adjusted risk difference -7 .3%, 95% CI -16.6 to 2.1, lower limit of one-sided 95% CI -15.1%, crossing the non-inferiority margin of - 12%). Symptomatic intracranial haemorrhage occurred in five (2%) of 201 patients undergoing thrombectomy alone and seven (3%) of 202 patients receiving intravenous alteplase plus thrombectomy ( risk difference -1.0%, 95% CI -4.8 to 2 .7). Successful reperfusion was less common in patients assigned to thrombectomy alone (182 [ 91%] of 201 vs 199 [96%] of 207, risk difference -5.1%, 95% CI -10.2 to 0. 0, p=0.047). Interpretation Thrombectomy alone was not shown to be non-inferior to intravenous alteplase plus thrombectomy and resulted in decreased reperfusion rates. These results do not support omitting intravenous alteplase before thrombectomy in eligible patients. Copyright (C) 2022 Elsevier Ltd. All rights reserved.

Summary purpose: Mechanical thrombectomies (MT) in patients with large vessel occlusion (LVO) related to calcified cerebral embolus (CCE) have been reported, through small case series, being associated with low reperfusion rate and worse outcome, compared to regular MT. The purpose of the MASC (Mechanical Thrombectomy in Acute Ischemic Stroke Related to Calcified Cerebral Embolus) study was to evaluate the incidence of CCEs treated by MT and the effectiveness of MT in this indication. Methods: The MASC study is a retrospective multicentric (n = 37) national study gathering the cases of adult patients who underwent MT for acute ischemic stroke with LVO related to a CCE in France from January 2015 to November 2019. Reperfusion rate (mTICI ≥ 2B), complication rate and 90-day mRS were systematically collected. We then conducted a systematic review by searching for articles in PubMed, Cochrane Library, Embase and Google Scholar from January 2015 to March 2020. A meta-analysis was performed to estimate clinical outcome at 90 days, reperfusion rate and complications. Results: We gathered data from 35 patients. Reperfusion was obtained in 57% of the cases. Good clinical outcome was observed in 28% of the patients. The meta-analysis retrieved 136 patients. Reperfusion and good clinical outcome were obtained in 50% and 29% of the cases, respectively. Conclusion: The MASC study found worse angiographic and clinical outcomes compared to regular thrombectomies. Individual patient-based meta-analysis including the MASC findings shows a 50% reperfusion rate and a 29% of good clinical outcome.

Cerebral peri-aneurysmal edema (PE) is typically associated with giant partially-thrombosed aneurysms and less frequently with smaller aneurysms treated with endovascular embolization. An understanding of the pathophysiologic mechanism of PE is still limited. We report 3 cases of cerebral aneurysms associated with PE. We describe 2 cases of giant partially thrombosed aneurysms surrounded by vasogenic edema with apposition of an intramural and juxtamural thrombus. Our third case is a smaller aneurysm inciting vasogenic edema several years after coil embolization. Vessel-wall magnetic resonance imaging (MRI) showed avid wall enhancement and an enhancing thrombus embedded within the coils, reflecting inflammation of the aneurysm wall and proliferation of the vasa vasorum. Thrombosis within the aneurysmal sac and walls, both in native and treated aneurysms, may promote inflammatory changes and sustain the occurrence of PE. Vessel-wall MRI has a potential role in the evaluation process of this subgroup of aneurysms.

BackgroundThe treatment of severe osteoporotic vertebral compression fractures (VCFs) with middle-column (MC) involvement, high fragmentation, large cleft and/or pedicular fracture is challenging. Minimally invasive 'stent-screw-assisted internal fixation' (SAIF) can reduce the fracture, reconstruct the vertebral body (VB) and fix it to the posterior elements.ObjectiveTo assess feasibility, safety, technical and clinical outcome of the SAIF technique in patients with severe osteoporotic VCFs.Methods80 treated vertebrae were analyzed retrospectively. Severe VCFs were characterized by advanced collapse (Genant grade 3), a high degree of osseous fragmentation (McCormack grade 2 and 3), burst morphology with MC injury, pediculo-somatic junction fracture, and/or large osteonecrotic cleft. VB reconstruction was evaluated on postprocedure radiographs and CT scans by two independent raters. Clinical and radiological follow-ups were performed at 1 and 6 months.ResultsSAIF was performed at 28 thoracic and 52 lumbar levels in 73 patients. One transient neurological complication occurred. VB reconstruction was satisfactory in 98.8% of levels (inter-rater reliability 96%, κ=1). Follow-up at 1 month was available for 78/80 levels and at 6 months or later (range 6–24, mean 7.9 months) for 73/80 levels. Significant improvement in the Visual Analog Scale score was noted at 1 and 6 months after treatment (pConclusionsSAIF is a minimally invasive, safe, and effective treatment for patients with severe osteoporotic VCFs with MC involvement.

PURPOSE CT-guided percutaneous procedures involving the skull base and atlanto-axial cervical spine pose particular challenges due to high density of vital vascular and nervous structures and because the ideal needle trajectory often has a cranio-caudal obliquity different from the axial scan plane. We describe how the variable CT gantry tilt, combined with gantry-needle-target alignment technique, is used to obtain precise and safe needle placement in conventional and non-conventional approaches to the skull base and the atlanto-axial spine. METHODS We retrospectively analyzed consecutive CT-guided needle accesses to the skull base and atlanto-axial spine performed for tissue sampling through fine-needle aspirates and core biopsies, cementoplasty of neoplastic lytic lesions of atlanto-axial spine, pain management injections, and dural puncture for cerebro-spinal fluid sampling. All the accesses were performed with the gantry-needle-target alignment technique. Procedural complications were recorded. RESULTS Thirty-nine CT-guided procedures were analyzed. Paramaxillary approach was used in 15 cases, postero-lateral in 11, subzygomatic in 3. Nine non-conventional approach were performed: submastoid in 3 cases, suprazygomatic in 2, trans-nasal in 2, trans-mastoid in 1, and trans-auricular in 1. Two peri-procedural complications occurred: one asymptomatic and one resolved within 24 h. All the procedures were successfully completed with successful needle access to the target. CONCLUSION The gantry tilt and gantry-needle-target alignment technique allows to obtain double-oblique needle accesses for CT-guided procedures involving the skull base and atlanto-axial cervical spine, minimizing uncertainty of needle trajectory and obtaining safe needle placement in conventional and non-conventional approaches.

INTRODUCTION/AIMS Hourglass-like constrictions (HGCs) occur in neuralgic amyotrophy (NA), but the earliest time at which they can be recognized by imaging is poorly understood. We aimed to determine the prevalence of abnormal imaging findings in the acute phase of NA. METHODS Magnetic resonance neurography (MRN) and high-resolution ultrasound (US) examinations were performed at 5 sites. The investigation included 39 patients with acute NA who underwent imaging within 31 days of symptom onset. Correlation between imaging and electromyography (EMG) findings was measured. RESULTS US was performed in 29 patients and MRN in 23; 16 patients underwent US only, 10 MRN only, and 13 had both. US and MRN showed nerve abnormalities within 1 month from NA onset in 90% of patients. HGCs were found in 74% (29/39) of the patients: 4 within 1 week, 8 within 2 weeks, 5 within 3 weeks, and 12 within 4 weeks. The earliest HGC on US was found within 12 hours, and on MRN within 3 days from symptom onset. MRN demonstrated a denervation edema pattern of affected muscles in 91% of the patients. The shortest time to observe an edema pattern on MRN was 8 days. EMG was performed in 30 patients and revealed fibrillation potentials in affected muscles in 22 (73%). A denervation edema pattern on MRN was significantly associated with the presence of HGCs both on MRN and US, and with fibrillation potentials on EMG. DISCUSSION In the early phase of NA, US and MRN are useful diagnostic techniques for demonstrating nerve abnormalities. This article is protected by copyright. All rights reserved.

BACKGROUND Spontaneous intracranial hypotension (SIH) is a��debilitating condition requiring effective treatment; however, objective data on treatment response are scarce. PURPOSE To assess the suitability of the brain MRI-based SIH score (bSIH) for monitoring treatment success in SIH patients with a��proven spinal cerebrospinal fluid (CSF) leak after microsurgical closure of the underlying dural breach. METHODS This retrospective cohort study included consecutive SIH patients with a��proven spinal CSF leak, investigated at dedicated referral centre January 2012 to March 2020. The bSIH score integrates 6��imaging findings; 3��major (2��points) and 3��minor (1��point), and ranges from 0��to 9, with 0��indicating low and 9��high probability of spinal CSF loss. The score was calculated using brain magnetic resonance imaging (MRI) before and after surgical treatment of the underlying CSF leak. Headache intensity was registered on a��numeric rating scale (NRS) (range 0-10). RESULTS In this study 52 SIH patients, 35��(67%) female, mean age 45.3��years, with a��proven spinal CSF leak were included. The mean bSIH score decreased significantly from baseline to after surgical closure of the underlying dural breach (6.9 vs. 1.3, P���

BACKGROUND Very small anterior communicating artery aneurysms (vsACoA) of

Low back pain with or without radicular leg pain is an extremely common health condition significantly impacting patient's activities and quality of life. When conservative management fails, epidural injections providing only temporary relief, are frequently utilized. Intradiscal oxygen-ozone may offer an alternative to epidural injections and further reduce the need for microdiscectomy.To compare the non-inferiority treatment status and clinical outcomes of intradiscal oxygen-ozone with microdiscectomy in patients with refractory radicular leg pain due to single-level contained lumbar disc herniations.Multicenter pilot prospective non-inferiority blocked randomized control trial conducted in three European hospital spine centers.Forty-nine patients (mean 40 years of age, 17 females/32 males) with a single-level contained lumbar disc herniation, radicular leg pain for more than six weeks, and resistant to medical management were randomized, 25 to intradiscal oxygen-ozone and 24 to microdiscectomy. 88% (43 of 49) received their assigned treatment and constituted the AS-Treated (AT) population.Primary outcome was overall 6-month improvement over baseline in leg pain. Other validated clinical outcomes, including back numerical rating pain scores (NRS), Roland Morris Disability Index (RMDI) and EQ-5D, were collected at baseline, 1 week, 1-, 3-, and 6-months. Procedural technical outcomes were recorded and adverse events were evaluated at all follow-up intervals.Oxygen-ozone treatment performed as outpatient day surgeries, included a one-time intradiscal injection delivered at a concentration of 35±3 μg/cc of oxygen-ozone by a calibrated delivery system. Discectomies performed as open microdiscectomy inpatient surgeries, were without spinal instrumentation, and not as subtotal microdiscectomies. Primary analyses with a non-inferiority margin of -1.94-point difference in 6-month cumulative weighted mean leg pain NRS scores were conducted using As-Treated (AT) and Intent-to-Treat (ITT) populations. In post hoc analyses, differences between treatment groups in improvement over baseline were compared at each follow-up visit, using baseline leg pain as a covariate.In the primary analysis, the overall 6-month difference between treatment groups in leg pain improvement using the AT population was -0.31 (SE, 0.84) points in favor of microdiscectomy and using the ITT population, the difference was 0.32 (SE, 0.88) points in favor of oxygen-ozone. The difference between oxygen-ozone and microdiscectomy did not exceed the non-inferiority 95% confidence lower limit of treatment difference in either the AT (95% lower limit, -1.72) or ITT (95% lower limit, -1.13) populations. Both treatments resulted in rapid and statistically significant improvements over baseline in leg pain, back pain, RMDI, and EQ-5D that persisted in follow-up. Between group differences were not significant for any outcomes. During 6-month follow-up, 71% (17 of 24) of patients receiving oxygen-ozone, avoided microdiscectomy. The mean procedure time for oxygen-ozone was significantly faster than microdiscectomy by 58 minutes (p.0010) and the mean discharge time from procedure was significantly shorter for the oxygen-ozone procedure (4.3±2.9 hours vs. 44.2±29.9 hours, p.001). No major adverse events occurred in either treatment group.Intradiscal oxygen-ozone chemonucleolysis for single-level lumbar disc herniations unresponsive to medical management, met the non-inferiority criteria to microdiscectomy on 6-month mean leg pain improvement. Both treatment groups achieved similar rapid significant clinical improvements that persisted and overall, 71% undergoing intradiscal oxygen-ozone were able to avoid surgery.

ObjectiveTo compare outcomes after endovascular therapy (EVT) and IV thrombolysis (IVT) in patients with stroke with emergent large vessel occlusion (LVO) and mild neurologic deficits.MethodsThis was a retrospective analysis of patients from the Swiss Stroke Registry with admission NIH Stroke Scale score ≤5 and LVO treated by EVT (± IVT) vs IVT alone. The primary endpoint was favorable functional outcome (modified Rankin Scale [mRS] score 0–1) at 3 months. Secondary outcomes were independence (mRS score 0–2), mRS score (ordinal shift analysis), and survival with high disability (mRS score 4–5). Safety endpoints were mortality and symptomatic hemorrhage.ResultsOf 11,356 patients, 312 met the criteria and propensity score method matched 108 in each group. A comparably large proportion of patients with EVT and IVT had favorable outcome (63% vs 65.7% respectively; odds ratio 0.94, 95% confidence interval 0.51–1.72; p = 0.840). Patients with EVT showed a nonsignificant trend toward higher mRS score at 3 months (p = 0.717), while the proportion of surviving patients with high disability was comparably very low in both groups (p = 0.419). Mortality was slightly higher among those with EVT (9.3% vs 2.8%; p = 0.06), and symptomatic intracranial hemorrhage was a rare event in both groups (2.8% vs 0%; p = 0.997).ConclusionsIn acute ischemic stroke, EVT and IVT appear similarly effective in achieving favorable outcome at 3 months for patients with LVO and mild neurologic symptoms. EVT might be marginally inferior to IVT regarding outcome across all levels of disability and mortality. Further studies are required to determine whether certain subgroups of patients with LVO and mild symptoms benefit from EVT.Classification of evidenceThis study provides Class III evidence that patients with LVO and mild symptoms receiving either EVT or IVT had similar favorable functional outcomes at 3 months.

ObjectivesTo describe a new technique to obtain minimally invasive but efficient vertebral body (VB) reconstruction, augmentation, and stabilization in severe osteoporotic and neoplastic fractures, combining two pre-existing procedures. The implant of vertebral body stents (VBS) is followed by insertion of percutaneous, fenestrated, cement-augmented pedicular screws that act as anchors to the posterior elements for the cement/stent complex. The screws reduce the risk of stent mobilization in a non-intact VB cortical shell and bridge middle column and pedicular fractures. This procedure results in a 360° non-fusion form of vertebral internal fixation that may empower vertebral augmentation and potentially avoid corpectomy in challenging fractures.Procedure detailsThis report provides step-by-step procedural details, rationale, and proposed indications for this procedure. The procedure is entirely percutaneous under fluoroscopic guidance. Through transpedicular trocars the VBS are inserted, balloon-expanded and implanted in the VB. Over k-wire exchange the transpedicular screws are inserted inside the lumen of the stents and cement is injected through the screws to augment the stents and fuse the screws to the stents.ApplicationsThis technique may find appropriate applications for the most severe osteoporotic fractures with large clefts, high-degree fragmentation and collapse, middle column and pedicular involvement, and in extensive neoplastic lytic lesions.ConclusionsStent-Screw-Assisted Internal Fixation (SAIF) might represent a minimally invasive option to obtain VB reconstruction and restoration of axial load capability in severe osteoporotic and neoplastic fractures, potentially obviating the need for more invasive surgical interventions in situations that would pose significant challenges to standard vertebroplasty or balloon kyphoplasty.

Delayed cerebral ischemia (DCI) is a frequent cause of morbidity and mortality in patients with cerebral vasospasm (CV) following aneurysmal subarachnoid hemorrhage (aSAH). Refractory CV remains challenging to treat and often leads to permanent deficits and death despite aggressive therapy. We hereby report the feasibility and safety of stellate ganglion block (SGB) performed with a vascular roadmap-guided technique to minimize the risk of accidental vascular puncture and may be coupled to a diagnostic or therapeutic cerebral angiography. In addition to a detailed description of the technique, we performed a retrospective analysis of a series of consecutive patients with refractory CV after aSAH that were treated with adjuvant roadmap-guided SGB. Clinical outcomes at discharge are reported. Nineteen SGB procedures were performed in 10 patients, after failure of traditional hemodynamic and endovascular treatments. Each patient received 1 to 3 SGB, usually interspaced by 24 h. In 4 patients, an indwelling microcatheter for continuous infusion was inserted. First SGB occurred on average 7.3 days after aSAH. SGB was coupled to intra-arterial nimodipine infusion or balloon angioplasty in 9 patients. SGB was technically successful in all patients. There were no technical or clinical complications. Adjuvant SGB may be coupled to endovascular therapy to treat refractory cerebral vasopasm within the same session. To guide needle placement, using a roadmap of the supra-aortic arteries may decrease the risk of complications. More prospective data is needed to evaluate the therapeutic efficacy, durability, and safety of SGB compared with the established standard of care.

BACKGROUND Osteoporotic vertebral fractures (OVFs) have become increasingly common, and previous nonrandomized and randomized controlled trials (RCTs) have compared the effects of cement augmentation versus nonoperative management on the clinical outcome. This meta-analysis focuses on RCTs and the calculated differences between cement augmentation techniques and nonsurgical management in outcome (e.g., pain reduction, adjacent-level fractures, and quality of life [QOL]). METHODS A systematic review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, and the following scientific search engines were used: MEDLINE, Embase, Cochrane, Web of Science, and Scopus. The inclusion criteria included RCTs that addressed different treatment strategies for OVF. The primary outcome was pain, which was determined by a visual analog scale (VAS) score; the secondary outcomes were the risk of adjacent-level fractures and QOL (as determined by the EuroQol-5 Dimension [EQ-5D] questionnaire, the Oswestry Disability Index [ODI], the Quality of Life Questionnaire of the European Foundation for Osteoporosis [QUALEFFO], and the Roland-Morris Disability Questionnaire [RDQ]). Patients were assigned to 3 groups according to their treatment: vertebroplasty (VP), kyphoplasty (KP), and nonoperative management (NOM). The short-term (weeks), midterm (months), and long-term (>1 year) effects were compared. A random effects model was used to summarize the treatment effect, including I2 for assessing heterogeneity and the revised Cochrane risk-of-bias 2 (RoB 2) tool for assessment of ROB. Funnel plots were used to assess risk of publication bias. The log of the odds ratio (OR) between treatments is reported. RESULTS After screening of 1,861 references, 53 underwent full-text analysis and 16 trials (30.2%) were included. Eleven trials (68.8%) compared VP and NOM, 1 (6.3%) compared KP and NOM, and 4 (25.0%) compared KP and VP. Improvement of pain was better by 1.31 points (95% confidence interval [CI], 0.41 to 2.21; p < 0.001) after VP when compared with NOM in short-term follow-up. Pain effects were similar after VP and KP (midterm difference of 0.0 points; 95% CI, -0.25 to 0.25). The risk of adjacent-level fractures was not increased after any treatment (log OR, -0.16; 95% CI, -0.83 to 0.5; NOM vs. VP or KP). QOL did not differ significantly between the VP or KP and NOM groups except in the short term when measured by the RDQ. CONCLUSIONS This meta-analysis provides evidence in favor of the surgical treatment of OVFs. Surgery was associated with greater improvement of pain and was unrelated to the development of adjacent-level fractures or QOL. Although improvements in sagittal balance after surgery were poorly documented, surgical treatment may be warranted if pain is a relevant problem. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

A holocord syringomyelia due to Chiari 1.5 malformation (CM) in a 12-year-old girl was serially imaged with 3 T MRI over 4 years. The serial MRI showed reduction in size of the syrinx, without any surgical intervention or CM improvement, but rather due to spontaneous spinal cord tear. The tear was clearly demonstrated by evidence of flow signal across the tear between syrinx and subarachnoid space at the upper thoracic level. The tear showed spontaneous closure at follow-up. A medullary tear has been described in the adult population as one of the putative causes of spontaneous syringomyelia reduction, but its clear demonstration with modern high-resolution MRI has not been reported in the paediatric population. Moreover, this is the first reported case of syrinx reduction due to spontaneous fissuration in a paediatric patient.

Background and Purpose: Extracellular vesicles (EVs) are promising biomarkers for cerebral ischemic diseases, but not systematically tested in patients with transient ischemic attacks (TIAs). We aimed at (1) investigating the profile of EV-surface antigens in patients with symptoms suspicious for TIA; (2) developing and validating a predictive model for TIA diagnosis based on a specific EV-surface antigen profile. Methods: We analyzed 40 subjects with symptoms suspicious for TIA and 20 healthy controls from a training cohort. An independent cohort of 28 subjects served as external validation. Patients were stratified according to likelihood of having a real ischemic event using the Precise Diagnostic Score, defined as: unlikely (score 0–1), possible-probable (score 2–3), or very likely (score 4–8). Serum vesicles were quantified by nanoparticle tracking analysis and EV-surface antigen profile characterized by multiplex flow cytometry. Results: EV concentration increased in patients with very likely or possible-probable TIA ( P R =0.712; P Conclusions: The EV-surface antigen profile appears to be different in patients with transient symptoms adjudicated to be very likely caused by brain ischemia compared with patients whose symptoms were less likely to due to brain ischemia. We propose an algorithm based on an EV-surface-antigen specific signature that might aid in the recognition of TIA.

BACKGROUND AND PURPOSE: Demyelinating lesions in the anterior visual pathways represent an underestimated marker of disease dissemination in patients with MS. We prospectively investigated whether a dedicated high-resolution MR imaging technique, the 3D-T2-STIR-ZOOMit, improves demyelinating lesion detection compared with the current clinical standard sequence, the 2D-T2-STIR. MATERIALS AND METHODS: 3T MR imaging of the anterior visual pathways (optic nerves, chiasm, and tracts) was performed using 3D-T2-STIR-ZOOMit and 2D-T2-STIR, in patients with MS and healthy controls. Two experienced neuroradiologists assessed, independently, demyelinating lesions using both sequences separately. 3D-T2-STIR-ZOOMit scan-rescan reproducibility was tested in 12 patients. The Cohen κ was used for interrater agreement, and the intraclass correlation coefficient for reproducibility. Between-sequence detection differences and the effects of location and previous acute optic neuritis were assessed using a binomial mixed-effects model. RESULTS: Forty-eight patients with MS with (n = 19) or without (n = 29) past optic neuritis and 19 healthy controls were evaluated. Readers' agreement was strong (3D-T2-STIR-ZOOMit: 0.85; 2D-T2-STIR: 0.90). The 3D-T2-STIR-ZOOMit scan-rescan intraclass correlation coefficient was 0.97 (95% CI, 0.96–0.98; P < .001), indicating excellent reproducibility. Overall, 3D-T2-STIR-ZOOMit detected more than twice the demyelinating lesions (n = 89) than 2D-T2-STIR (n = 43) (OR = 2.7; 95% CI, 1.7–4.1; P < .001). In the intracranial anterior visual pathway segments, 33 of the 36 demyelinating lesions (91.7%) detected by 3D-T2-STIR-ZOOMit were not disclosed by 2D-T2-STIR. 3D-T2-STIR-ZOOMit increased detection of demyelinating lesion probability by 1.8-fold in patients with past optic neuritis (OR = 1.8; 95% CI, 1.2–3.1; P = .01) and 5.9-fold in patients without past optic neuritis (OR = 5.9; 95% CI, 2.5–13.8; P < .001). No false-positive demyelinating lesions were detected in healthy controls. CONCLUSIONS: Dedicated 3D-T2-STIR-ZOOMit images improved substantially the detection of MS disease dissemination in the anterior visual pathways, particularly in the intracranial segments and in patients without past optic neuritis.

Introduction: -TIA diagnosis is challenge. A circulating blood-based biomarker, supporting clinical and imaging evaluation, would be fundamental for optimizing the diagnosis of true brain ischemic events. Surface proteins carried by cellular secreted extracellular vesicles (EV), reflect abnormal inflammation and coagulation. We aimed to test the performance of EV surface proteins in discriminating true ischemic TIA. Methods: - We analyzed n=40 patients with suspicion of TIA, and n=20 asymptomatic matched controls. According to the PREDISC score, which includes clinical and imaging (multimodal MRI) criteria, patients were stratified as “unlikely” (score 0-1, n=10), “possibly” (score 2-3, n=15), or “very likely” (score 4-8, n=15) of having true ischemic TIA. Serum-derived EV were quantified by nanoparticle tracking analysis and EV-surface profile characterized by flow cytometry assay. Linear discriminant analysis (LDA) and random forest (RF) were built and validated through supervised machine learning algorithms. Results: - The concentration of circulating serum-derived EV was significantly increased in patients with proven ischemic events ranging in PREDISC score of 4-8 (p Conclusion: - Patients with recent true ischemic TIA appear to have a different cellular secreted EV profile in blood compared to controls. EV profile measurement is a promising novel biomarker to be validated in future studies addressing the optimization of TIA diagnosis.

OBJECTIVESevere lytic cancerous lesions of the spine are associated with significant morbidity and treatment challenges. Stabilization and restoration of the axial load capability of the vertebral body (VB) are important to prevent or arrest vertebral collapse. Percutaneous stent screw–assisted internal fixation (SAIF), which anchors a VB stent/cement complex with pedicular screws to the posterior vertebral elements, is a minimally invasive, image-guided, 360° internal fixation technique that can be utilized in this patient cohort. The purpose of this study was to assess the feasibility, safety, and stabilization efficacy of VB reconstruction via the SAIF technique in a cohort of patients with extensive lytic vertebral lesions, who were considered to have an unstable or potentially unstable spine according to the Spinal Instability Neoplastic Score (SINS).METHODSThis study was a retrospective assessment of a prospectively maintained database of a consecutive series of patients with neoplastic extensive extracompartmental osteolysis (Tomita type 4–6) of the VB treated with the SAIF technique. VB reconstruction was assessed on postprocedure plain radiographs and CT by two independent raters. Technical and clinical complications were recorded. Clinical and imaging follow-ups were assessed.RESULTSThirty-five patients with extensive osteolytic metastatic lesions of the VB underwent 36 SAIF procedures. SAIF was performed as a stand-alone procedure in 31/36 cases and was associated with posterior surgical fixation in 5/36 (4/5 with decompressive laminectomy). In 1 case an epidural cement leak required surgical decompression. VB reconstruction was categorized as satisfactory (excellent or good rating) by the two raters in 34/36 cases (94.5%) with an interrater reliability of 94.4% (Cohen’s kappa of 0.8). Follow-up, ranging from 1 to 30 months, was available for 30/36 levels. Long-term follow-up (6–30 months, mean 11.5 months) was available for 16/36 levels. Stability during follow-up was noted in 29/30 cases.CONCLUSIONSSAIF provides 360° nonfusion internal fixation that stabilizes the VB in patients with extensive lytic lesions that would otherwise be challenging to treat.

A 65-year-old woman presented to the emergency department with sudden onset of left-sided weakness, headache and vomiting. A cerebral CT showed an acute intracerebral haemorrhage involving the right caudate nucleus and lentiform nucleus with mild midline shift and intraventricular extension. CT angiography did not reveal aneurysm or other vascular anomaly. Conventional cerebral angiography demonstrated a 3 mm right medial lenticulostriate branch aneurysm, arising from the right anterior cerebral artery (ACA). Endovascular treatment was performed from the left internal carotid via the anterior communicating artery into the right ACA. Complete occlusion was achieved with injection of N-butyl-2-cyanoacrylate. The patient had neurological rehabilitation during hospitalisation followed by outpatient physical therapy. Two years later, clinical follow-up demonstrated excellent recovery.

Lumbar disc prolapse, protrusion, and extrusion are the most common causes of back and nerve root pain. The primary modality of treatment continues to be either open or microdiscectomy. Although open surgery is effective, it has well-known disadvantages, including epidural scarring, damage to bone, denervation of paraspinal muscles with consequent lumbar instability, long postoperative inactivity, and the not infrequent “failed back surgery syndrome.” For these reasons, there has been, since more than half a century now, an ongoing search for less invasive methods of treatment. Percutaneous discectomy techniques attempt nerve root decompression indirectly by decreasing the central disc pressure. Different minimally invasive percutaneous decompression techniques have been proposed, and most of them are still part of the surgical armamentarium. Many are mechanical or entail use of physical energies, such as radiofrequency waves or laser. The most effective, most utilized, and safest among them are described in this chapter.

BackgroundExtensive lytic lesions of the vertebral body (VB) increase risk of fracture and instability and require stabilization of the anterior column. Vertebral augmentation is an accepted treatment option, but when osteolysis has extensively destroyed the VB cortical boundaries (a condition herein defined as ‘extreme osteolysis’), the risk of cement leakage and/or insufficient filling is high. Vertebral body stents (VBSs) might allow partial restoration of VB height, cement containment, and reinforcement, but their use in extreme osteolysis has not been investigated.ObjectiveTo assess retrospectively the feasibility and safety of VBS augmentation in patients with ‘extreme osteolysis’ of the VB.MethodsWe retrospectively analyzed 41 treated vertebrae (from T1 to L5). VB reconstruction was assessed on postprocedure CT images and rated on a qualitative 4-point scale (poor-fair-good-excellent). Clinical and radiological follow-up was performed at 1 month and thereafter at intervals in accordance with oncological protocols.ResultsVBS augmentation was performed at 12 lumbar and 29 thoracic levels, with bilateral VBS in 23/41. VB reconstruction was judged satisfactory (good or excellent) in 37/41 (90%) of levels. Bilateral VBS received higher scores than unilateral (p=0.057, Pearson’s X2). We observed no periprocedural complications. Cement leaks (epidural or foraminal) occurred at 5/41 levels (12.2%) without clinical consequences. Follow-up data were available for 27/29 patients, extending beyond 6 months for 20 patients (7–28 months, mean 15.3 months). VBS implant stability was observed in 40/41 cases (97.5%).ConclusionsOur results support the use of VBS as a minimally invasive, safe and effective option for reconstructing the anterior column in prominent VB osteolysis.

OBJECTIVENavigation-enabling technology such as 3D-platform (O-arm) or intraoperative mobile CT (iCT-Airo) systems for use in spinal surgery has considerably improved accuracy over that of traditional fluoroscopy-guided techniques during pedicular screw positioning. In this study, the authors compared 2 intraoperative imaging systems with navigation, available in their neurosurgical unit, in terms of the accuracy they provided for transpedicular screw fixation in the thoracic and lumbar spine.METHODSThe authors performed a retrospective analysis of clinical and surgical data of 263 consecutive patients who underwent thoracic and lumbar spine screw placement in the same center. Data on 97 patients who underwent surgery with iCT-Airo navigation (iCT-Airo group) and 166 with O-arm navigation (O-arm group) were analyzed. Most patients underwent surgery for a degenerative or traumatic condition that involved thoracic and lumbar pedicle screw fixation using an open or percutaneous technique. The primary endpoint was the proportion of patients with at least 1 screw not correctly positioned according to the last intraoperative image. Secondary endpoints were the proportion of screws that were repositioned during surgery, the proportion of patients with a postoperative complication related to screw malposition, surgical time, and radiation exposure. A blinded radiologist graded screw positions in the last intraoperative image according to the Heary classification (grade 1–3 screws were considered correctly placed).RESULTSA total of 1361 screws placed in 97 patients in the iCT-Airo group (503 screws) and in 166 in the O-arm group (858 screws) were graded. Of those screws, 3 (0.6%) in the iCT-Airo group and 4 (0.5%) in the O-arm group were misplaced. No statistically significant difference in final accuracy between these 2 groups or in the subpopulation of patients who underwent percutaneous surgery was found. Three patients in the iCT-Airo group (3.1%, 95% CI 0%–6.9%) and 3 in the O-arm group (1.8%, 95% CI 0%–4.0%) had a misplaced screw (Heary grade 4 or 5). Seven (1.4%) screws in the iCT-Airo group and 37 (4.3%) in the O-arm group were repositioned intraoperatively (p = 0.003). One patient in the iCT-Airo group and 2 in the O-arm group experienced postoperative neurological deficits related to hardware malposition. The mean surgical times in both groups were similar (276 [iCT-Airo] and 279 [O-arm] minutes). The mean exposure to radiation in the iCT-Airo group was significantly lower than that in the O-arm group (15.82 vs 19.12 mSv, respectively; p = 0.02).CONCLUSIONSIntroduction of a mobile CT scanner reduced the rate of screw repositioning, which enhanced patient safety and diminished radiation exposure for patients, but it did not improve overall accuracy compared to that of a mobile 3D platform.

Objectives To perform a pilot study to quantify the radiation dose incident on operators during CT-guided interventional spine procedures, and provide a quick method to approximate it based on the total amount of radiation reported by the CT scanner. Patients and Methods Data retrospectively obtained from 26 consecutive CT-guided spine procedures, encompassing a variety of interventions. Intermittent low-dose limited-coverage CT-scanning performed using a "step and shoot" mode to visualize needle advancement. The operator wore an electronic direct dosimeter to record the dose measured above the operator's lead apron [μGy] for each procedure. Total amount of radiation used for CT-guidance quantified by the Dose-Length Product (DLP) [mGy-cm] provided by the CT scanner. The relationship between the operator's dose and the DLP was assessed. Results Average and median operator's dose were 2.3 and 1.9 μGy, respectively, with half of these values ranging between 0.7 and 2.5 μGy. Average and median DLP values used to perform the CT-guided procedure were 58 and 54 mGy-cm respectively, and half of these values ranged between 38 and 68 mGy-cm. There was a statistically significant correlation between the operator's dose and the DLP used to perform CT-guidance (r = 0.61), with an operator's dose-DLP conversion factor of 0.04 μGy / 1 mGy-cm (range: 0.006-0.083 μGy / 1 mGy-cm). Conclusions In our series, the average amount of radiation used during CT guided procedures was about 50 mGy-cm (DLP), and the corresponding average operator's dose was about 2 μGy. We showed how an approximate estimate of the operator's dose could be obtained right after each procedure, based on the CT-scanner DLP output.

BACKGROUND AND PURPOSE: Altered biomechanics or bone fragility or both contribute to spine instrumentation failure. Although revision surgery is frequently required, minimally invasive alternatives may be feasible. We report the largest to-date series of percutaneous fluoroscopically guided vertebral cement augmentation procedures to address feasibility, safety, results and a variety of spinal instrumentation failure conditions. MATERIALS AND METHODS: A consecutive series of 31 fluoroscopically guided vertebral augmentation procedures in 29 patients were performed to address screw loosening (42 screws), cage subsidence (7 cages), and fracture within (12 cases) or adjacent to (11 cases) the instrumented segment. Instrumentation failure was deemed clinically relevant when resulting in pain or jeopardizing spinal biomechanical stability. The main study end point was the rate of revision surgery avoidance; feasibility and safety were assessed by prospective recording of periprocedural technical and clinical complications; and clinical effect was measured at 1 month with the Patient Global Impression of Change score. RESULTS: All except 1 procedure was technically feasible. No periprocedural complications occurred. Clinical and radiologic follow-up was available in 28 patients (median, 16 months) and 30 procedures. Revision surgery was avoided in 23/28 (82%) patients, and a global clinical benefit (Patient Global Impression of Change, 5–7) was reported in 26/30 (87%) cases at 1-month follow-up, while no substantial change (Patient Global Impression of Change, 4) was reported in 3/30 (10%), and worsening status (Patient Global Impression of Change, 3), in 1/30 (3%). CONCLUSIONS: Our experience supports the feasibility of percutaneous vertebral augmentation in the treatment of several clinically relevant spinal instrumentation failure conditions, with excellent safety and efficacy profiles, both in avoidance of revision surgery and for pain palliation.

The AJNR published a game changing manuscript in 1997. A group composed mostly of neurointerventionalists described the use of polymethylmethacrylate in painful osteoporotic vertebral compression fractures.1 Soon thereafter, this then nascent technique began to flourish throughout many parts of the world. Since its inception, the JNIS has published content covering all aspects of neurointervention, including spine intervention; the first issue featured an article prospectively evaluating pain and functional outcomes after vertebroplasty.2 Over the years, JNIS has featured a variety of articles that advanced our knowledge and improved the capability of percutaneous approaches to treat spinal lesions, for example, in cancer patients.3 4 Moreover, the manuscripts have promoted understanding of the capabilities of percutaneous approaches to treating extra-spinal locations, for example, sacroplasty,5 6 acetabuloplasty,7 and even calcaneoplasty.8 JNIS has been receiving an ever-increasing number of high-quality manuscript submissions. This was very apparent during the most acute period of the COVID-19 pandemic.9 Topics related to mechanical spine have been a critical part of that growth. This commentary will highlight that subject matter—important spine articles from the last few years. Driven by clinical results, the number of patients treated with cement augmentation increased year over year from the time of the seminal Jensen AJNR paper. The simultaneous 2009 publication of two blinded studies in the NEJM raised some questions regarding the effectiveness of vertebroplasty over a sham procedure. Subsequent randomized control trials demonstrated vertebroplasty provided improved patient outcomes compared with sham procedures. These results have been extensively discussed in JNIS and other venues.10 The scientific discourse and conflicting results have impacted patient …

Ophthalmoplegia (OP) can have numerous etiologies and different clinical presentations. Most causes of OP can be narrowed down to specific anatomical locations based on clinical information. The aim of this study was to outline the different categories of diseases encountered in patients with OP, based on the location along the ocular motor pathways, and the most appropriate imaging modality for the given scenarios. Representative neuroimaging examples of pathological processes causing OP are displayed, sequenced by anatomical location and disease category. Correlations between the clinical presentation and site of pathology with imaging protocol recommendations are also presented. Diseases affecting ocular movement can be divided into categories including: injuries or diseases of the cerebral hemispheres, midbrain, pons, and cerebellum, ocular motor nerve palsies, intrinsic extraocular muscle diseases and orbital diseases secondarily affecting the extraocular muscles. The cranial nerves responsible for ocular movements can be affected intrinsically or extrinsically along their nuclei, their course in the brainstem, in the cisterns, skull base, cavernous sinuses and orbits. The extraocular muscles can be affected primarily or secondarily by adjacent pathological processes in the orbit. Clinical information can help narrow down the differential diagnoses in terms of anatomical site of involvement and prompt the most appropriate neuroimaging techniques. By understanding the pathophysiology of OP the neuroradiologist can discuss clinical cases with the referring clinician and determine a timely, accurate method of imaging to achieve the most precise differential diagnosis.

BACKGROUND AND PURPOSE: Burst fractures are characterized by middle column disruption and may feature posterior wall retropulsion. Indications for treatment remain controversial. Recently introduced vertebral augmentation techniques using intravertebral distraction devices, such as vertebral body stents and SpineJack, could be effective in fracture reduction and fixation and might obtain central canal clearance through ligamentotaxis. This study assesses the results of armed kyphoplasty using vertebral body stents or SpineJack in traumatic, osteoporotic, and neoplastic burst fractures with respect to vertebral body height restoration and correction of posterior wall retropulsion. MATERIALS AND METHODS: This was a retrospective assessment of 53 burst fractures with posterior wall retropulsion and no neurologic deficit in 51 consecutive patients treated with armed kyphoplasty. Posterior wall retropulsion and vertebral body height were measured on pre- and postprocedural CT. Clinical and radiologic follow-up charts were reviewed. RESULTS: Armed kyphoplasty was performed as a stand-alone treatment in 43 patients, combined with posterior instrumentation in 8 and laminectomy in 4. Pre-armed kyphoplasty and post-armed kyphoplasty mean posterior wall retropulsion was 5.8 and 4.5 mm, respectively (P < .001), and mean vertebral body height was 10.8 and 16.7 mm, respectively (P < .001). No significant clinical complications occurred. Clinical and radiologic follow-up (1–36 months; mean, 8 months) was available in 39 patients. Three treated levels showed a new fracture during follow-up without neurologic deterioration, and no retreatment was deemed necessary. CONCLUSIONS: In the treatment of burst fractures with posterior wall retropulsion and no neurologic deficit, armed kyphoplasty yields fracture reduction, internal fixation, and indirect central canal decompression. In selected cases, it might represent a suitable minimally invasive treatment option, stand-alone or in combination with posterior stabilization.

BACKGROUND AND PURPOSE: Large intracranial vessel occlusion due to calcified emboli is a rare cause of major stroke. We assessed the prevalence, imaging appearance, the effectiveness of mechanical thrombectomy, and clinical outcome of patients with large-vessel occlusion due to calcified emboli. MATERIALS AND METHODS: We performed a retrospective analysis of clinical and procedural data of consecutive patients who underwent mechanical thrombectomy due to calcified emboli in 7 European stroke centers. RESULTS: We screened 2969 patients, and 40 patients matched the inclusion criteria, accounting for a prevalence of 1.3%. The mean maximal density of the thrombus was 327 HU (range, 150–1200 HU), and the mean thrombus length was 9.2 mm (range, 4–20 mm). Four patients had multiple calcified emboli, and 2 patients had an embolic event during an endovascular intervention. A modified TICI score of ≥2b was achieved in 57.5% (23/40), with minimal-to-no reperfusion (modified TICI 0–1) in 32.5% (13/40) and incomplete reperfusion (modified TICI 2a) in 10% (4/40). Excellent outcome (mRS 0–1) was achieved in only 20.6%, functional independence (mRS 0–2) in 26.5% and 90-day mortality was 55.9%. CONCLUSIONS: Acute ischemic stroke with large-vessel occlusion due to calcified emboli is a rare entity in patients undergoing thrombectomy, with considerably worse angiographic outcome and a higher mortality compared with patients with noncalcified thrombi. Good functional recovery at 3 months can still be achieved in about a quarter of patients.

No aspect of neurointerventional practice has been associated with as longstanding contention and debate as to its effectiveness as has vertebroplasty (VP). Four blinded randomized controlled trials published since 2009 have demonstrated conflicting results regarding a conferred benefit in pain reduction and functional improvement for patients who undergo VP for osteoporotic vertebral compression fractures. Significant heterogeneity exists between each of these trials, which has resulted in difficulty for interventionalists and surgeons to translate the trial findings into routine clinical practice. In addition, patients and their families are ever more enlightened and enabled via the internet and social media to review both medical literature and websites. Without the proper background and context, their decisions may be lacking appropriate and necessary scientific discussion. This review article summarizes the randomized controlled trial data to date, with particular focus on the aforementioned four blinded studies. We will also evaluate the profound impact of the decrease in vertebral augmentation utilization on short- and long-term patient morbidity and mortality using available national and administrative datasets from both within the USA and internationally. We also consider future trial design to help evaluate this procedure and determine its role in modern neurointerventional practice.

Piriformis syndrome is due to entrapment of the sciatic nerve by the piriformis muscle. Buttock pain is exacerbated by activities that promote internal rotation of the hip, as the muscle promotes external hip rotation. This entity is unusual, sometimes even controversial, and is difficult to

Virchow&ndash, Robin spaces or perivascular spaces are pial-lined fluid-filled interstitial spaces recognized throughout brain parenchyma along the path of penetrating vessels. Occasionally, they may become enlarged, cause mass effect, and be mistaken for cystic neoplasms or infections. We report three cases of giant tumefactive perivascular spaces (GTPVS) incidentally found at brain magnetic resonance imaging (MRI). The lesions were multilocular cystic-appearing, isointense to cerebrospinal fluid on all pulse sequences, and did not enhance. They were located both in typical and atypical locations and in one case associated with hydrocephalus. We describe the key features of GTPVS on MRI and illustrate the need to acknowledge and promptly recognize these entities in daily practice in order to avoid unnecessary treatment.

Objective A new stent-screw−assisted internal fixation (SAIF) minimally invasive cement-augmentation technique has been introduced to treat patients with extreme osteolytic lesions of the vertebral body. The aim of the current finite element study, employing a spine model with an extreme osteolytic defect, was to assess the effect of the SAIF technique in reducing strains in the vertebral body in comparison with a standard surgical short posterior fixation. Methods Different finite element models of a L1−S1 spine were developed, representing an intact condition (reference configuration), an extreme osteolysis condition, and its treatment, respectively with stand-alone SAIF, SAIF and posterior fixation, and with stand-alone posterior fixation. Each model was loaded to reproduce standing and upper body bending. Principal strains were calculated on the superior endplate, anterior and posterior cortical walls. A paired Wilcoxon test with a 0.05 significance level was performed to statistically analyze the results. Results Median strains on the bony structures increased in the osteolysis model compared with the intact model, and the SAIF technique was effective in reducing such strains under both standing and flexion conditions. Additional posterior fixation, combined with the SAIF technique, produced minimal further reduction of the median strains on the bony structures. Stand-alone posterior fixation only shielded the osteolytic vertebra avoiding excessive displacements but failed in restoring the axial stiffness to values typical of the intact vertebra. Conclusions The new SAIF technique resulted effective in restoring the load-bearing capacity of the extensively osteolytic vertebra; additional posterior fixation provided only further minor advantages.

BACKGROUND AND PURPOSE: Postgadolinium MR imaging is crucial for brain tumor diagnosis and morphometric assessment. We compared brain tumor enhancement visualization and the “target” object morphometry obtained with the most commonly used 3D MR imaging technique, MPRAGE, with 2 other routinely available techniques: sampling perfection with application-optimized contrasts by using different flip angle evolutions (SPACE) and volumetric interpolated brain examination (VIBE). MATERIALS AND METHODS: Fifty-four contrast-enhancing tumors (38 gliomas and 16 metastases) were assessed using MPRAGE, VIBE, and SPACE techniques randomly acquired after gadolinium-based contrast agent administration on a 3T scanner. Enhancement conspicuity was assessed quantitatively by calculating the contrast rate and contrast-to-noise ratio, and qualitatively, by consensus visual comparative ratings. The total enhancing tumor volume and between-sequence discrepancy in the margin delineation were assessed on the corresponding 3D target objects contoured with a computer-assisted software for neuronavigation. The Wilcoxon signed rank and Pearson χ(2) nonparametric tests were used to investigate between-sequence discrepancies in the contrast rate, contrast-to-noise ratio, visual conspicuity ratings, tumor volume, and margin delineation estimates. Differences were also tested for 1D (Response Evaluation Criteria in Solid Tumors) and 2D (Response Assessment in Neuro-Oncology) measurements. RESULTS: Compared with MPRAGE, both SPACE and VIBE obtained higher contrast rate, contrast-to-noise ratio, and visual conspicuity ratings in both gliomas and metastases (P range

Objective: To investigate the dynamic temporal changes of brain resting-state functional connectivity (RS-FC) following mental effort in multiple sclerosis (MS) patients with cognitive fatigue (CF). Methods: Twenty-two MS patients, 11 with (F) and 11 without CF, and 12 healthy controls were included. Separate RS-FC scans were acquired on a 3T MR scanner immediately before ( t0), immediately after ( t1) and 30 minutes after ( t2) execution of the paced auditory serial addition test (PASAT), a cognitively demanding task. Subjectively perceived CF after PASAT execution was also assessed. RS-FC changes were investigated by using a data-driven approach (the Intrinsic Connectivity Contrast-power), complemented by a priori defined regions of interest analyses. Results: The F-group patients experienced stronger RS-FC at t2 between the left superior frontal gyrus (L-SFG) and occipital, frontal and temporal areas, which increased over time after PASAT execution. In the F-group patients, the L-SFG was hyperconnected at t1 with the left caudate nucleus and hypoconnected at t2 with the left anterior thalamus. These variations were correlated with both subjectively perceived and clinically assessed CF, and—for the left thalamus—with PASAT performance. Conclusion: The development of cortico–cortical and cortico–subcortical hyperconnectivity following mental effort is related to CF symptoms in MS patients.