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It has been suggested that spontaneous cervical carotid artery dissection (sCAD) may result from arterial inflammation. Periarterial edema (PAE), occasionally described in the vicinity of the mural hematoma in patients with sCAD, may support this hypothesis. Using cervical high-resolution magnetic resonance imaging, three readers, blinded to the mechanism of carotid artery dissection, searched for PAE, defined as periarterial T2-hyperintensity and T1-hypointensity, in 29 consecutive CAD patients categorized as spontaneous CAD (sCAD, n = 18) or traumatic CAD (tCAD, n = 11; i.e., major head or neck trauma within 2 weeks before the clinical onset). The relationships between PAE, inflammatory biological markers, history of infection and CAD mechanism were explored. Multiple CADs (n = 8) were found only in sCAD patients. Compared with tCAD, patients with sCAD were more likely to have a recent history of infection (OR = 12.5 [(95%)CI = 1.3-119], p = 0.03), PAE (83% vs. 27%; OR = 13.3 [(95%)CI = 2.2-82.0], p = 0.005) and to have elevated CRP (OR = 6.1 [(95%)CI = 1.2-32.1], p = 0.0002) or ESR (OR = 8.8 [(95%)CI = 1.5-50.1], p = 0.002) values. Interobserver agreement was 0.84 or higher for PAE identification. sCAD was associated with PAE and biological inflammation. Our results support the hypothesis of an underlying arterial inflammation in sCAD. [ABSTRACT FROM AUTHOR]

The purpose of this case-control study was to determine whether an asymmetry of size of the intracranial internal carotid artery (ICA) on 3D time-of-flight MR angiography (MRA) is predictive of a high-grade cervical ICA stenosis. Ninety-six stroke/TIA consecutive patients were recruited for the study, of whom 32 had unilateral high-grade ICA stenosis (>or=70% NASCET) and were included into the case group, and the remaining 64 did not have such high-grade stenosis and were included in the control group. On intracranial MRA, two observers, blinded to the characteristics of cervical ICA stenosis, independently searched for qualitative size asymmetry between ICAs and measured the cross-sectional surface of the intracranial ICAs. An intracranial size asymmetry was seen in 28 of the 32 high-grade stenoses by both readers, and in 10 (reader(1)) and 8 (reader(2)) of the 64 controls (sensitivity =88%, specificity =84-88%). In patients without agenesia of the A1 segment of the circle of Willis (n=70), sensitivity was >or=90% and specificity =96%. Surfaces ratios were significantly different (p<0.001) between cases and controls. However, using ROC curves analysis, the quantitative processing did not improve the detection when compared with the qualitative assessment of intracranial ICA asymmetry. A size asymmetry of the intracranial ICAs reveals the presence of an underlying high-grade cervical stenosis, with a high degree of confidence, especially in patients without anatomical variant of the anterior part of the circle of Willis. This sign may allow an early detection of high-grade cervical carotid stenosis in stroke patients before dedicated neck imaging is performed. [ABSTRACT FROM AUTHOR]

Purpose: In 2022, the French Society of Radiology together with the French Society of Thoracic Imaging and CentraleSupelec organized their 13th data challenge. The aim was to aid in the diagnosis of pulmonary embolism, by identifying the presence of pulmonary embolism and by estimating the ratio between right and left ventricular (RV/LV) diameters, and an arterial obstruction index (Qanadli's score) using artificial intelligence., Materials and Methods: The data challenge was composed of three tasks: the detection of pulmonary embolism, the RV/LV diameter ratio, and Qanadli's score. Sixteen centers all over France participated in the inclusion of the cases. A health data hosting certified web platform was established to facilitate the inclusion process of the anonymized CT examinations in compliance with general data protection regulation. CT pulmonary angiography images were collected. Each center provided the CT examinations with their annotations. A randomization process was established to pool the scans from different centers. Each team was required to have at least a radiologist, a data scientist, and an engineer. Data were provided in three batches to the teams, two for training and one for evaluation. The evaluation of the results was determined to rank the participants on the three tasks., Results: A total of 1268 CT examinations were collected from the 16 centers following the inclusion criteria. The dataset was split into three batches of 310, 580 and 378 C T examinations provided to the participants respectively on September 5, 2022, October 7, 2022 and October 9, 2022. Seventy percent of the data from each center were used for training, and 30% for the evaluation. Seven teams with a total of 48 participants including data scientists, researchers, radiologists and engineering students were registered for participation. The metrics chosen for evaluation included areas under receiver operating characteristic curves, specificity and sensitivity for the classification task, and the coefficient of determination r 2 for the regression tasks. The winning team achieved an overall score of 0.784., Conclusion: This multicenter study suggests that the use of artificial intelligence for the diagnosis of pulmonary embolism is possible on real data. Moreover, providing quantitative measures is mandatory for the interpretability of the results, and is of great aid to the radiologists especially in emergency settings., Competing Interests: Disclosure of Interests The authors declare that they have no known competing financial or personal relationships that could be viewed as influencing the work reported in this paper., (Copyright © 2023 Société française de radiologie. Published by Elsevier Masson SAS. All rights reserved.)

Purpose: The 2021 edition of the Artificial Intelligence Data Challenge was organized by the French Society of Radiology together with the Centre National d'Études Spatiales and CentraleSupélec with the aim to implement generative adversarial networks (GANs) techniques to provide 1000 magnetic resonance imaging (MRI) cases of macrotrabecular-massive (MTM) hepatocellular carcinoma (HCC), a rare and aggressive subtype of HCC, generated from a limited number of real cases from multiple French centers., Materials and Methods: A dedicated platform was used by the seven inclusion centers to securely upload their anonymized MRI examinations including all three cross-sectional images (one late arterial and one portal-venous phase T1-weighted images and one fat-saturated T2-weighted image) in compliance with general data protection regulation. The quality of the database was checked by experts and manual delineation of the lesions was performed by the expert radiologists involved in each center. Multidisciplinary teams competed between October 11 th , 2021 and February 13 th , 2022., Results: A total of 91 MTM-HCC datasets of three images each were collected from seven French academic centers. Six teams with a total of 28 individuals participated in this challenge. Each participating team was asked to generate one thousand 3-image cases. The qualitative evaluation was performed by three radiologists using the Likert scale on ten randomly selected cases generated by each participant. A quantitative evaluation was also performed using two metrics, the Frechet inception distance and a leave-one-out accuracy of a 1-Nearest Neighbor algorithm., Conclusion: This data challenge demonstrates the ability of GANs techniques to generate a large number of images from a small sample of imaging examinations of a rare malignant tumor., Competing Interests: Declaration of Competing Interest The authors declare that they have no competing interest., (Copyright © 2022 Société française de radiologie. Published by Elsevier Masson SAS. All rights reserved.)

Purpose: During the first wave of the COVID-19 pandemic, the French Society of Radiology and the French College of Radiology, in partnership with NEHS Digital, have set up a system to collect chest computed tomography (CT) examinations with clinical, virological and radiological metadata, from patients clinically suspected of COVID-19 pneumonia. This allowed the constitution of an anonymized multicenter database, named FIDAC (French Imaging Database Against Coronavirus). The aim of this report was to describe the content of this public database., Materials and Methods: Twenty-two French radiology centers participated to the data collection. The data collected were chest CT examinations in DICOM format associated with the following metadata: patient age and sex, originating facility identifier, originating facility region, time from symptom onset to CT examination, indication for CT examination, reverse transcription-polymerase chain reaction (RT-PCR) results and normalized CT report performed by a senior radiologist. All the data were anonymized and sent through a NEHS Digital system to a centralized data center., Results: A total of 5944 patients were included from the 22 centers aggregated into 8 regions with a mean number of patients of 743 ± 603.3 [SD] per region (range: 102-1577 patients). Reasons for CT examination and normalized CT reports were provided for all patients. RT-PCR results were provided in 5574 patients (93.77%) with a positive result of RT-PCR in 44.6% of patients., Conclusion: The FIDAC project allowed the creation of a large database of chest CT images and metadata available, under conditions, in open access through the CERF-SFR website., (Copyright © 2022 Société française de radiologie. Published by Elsevier Masson SAS. All rights reserved.)

Age estimation is a key factor for identification procedure in forensic context. Based on anthropological findings, degenerative changes of the sternal extremity of the 4th rib are currently used for age estimation. These have been adapted to post-mortem computed tomography (PMCT). The aim of this study was to validate a post-mortem computed tomography method based on a revision of the Iscan's method on a French sample. A total of 250 PMCT (aged from 18-98 years (IQR 36-68 years, median 51 years); 68 (27%) females) from the Medicolegal Institute of Paris (MLIP) were analyzed by two radiologists. The sternal extremity of 4th right rib was scored using method adapted from Iscan et al. Weighted κ was used to evaluate intra- and inter-observer reliability and Spearman correlation was performed to evaluate relationship between age and score. Confidence intervals for individual prediction of age based on 4th rib score and sex were computed with bootstrapping. The intra-observer reliability and inter-observer reliability were almost perfect (weighted κ = 0.85 [95%CI: 0.78-0.93] and 0.82 [95%CI 0.70-0.96] respectively). We confirmed a high correlation between the 4th rib score and subject age (rho = 0.72, p < 0.001), although the confidence intervals for individual age prediction were large, spanning over several decades. This study confirms the high reliability of Iscan method applied to PMCT for age estimation, although future multimodal age prediction techniques may help reducing the span of confidence intervals for individual age estimation.Trial registration: INDS 0,509,211,020, October 2020, retrospectively registered., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: The 2020 edition of these Data Challenges was organized by the French Society of Radiology (SFR), from September 28 to September 30, 2020. The goals were to propose innovative artificial intelligence solutions for the current relevant problems in radiology and to build a large database of multimodal medical images of ultrasound and computed tomography (CT) on these subjects from several French radiology centers., Materials and Methods: This year the attempt was to create data challenge objectives in line with the clinical routine of radiologists, with less preprocessing of data and annotation, leaving a large part of the preprocessing task to the participating teams. The objectives were proposed by the different organizations depending on their core areas of expertise. A dedicated platform was used to upload the medical image data, to automatically anonymize the uploaded data., Results: Three challenges were proposed including classification of benign or malignant breast nodules on ultrasound examinations, detection and contouring of pathological neck lymph nodes from cervical CT examinations and classification of calcium score on coronary calcifications from thoracic CT examinations. A total of 2076 medical examinations were included in the database for the three challenges, in three months, by 18 different centers, of which 12% were excluded. The 39 participants were divided into six multidisciplinary teams among which the coronary calcification score challenge was solved with a concordance index > 95%, and the other two with scores of 67% (breast nodule classification) and 63% (neck lymph node calcifications)., (Published by Elsevier Masson SAS.)

Background: Meningioangiomatosis is a poorly studied, rare, benign, and epileptogenic brain lesion., Objective: To demonstrate that surgical resection and a short-time interval to surgery improves epileptic seizure control, we performed a systematic review and meta-analysis of meningioangiomatosis cases., Methods: Using PRISMA-IPD guidelines, the authors performed a systematic review and meta-analysis of histopathologically-proven meningioangiomatosis cases. Literature search in French and English languages (PubMed, Embase, the Cochrane Library, and the Science Citation Index) including all studies (January 1981 to June 2020) dealing with histopathologically-proven meningioangiomatosis, without age restriction. We assessed clinical, imaging, histomolecular, management, and outcome findings of patients with meningioangiomatosis., Results: Two-hundred and seven cases of meningioangiomatosis from 78 studies were included. Most meningioangiomatosis was sporadic, preferentially concerned male patients, younger than 20 years old, and allowed a functionally independent status. Epileptic seizure was the main symptom, with 81.4% of patients having uncontrolled seizures at the time of surgery. Meningioangiomatosis mainly had frontal (32.3%) or temporal (30.7%) locations. Imaging presentation was heterogeneous, and the diagnosis was often missed preoperatively. The histopathologic pattern was similar whatever the clinical presentation, and immunohistochemistry had limited diagnostic value. On molecular analysis, allelic loss at 22q12 was more frequent in samples of meningioangiomatosis-associated meningioma (37.5%) than in isolated meningioangiomatosis (23.1%). Time interval from diagnosis to surgery ( p = 0.011) and lack of surgical resection of the meningioangiomatosis ( p = 0.009) were independent predictors of postoperative seizure control., Conclusions: Owing to low scientific evidence, a multicentric prospective study should help refining the management of meningioangiomatosis., (© 2020 American Academy of Neurology.)

Purpose: The second edition of the artificial intelligence (AI) data challenge was organized by the French Society of Radiology with the aim to: (i), work on relevant public health issues; (ii), build large, multicentre, high quality databases; and (iii), include three-dimensional (3D) information and prognostic questions., Materials and Methods: Relevant clinical questions were proposed by French subspecialty colleges of radiology. Their feasibility was assessed by experts in the field of AI. A dedicated platform was set up for inclusion centers to safely upload their anonymized examinations in compliance with general data protection regulation. The quality of the database was checked by experts weekly with annotations performed by radiologists. Multidisciplinary teams competed between September 11 th and October 13 th 2019., Results: Three questions were selected using different imaging and evaluation modalities, including: pulmonary nodule detection and classification from 3D computed tomography (CT), prediction of expanded disability status scale in multiple sclerosis using 3D magnetic resonance imaging (MRI) and segmentation of muscular surface for sarcopenia estimation from two-dimensional CT. A total of 4347 examinations were gathered of which only 6% were excluded. Three independent databases from 24 individual centers were created. A total of 143 participants were split into 20 multidisciplinary teams., Conclusion: Three data challenges with over 1200 general data protection regulation compliant CT or MRI examinations each were organized. Future challenges should be made with more complex situations combining histopathological or genetic information to resemble real life situations faced by radiologists in routine practice., (Copyright © 2020 Société française de radiologie. Published by Elsevier Masson SAS. All rights reserved.)

Competing Interests: The authors report no conflict of interest.

Neuroimaging and especially MRI has emerged as a necessary imaging modality to detect, measure, characterize and monitor brain tumours. Advanced MRI sequences such as perfusion MRI, diffusion MRI and spectroscopy as well as new post-processing techniques such as automatic segmentation of tumours and radiomics play a crucial role in characterization and follow up of brain tumours. The purpose of this review is to provide an overview on anatomical and functional MRI use for brain tumours boundaries determination and tumour characterization in the specific context of radiotherapy. The usefulness of anatomical and functional MRI on particular challenges posed by radiotherapy such as pseudo progression and pseudo esponse and new treatment strategies such as dose painting is also described., (Copyright © 2020 Société française de radiothérapie oncologique (SFRO). Published by Elsevier Masson SAS. All rights reserved.)

Background Tumor location is a main prognostic parameter in patients with glioblastoma. Probabilistic MRI-based brain atlases specifying the probability of tumor location associated with important demographic, clinical, histomolecular, and management data are lacking for isocitrate dehydrogenase (IDH) wild-type glioblastomas. Purpose To correlate glioblastoma location with clinical phenotype, surgical management, and outcomes by using a probabilistic analysis in a three-dimensional (3D) MRI-based atlas. Materials and Methods This retrospective study included all adults surgically treated for newly diagnosed IDH wild-type supratentorial glioblastoma in a tertiary adult surgical neuro-oncology center (2006-2016). Semiautomated tumor segmentation and spatial normalization procedures to build a 3D MRI-based atlas were validated. The authors performed probabilistic analyses by using voxel-based lesion symptom mapping technology. The Liebermeister test was used for binary data, and the generalized linear model was used for continuous data. Results A total of 392 patients (mean age, 61 years ± 13; 233 men) were evaluated. The authors identified the preferential location of glioblastomas according to subventricular zone, age, sex, clinical presentation, revised Radiation Therapy Oncology Group-Recursive Partitioning Analysis class, Karnofsky performance status, O 6 -methylguanine DNA methyltransferase promoter methylation status, surgical management, and survival. The superficial location distant from the eloquent area was more likely associated with a preserved functional status at diagnosis (348 of 392 patients [89%], P < .05), a large surgical resection (173 of 392 patients [44%], P < .05), and prolonged overall survival (163 of 334 patients [49%], P < .05). In contrast, deep location and location within eloquent brain areas were more likely associated with an impaired functional status at diagnosis (44 of 392 patients [11%], P < .05), a neurologic deficit (282 of 392 patients [72%], P < .05), treatment with biopsy only (183 of 392 patients [47%], P < .05), and shortened overall survival (171 of 334 patients [51%], P < .05). Conclusion The authors identified the preferential location of isocitrate dehydrogenase wild-type glioblastomas according to parameters of interest and provided an image-based integration of multimodal information impacting survival results. This suggests the role of glioblastoma location as a surrogate and multimodal parameter integrating several known prognostic factors. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Huang in this issue.

Purpose: Investigating the associations between cerebral small vessel disease (cSVD) burden and cerebral vasospasm (CVS), delayed cerebral ischemia (DCI) and clinical outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH)., Methods: Consecutive aSAH patients with initial (<7 days after onset) and 3-month follow-up brain magnetic resonance imaging (MRI) and clinical evaluation at 6 months were included. The cSVD burden score was built using MRI criteria. CVS was defined according to transcranial Doppler examination and computed tomography (CT) or digital subtraction angiography. DCI was defined by the appearance of hyperintense fluid-attenuated inversion recovery lesions, with territorial or cortico-subcortical distribution, between initial MRI and 3-month MRI. The modified Rankin scale of ≤2 at 6 months was considered a favorable outcome. Using univariate and multivariable analyses, we investigated the associations between cSVD and CVS, DCI and clinical outcome., Results: A total of 113 patients were included in the study sample (median age 49.1 years (IQR 42.1-60.8), 70/113 females). The burden of cSVD was mild with a median of 0 (IQR 0-1). When comparing patients with no/mild versus those with moderate/severe cSVD burden, we did not find a univariable difference regarding vasospasm occurrence (60% versus 46.1%, p  = 0.54), DCI (20.2% versus 23%, p  = 0.66) or favorable outcome at 3 months (94% versus 83.3%, p  = 0.20). There was a univariable trend towards more frequent favorable outcome in patients with no/milde white matter hyperintensities versus those with moderate/severe white matter hyperintensities (92% versus 85%, p = 0.09). In multivariable models, cSVD markers were not associated with CVS occurrence and severity, DCI or clinical outcome., Conclusions: In patients with mild aSAH, the burden of cSVD as assessed by MRI is minimal and is not associated with CVS, DCI or clinical outcome.

Purpose: In patients with ICA stenosis, increased peak systolic velocity is a marker of stenosis at risk of ischemic stroke. 4DFlow MRI is a reproducible technique to evaluate velocities in ICA stenosis, although it seems to underestimate velocities as compared with Doppler ultrasonography. The purpose of our study was to confirm that velocities were underestimated on a new set of data acquired with a clinical 4DFlow sequence, and to devise optimal acquisition parameters for ICA stenosis exploration based on a numerical simulation., Methods: After review board approval, 15 healthy controls and 12 patients presenting ICA stenosis were explored with Doppler ultrasonography and 4DFlow MRI. We created a 2-dimensional simulation of ICA stenosis and its corresponding 4DFlow acquisition, and compared its mean peak systolic velocity underestimation to real MRI and Doppler. We then simulated the acquisition for voxel size ranging from 0.5 to 1.25 mm and number of phases per cardiac cycle ranging from 10 to 25., Results: On acquired data, 4DFlow MR underestimated peak systolic velocities (mean difference between Doppler and 4DFlow: - 35 cm/s), especially high velocities. With spatial and temporal resolutions equivalent to MR acquisition, our simulation yielded similar underestimation (mean difference: - 31 cm/s, P = 0.30). Simulations showed that 0.7-mm resolution and 20 phases per cardiac cycle would be necessary to record peak systolic velocities up to 250 cm/s., Conclusion: Higher spatial resolution can provide accurate peak systolic velocities measurement with 4DFlow MRI, thus allowing better ICA stenosis assessment. Further studies are needed to validate the proposed parameters.

Purpose: The goal of this data challenge was to create a structured dynamic with the following objectives: (1) teach radiologists the new rules of General Data Protection Regulation (GDPR), while building a large multicentric prospective database of ultrasound, computed tomography (CT) and MRI patient images; (2) build a network including radiologists, researchers, start-ups, large companies, and students from engineering schools, and; (3) provide all French stakeholders working together during 5 data challenges with a secured framework, offering a realistic picture of the benefits and concerns in October 2018., Materials and Methods: Relevant clinical questions were chosen by the Société Francaise de Radiologie. The challenge was designed to respect all French ethical and data protection constraints. Multidisciplinary teams with at least one radiologist, one engineering student, and a company and/or research lab were gathered using different networks, and clinical databases were created accordingly., Results: Five challenges were launched: detection of meniscal tears on MRI, segmentation of renal cortex on CT, detection and characterization of liver lesions on ultrasound, detection of breast lesions on MRI, and characterization of thyroid cartilage lesions on CT. A total of 5,170 images within 4 months were provided for the challenge by 46 radiology services. Twenty-six multidisciplinary teams with 181 contestants worked for one month on the challenges. Three challenges, meniscal tears, renal cortex, and liver lesions, resulted in an accuracy>90%. The fourth challenge (breast) reached 82% and the lastone (thyroid) 70%., Conclusion: Theses five challenges were able to gather a large community of radiologists, engineers, researchers, and companies in a very short period of time. The accurate results of three of the five modalities suggest that artificial intelligence is a promising tool in these radiology modalities., (Copyright © 2019 Soci showét showé françaises de radiologie. Published by Elsevier Masson SAS. All rights reserved.)

Objective: Our aim was to compare the clinical outcome of patients with ischaemic stroke with anterior large vessel occlusion treated with stent retrievers and/or contact aspiration mechanical thrombectomy (MT) under general anaesthesia (GA) or conscious sedation non-GA through a systematic review and meta-analysis., Methods: The literature was searched using PubMed, Embase and Cochrane databases to identify studies reporting on anaesthesia and MT. Using fixed or random weighted effect, we evaluated the following outcomes: 3-month mortality, modified Rankin Score (mRs) 0-2, recanalisation success (thrombolysis in cerebral infarction (TICI) ≥2b) and symptomatic intracerebral haemorrhagic (sICH) transformation., Results: We identified seven cohorts (including three dedicated randomised controlled trials), totalling 1929 patients (932 with GA). Over the entire sample, mortality, mRs 0-2, TICI≥2b and sICH rates were, respectively 17.5% (99% CI 9.7% to 29.6%; Q-value: 60.1; I 2 : 93%, 1717 patients), 42.1% (99% CI 33.3% to 51.7%; Q-value: 41.3; I 2 : 87.9%), 82.9% (99% CI 74.0% to 89.1%; Q-value: 20.7; I 2 : 80.6%, 1006 patients) and 5.5% (99% CI 2.8% to 10.8%; Q-value: 18.6; I 2 : 78.5%). MT performed in non-GA patients was associated with better 3-month functional outcome (pooled OR, 1.35; 99% CI 1.04 to 1.76; Q-value: 24.0; I 2 : 9.2%, 1845 patients) and lower 3-month mortality rate (pooled OR, 0.70; 99% CI 0.49 to 0.98; Q-value: 1.4; I 2 : 0%, 1717 patients; fixed weighted effect model) compared with GA. MT performed under conscious sedation non-GA had significantly shorter onset-to-recanalisation and onset-to-groin delay compared with GA, and recanalisation success and sICH were similar., Conclusion: Non-GA during MT for anterior acute ischaemic stroke with current-generation stent retriever/aspiration devices is associated with better 3-month functional outcome and lower mortality rates. These unadjusted estimates are subject to biases and should be interpreted with caution., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose To identify wall enhancement patterns on vessel wall MRI that discriminate between stable and unstable unruptured intracranial aneurysm (UIA). Materials and Methods Patients were included from November 2012 through January 2016. Vessel wall MR images were acquired at 3 T in patients with stable (incidental and nonchanging over 6 months) or unstable (symptomatic or changing over 6 months) UIA. Each aneurysm was evaluated by using a four-grade classification of enhancement: 0, none; 1, focal; 2, thin circumferential; and 3, thick (>1 mm) circumferential. Inter- and intrareader agreement for the presence and the grade of enhancement were assessed by using κ statistics and 95% confidence interval (CI). The sensitivity, specificity, and negative and positive predictive values of each enhancement grade for differentiating stable from unstable aneurysms was compared. Results The study included 263 patients with 333 aneurysms. Inter- and intrareader agreement was excellent for both the presence of enhancement (κ values, 0.82 [95% CI: 0.67, 0.99] and 0.87 [95% CI: 0.7, 1.0], respectively) and enhancement grade (κ = 0.92 [95% CI: 0.87, 0.95]). In unruptured aneurysms (n = 307), grade 3 enhancement exhibited the highest specificity (84.4%; 233 of 276; 95% CI: 80.1%, 88.7%; P = .02) and negative predictive value (94.3%; 233 of 247) for differentiating between stable and unstable lesions. There was a significant association between grade 3 enhancement and aneurysm instability (P < .0001). Conclusion In patients with intracranial aneurysm, a thick (>1 mm) circumferential pattern of wall enhancement demonstrated the highest specificity for differentiating between stable and unstable aneurysms. © RSNA, 2018.

Background: Cranioplasties are an important neurosurgical procedure not only for improved cosmesis but also for improved functional recovery after craniectomy with a large cranial defect. The aim of this study was to identify predictive factors of postcranioplasty complications using custom-made porous hydroxyapatite cranioplasty., Methods: Retrospective review was performed of all patients who underwent a reconstructive cranioplasty using custom-made hydroxyapatite at our institution between February 2008 and September 2017. Postoperative complications considered included bacterial infection, seizures, hydrocephalus requiring ventricular shunt placement, and cranioplasty-to-bone shift. Variables associated at P < 0.1 level in unadjusted analysis were entered into backward stepwise logistic regression models., Results: Of 109 patients included, 15 (13.8%) experienced postoperative infection, with craniectomy performed at an outside institution (adjusted odds ratio [OR] 10.37 [95% confidence interval [CI], 2.03-75.27], P = 0.012) and a previous infection at the surgical site (adjusted OR 6.15 [95%CI, 1.90-19.92], P = 0.003) identified as independent predictors. Six patients (5.5%) experienced postoperative seizures, with stroke (ischemic and hemorrhagic) as a reason for craniectomy (adjusted OR 11.68 [95% CI, 2.56-24.13], P < 0.001) and the presence of seizures in the month before cranioplasty (adjusted OR 9.39 [95% CI, 2.04-127.67], P = 0.002) identified as independent predictors. Four patients (3.7%) experienced postcranioplasty hydrocephalus necessitating shunt placement, and 5 patients (4.6%) experienced cranioplasty-to-bone shift ≥5 mm, but no significant predictive factors were identified for either complication., Conclusions: This study identified possible predictive factors for postcranioplasty complications to help identify at-risk patients, guide prophylactic care, and improve morbidity of this important surgical procedure., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose To propose and validate a modified pediatric intracerebral hemorrhage (PICH) (mPICH) score and to compare its association with functional outcome to that of the original PICH score. Materials and Methods Data from prospectively included patients were retrospectively analyzed. Consecutive patients with nontraumatic PICH who had undergone clinical follow-up were included. The study population was divided into a development cohort (2008-2012, n = 100) and a validation cohort (2013-2016, n = 43). An mPICH score was developed after variables associated with poor outcome were identified at multivariate analysis (King's Outcome Scale for Childhood Head Injury score < 5a) in the development cohort. The accuracy of the score for prediction of poor outcome was evaluated (sensitivity, specificity). Discrimination and calibration of associations between the mPICH score and poor outcome cohorts were assessed (C statistics, Hosmer-Lemeshow test). Results The mPICH score assessed as follows: brain herniation, four points; altered mental status, three points; hydrocephalus, two points; infratentorial PICH, two points; intraventricular hemorrhage, one point; PICH volume greater than 2% of total brain volume, one point. An mPICH score greater than 5 was associated with severe disability or worse, with sensitivity of 97% (95% confidence interval [CI]: 83%, 100%) and specificity of 61% (95% CI: 49%, 73%). The C statistic was 0.81 (95% CI: 0.73, 0.89). In the validation cohort, sensitivity and specificity were 95.2% (95% CI: 76%, 99%) and 77% (95% CI: 55%, 92%), respectively. There was no significant difference between the observed and predicted risks of poor outcome (P = .46). Conclusion An mPICH score was developed as a simple clinical and imaging grading scale for acute prognosis in patients with PICH. © RSNA, 2017.

Background and Purpose: In acute ischemic stroke, whether FLAIR vascular hyperintensities represent good or poor collaterals remains controversial. We hypothesized that extensive FLAIR vascular hyperintensities correspond to good collaterals, as indirectly assessed by the hypoperfusion intensity ratio., Materials and Methods: We included 244 consecutive patients eligible for reperfusion therapy with MCA stroke and pretreatment MR imaging with both FLAIR and PWI. The FLAIR vascular hyperintensity score was based on ASPECTS, ranging from 0 (no FLAIR vascular hyperintensity) to 7 (FLAIR vascular hyperintensities abutting all ASPECTS cortical areas). The hypoperfusion intensity ratio was defined as the ratio of the time-to-maximum >10-second over time-to-maximum >6-second lesion volumes. The median hypoperfusion intensity ratio was used to dichotomize good (low hypoperfusion intensity ratio) versus poor (high hypoperfusion intensity ratio) collaterals. We then studied the association between FLAIR vascular hyperintensity extent and hypoperfusion intensity ratio., Results: Hypoperfusion was present in all patients, with a median hypoperfusion intensity ratio of 0.35 (interquartile range, 0.19-0.48). The median FLAIR vascular hyperintensity score was 4 (interquartile range, 3-5). The FLAIR vascular hyperintensities were more extensive in patients with good collaterals (hypoperfusion intensity ratio ≤0.35) than with poor collaterals (hypoperfusion intensity ratio >0.35; P for Trend = .016). The FLAIR vascular hyperintensity score was independently associated with good collaterals ( P for Trend = .002)., Conclusions: In patients eligible for reperfusion therapy, FLAIR vascular hyperintensity extent was associated with good collaterals, as assessed by the pretreatment hypoperfusion intensity ratio. The ASPECTS assessment of FLAIR vascular hyperintensities could be used to rapidly identify patients more likely to benefit from reperfusion therapy., (© 2018 by American Journal of Neuroradiology.)

The management of patients with unruptured intracranial aneurysms (UIAs) is a complex clinical challenge and constitutes an immense field of research. While a preponderant proportion of these aneurysms never rupture, the consequences of such an event are severe and represent an important healthcare problem. To date, however, the natural history of UIAs is not completely understood and there is no accurate means to discriminate the UIAs that will rupture from those that will not. Yet, a good understanding of the recent evidence and future perspectives is needed when advising a patient with IA to tailor any information to the given patient's level of risk and psychoaffective status. Thus, this review addresses the current concepts of epidemiology, risk factors, detection and management of UIAs., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Objectives: To examine the clinical outcome of aneurysmal subarachnoid haemorrhage (aSAH) patients exposed to cerebral vasospasm (CVS)-targeted treatments in a meta-analysis and to evaluate the efficacy of intra-arterial (IA) approaches in patients with severe/refractory vasospasm., Methods: Randomised controlled trials, prospective and retrospective observational studies reporting clinical outcomes of aSAH patients exposed to CVS targeted treatments, published between 2006-2016 were searched using PubMed, EMBASE and the Cochrane Library. The main endpoint was the proportion of unfavourable outcomes, defined as a modified Rankin score of 3-6 at last follow-up., Results: Sixty-two studies, including 26 randomised controlled trials, were included (8,976 patients). At last follow-up 2,490 of the 8,976 patients had an unfavourable outcome, including death (random-effect weighted-average, 33.7%; 99% confidence interval [CI], 28.1-39.7%; Q value, 806.0; I 2  = 92.7%). The RR of unfavourable outcome was lower in patients treated with Cilostazol (RR = 0.46; 95% CI, 0.25-0.85; P = 0.001; Q value, 1.5; I 2  = 0); and in refractory CVS patients treated by IA intervention (RR = 0.68; 95% CI, 0.57-0.80; P < 0.0001; number needed to treat with IA intervention, 6.2; 95% CI, 4.3-11.2) when compared with the best available medical treatment., Conclusions: Endovascular treatment may improve the outcome of patients with severe-refractory vasospasm. Further studies are needed to confirm this result., Key Points: • 33.7% of patients with cerebral Vasospasm following aneurysmal subarachnoid-hemorrhage have an unfavorable outcome. • Refractory vasospasm patients treated using endovascular interventions have lower relative risk of unfavourable outcome. • Subarachnoid haemorrhage patients with severe vasospasm may benefit from endovascular interventions. • The relative risk of unfavourable outcome is lower in patients treated with Cilostazol.

Surgical resection of gliomas involving eloquent brain areas must be maximal in order to improve patients' survival, and safe to prevent postoperative impairments. Therefore, the precise spatial relationship between the lesion and eloquent brain areas needs to be established. Functional magnetic resonance imaging and diffusion tensor imaging are robust methods with increasing indications in neurosurgery for past decade. The aim of this review article is not only to pinpoint the major limitations of these methods in order to avoid erroneous conclusions, but also to detail practical aspects associated with the main paradigms routinely used in functional magnetic resonance imaging, and to discuss recent validation of functional magnetic resonance imaging and diffusion tensor imaging results with direct electrical stimulation during awake surgery., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Background and Purpose: Triage imaging facilitates the timely recognition of acute stroke with prognostic implications. Improvement in MR acquisition speed is needed given the extreme time constraints before treatment. We compared an ultrafast Echo-Planar FLAIR sequence (EPI-FLAIR) and a conventional FLAIR sequence (cFLAIR) for their diagnostic performances and ability to estimate the age of infarction., Material and Methods: Between June and August 2014, 125 consecutive patients (age 69±18 years, 48% men) admitted for a suspicion of acute (≤48-hrs) stroke were explored by both FLAIR sequences at 1.5-Tesla. EPI-FLAIR (15-sec) and cFLAIR (2-min and 15-sec) were compared by two readers, blinded to clinical data., Results: EPI-FLAIR was less prone to kinetic artefacts than cFLAIR (2-3% vs. 23-49% depending on the reader, P<0.001). Diagnostic concordance was excellent for both readers (к>0.9). Amongst 8 hemorrhages, one subarachnoid hemorrhage presenting as a sudden deficit was missed on EPI-FLAIR sequence. Amongst 60 infarctions, cFLAIR and EPI-FLAIR were concordant in 50 (83%), while signal changes were visible on cFLAIR only in the remaining 10 (17%) cases. Amongst the 43 patients with known onset time (n=17 within 4.5hrs), FLAIR-DWI mismatch identified<4.5-hrs infarction with the same sensitivity (65%) using cFLAIR and EPI-FLAIR, but the positive predictive value (PPV) was higher for cFLAIR than for EPI-FLAIR (73% vs. 50%, P=0.008)., Conclusion: EPI-FLAIR allows a drastic reduction of acquisition time devoted to FLAIR sequence and minimizes motion artifacts. Compared with cFLAIR, it is however associated with increased risk of undiagnosed stroke mimics and lower PPV for identifying<4.5-hrs infarctions., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Aim: Prevalence and predictors of epileptic seizures are unknown in the malignant variant of ganglioglioma., Methods: In a retrospective exploratory dataset of 18 supratentorial anaplastic World Health Organization grade III gangliogliomas, we studied: (i) the prevalence and predictors of epileptic seizures at diagnosis; (ii) the evolution of seizures during tumor evolution; (iii) seizure control rates and predictors of epilepsy control after oncological treatments., Results: Epileptic seizures prevalence progresses throughout the natural course of anaplastic gangliogliomas: 44% at imaging discovery, 67% at histopathological diagnosis, 69% following oncological treatment, 86% at tumor progression, and 100% at the end-of-life phase. The medical control of seizures and their refractory status worsened during the tumor's natural course: 25% of uncontrolled seizures at histopathological diagnosis, 40% following oncological treatment, 45.5% at tumor progression, and 45.5% at the end-of-life phase. Predictors of seizures at diagnosis appeared related to the tumor location (i.e. temporal and/or cortical involvement). Prognostic parameters of seizure control after first-line oncological treatment were temporal tumor location, eosinophilic granular bodies, TP53 mutation, and extent of resection. Prognostic parameters of seizure control at tumor progression were a history of epileptic seizures at diagnosis, seizure control after first-line oncological treatment, eosinophilic granular bodies, and TP53 mutation., Conclusion: Epileptic seizures are frequently observed in anaplastic gangliogliomas and both prevalence and medically refractory status worsen during the tumor's natural course. Both oncological and antiepileptic treatments should be employed to improve the control of epileptic seizures and the quality of life of patients harboring an anaplastic ganglioglioma.

OBJECTIVE There are no guidelines for the management of postoperative lateral sinus thrombosis following posterior fossa surgery. Introducing treatment-dose anticoagulant therapy during the immediate postoperative period increases the risk of intracranial bleeding. This study assessed the incidence of and risk factors associated with postoperative lateral sinus thrombosis and the complications related to thrombosis and/or anticoagulation. METHODS This study was a retrospective monocentric analysis of adult patients who underwent surgical removal of a posterior fossa space-occupying lesion with available postoperative imaging. Postoperative lateral sinus thrombosis was defined as a T2 * hypointensity within the venous sinus and/or a filling defect on postcontrast MRI or CT scan. RESULTS Among 180 patients, 12 (6.7%; 95% CI 3.0-10.4) were found to have lateral sinus thrombosis on postoperative imaging, none of whom were symptomatic. Unadjusted risk factors for postoperative lateral sinus thrombosis were a history of deep venous thrombosis (p = 0.016), oral contraceptive pill (p = 0.004), midline surgical approach (p = 0.035), and surgical exposure of the sinus (p < 0.001). Seven of the patients (58.3%) with a postoperative lateral sinus thrombosis received immediate treatment-dose anticoagulant therapy. Lateral sinus recanalization occurred radiologically at a mean time of 272 ± 23 days in 85.7% of patients (6 of 7) undergoing treatment-dose anticoagulant therapy and in 20% of patients (1 of 5) not receiving treatment-dose anticoagulant therapy. Postoperative complications occurred in 56.2% of patients (9 of 16) who received treatment-dose curative anticoagulant therapy and in 27% of patients (45 of 164) who did not. CONCLUSIONS Incidental radiological lateral sinus thrombosis following posterior fossa surgery has an incidence of 6.7%. To further define the benefit-to-risk ratio of a treatment-dose anticoagulant therapy, a prospective trial should be considered.

Anaplastic ganglioglioma (AGG) is a rare and malignant variant of ganglioglioma. According to the World Health Organization classification version 2016, their histopathological grading criteria are still ill-defined. The aim of the present study was to assess the clinical, imaging, histopathological, and molecular characteristics and outcomes of AGGs in a large consecutive and retrospective adult and pediatric case series. Eighteen patients with AGGs (13 adults and 5 children) were identified (14 de novo and 4 secondary) from a cohort of 222 gangliogliomas (GG) (8%) treated at our institution between 2000 and 2015. AGGs represented a very aggressive disease with poor outcome (median progression-free survival, 10 months; median overall survival, 27 months). They were located in the temporal lobe only in 22% and presented with seizures (44%) or increased intracranial pressure (44%) at diagnosis. Concerning histopathological and molecular data, they shared morphological characteristics and BRAF V600E mutation (39%) with their benign counterparts but also showed hTERT promoter mutation (61%), p53 accumulation (39%), ATRX loss (17%), or p.K27M H3F3A mutation (17%). AGGs are malignant neoplasms requiring aggressive oncological treatment. In the perspective of targeted therapies, AGGs should be screened for BRAF V600E, hTERT, ATRX, and mutations of histone genes., (© 2016 American Association of Neuropathologists, Inc. All rights reserved.)

Background and Purpose: Rapid and reliable assessment of the perfusion-weighted imaging (PWI)/diffusion-weighted imaging (DWI) mismatch is required to promote its wider application in both acute stroke clinical routine and trials. We tested whether an evaluation based on the Alberta Stroke Program Early CT Score (ASPECTS) reliably identifies the PWI/DWI mismatch., Methods: A total of 232 consecutive patients with acute middle cerebral artery stroke who underwent pretreatment magnetic resonance imaging (PWI and DWI) were retrospectively evaluated. PWI-ASPECTS and DWI-ASPECTS were determined blind from manually segmented PWI and DWI volumes. Mismatch-ASPECTS was defined as the difference between PWI-ASPECTS and DWI-ASPECTS (a high score indicates a large mismatch). We determined the mismatch-ASPECTS cutoff that best identified the volumetric mismatch, defined as VolumeTmax>6s/VolumeDWI≥1.8, a volume difference≥15 mL, and a VolumeDWI<70 mL., Results: Inter-reader agreement was almost perfect for PWI-ASPECTS (κ=0.95 [95% confidence interval, 0.90-1]), and DWI-ASPECTS (κ=0.96 [95% confidence interval, 0.91-1]). There were strong negative correlations between volumetric and ASPECTS-based assessments of DWI lesions (ρ=-0.84, P<0.01) and PWI lesions (ρ=-0.90, P<0.01). Receiver operating characteristic curve analysis showed that a mismatch-ASPECTS ≥2 best identified a volumetric mismatch, with a sensitivity of 0.93 (95% confidence interval, 0.89-0.98) and a specificity of 0.82 (95% confidence interval, 0.74-0.89)., Conclusions: The mismatch-ASPECTS method can detect a true mismatch in patients with acute middle cerebral artery stroke. It could be used for rapid screening of patients with eligible mismatch, in centers not equipped with ultrafast postprocessing software., (© 2016 American Heart Association, Inc.)

Objectives: To prospectively evaluate the predictive value of cerebral perfusion-computerized tomography (CTP) parameters variation between day0 and day4 after aneurysmal subarachnoid haemorrhage (aSAH)., Methods: Mean transit time (MTT) and cerebral blood flow (CBF) values were compared between patients with delayed cerebral ischemia (DCI+ group) and patients without DCI (DCI- group) for previously published optimal cutoff values and for variations of MTT (ΔMTT) and of CBF (ΔCBF) values between day0 and day4. DCI+ was defined as a cerebral infarction on 3-months follow-up MRI., Results: Among 47 included patients, 10 suffered DCI+. Published optimal cutoff values did not predict DCI, either at day0 or at day4. Conversely, ΔMTT and ΔCBF significantly differed between the DCI+ and DCI- groups, with optimal ΔMTT and ΔCBF values of 0.91 seconds (83.9 % sensitivity, 79.5 % specificity, AUC 0.84) and -7.6 mL/100 g/min (100 % sensitivity, 71.4 % specificity, AUC 0.86), respectively. In multivariate analysis, ΔCBF (OR = 1.91, IC95% 1.13-3.23 per each 20 % decrease of ΔCBF) and ΔMTT values (OR = 14.70, IC95% 4.85-44.52 per each 20 % increase of ΔMTT) were independent predictors of DCI., Conclusions: Assessment of MTT and CBF value variations between day0 and day4 may serve as an early imaging surrogate for prediction of DCI in aSAH., Key Points: • CT perfusion values are an imaging surrogate for prediction of DCI. • Early variations (day0-day4) after aneurysmal subarachnoid haemorrhage predicted DCI. • A CBF decrease of 7.6 mL/min/100 g predicted DCI with 100 % sensitivity. • An MTT increase of 0.91 seconds predicted DCI with 83.9 % sensitivity. • DCI risk multiplied by 2 per 20 % ΔCBF decrease and by 15 per 20 % ΔMTT increase.

Objective: The aim of this study was to evaluate the safety profile of gadoterate meglumine from clinical trials, postmarketing observational studies, and pharmacovigilance reports of adverse drug reactions (ADRs) encompassing 25 years of clinical use and over 50 million administered doses., Materials and Methods: Assessment of the safety of gadoterate meglumine through processing and review of all safety data was collected after magnetic resonance imaging procedures. All ADRs originated from 3 major sources: (1) a clinical study database including 50 phase I to IV studies involving 2822 patients, (2) a safety database including 8 postmarketing safety studies (PMSs) involving 151,050 patients, and (3) a pharmacovigilance database compiling safety experience following over 50 million doses administered between March 1989 and September 2015., Results: Among the 2822 patients receiving gadoterate meglumine in the clinical trials, 241 (8.5%) experienced 405 postinjection adverse events (AEs), considered related to the contrast agent for 113 patients (4.0%). Serious AEs were reported for 27 patients (1.0%) and assessed as related to gadoterate meglumine for 2 patients (0.07%). None of the PMS studies showed evidence of unexpected safety issues, with a very low rate of AEs (<1%). Postmarketing safety experience with over 50 million doses of gadoterate meglumine prescribed for 25 years of approved use worldwide compiled spontaneous reports for 3797 patients who experienced 8397 ADRs, yielding a very low reported incidence of ADRs of 0.007% of patients. There was no single-agent case of confirmed nephrogenic systemic fibrosis with gadoterate meglumine either from clinical development programs or from postmarketing experience., Conclusions: Based on clinical trials, postmarketing observational studies and pharmacovigilance data, a very low incidence of ADRs was reported with gadoterate meglumine, which has no impact on its favourable benefit-risk ratio.

A major feature of the human cortex is its huge morphological variability. Although a comprehensive literature about the sulco-gyral pattern of the central region is available from post-mortem data, a reliable and reproducible characterization from in vivo data is still lacking. The aim of this study is to test the reliability of morphological criteria of the central region sulci used in post-mortem data, when applied to in vivo magnetic resonance imaging (MRI) data. Thirty right-handed healthy individuals were included in the study. Automated segmentation and three dimensional (3D) surface-based rendering were obtained from clinical 3D T1-weighted MRI. Two senior radiologists labeled the three sulci composing the central region (precentral [PreCS], central [CS] and postcentral [PostCS]) and analyzed their morphological variations using 47 standard criteria derived from Ono's atlas based on post-mortem data. For each criterion, inter-rater concordance and comparison with the occurrence frequency provided in Ono's atlas were estimated. Overall, the sulcal pattern criteria derived from MRI data were highly reproducible between the raters with a high mean inter-rater concordance in the three sulci (CS: κ = 0.92 in left hemisphere/κ = 0.91 in right hemisphere; PreCS: κ = 0.91/κ = 0.93; PostCS: κ = 0.84/0.79). Only a very limited number of sulcal criteria significantly differed between the in vivo and the post-mortem data (CS: 2 criteria in the left hemisphere/3 criteria in the right hemisphere; PreCS: 3 in the left and right hemispheres; PostCS: 3 in the left hemisphere and 5 in the right hemisphere). Our study provides a comprehensive description of qualitative sulcal patterns in the central region from in vivo clinical MRI with high agreement with previous post-mortem data. Such identification of reliable sulcal patterns of the central region visible with standard clinical MRI data paves the way for the detection of subtle variations of the central sulcation associated with variations of normal or pathological functioning.

Background: Infarct growth (IG) is used as surrogate end-point in therapeutic trials. For practical reasons, infarct growth is commonly assessed using simple subtraction of acute from follow-up diffusion-weighted imaging (DWI) lesion volumes. However, the volume subtraction method will underestimate true infarct growth in case of diffusion-weighted imaging lesion reversal., Aim: To measure the size of the difference between true infarct growth on voxel-based coregistration and infarct growth approximated with simple volume subtraction., Methods: We retrospectively analyzed 322 consecutive stroke patients (median (IQR) age: 70 years (57-80), National Institute of Health Stroke Score at admission 14 (8-19)), who underwent a magnetic resonance imaging before (DWI1) and ≈24 h (DWI2) after i.v.-thrombolysis. IGvoxel-based was defined as the volume of signal changes on DWI2 that did not overlap with that on coregistered DWI1. This was compared with simply subtracting DWI1 from DWI2 lesion volume (IGsubtracted). We also compared these two metrics for the prediction of three-month unfavorable outcome (mRS ≥ 2) using c-statistics of multivariable models, adjusted for age, and National Institute of Health Stroke Score., Results: Infarct growth volume metrics were strongly correlated (ρ = 0.94), but IGsubtracted substantially underestimated IGvoxel-based (median (IQR): 9.52 (0.23-38.9) vs. 16.98 (4.4-45.4) mL). Of the 75 patients with shrinking or stable diffusion-weighted imaging lesion using volume subtraction, IGvoxel-based was ≥5 mL in 20 (27% of the subset, 6.2% of the whole population). Moreover, IGvoxel-based better predicted unfavorable outcome than IGsubtracted (c-statistics = 0.86 (95% CI, 0.82-0.90) vs. 0.82 (0.78-0.87), P = 0.003)., Conclusion: At early post-thrombolysis time points, the simple subtraction of lesion volumes masked substantial diffusion-weighted imaging lesion growth in 6.2% of patients. Although more time-consuming, the voxel-based method may impact results of trials that use infarct growth attenuation as an end-point., (© 2016 World Stroke Organization.)