The late renaissance Dutch painter Frans Hals (1582–1666) was a master of revealing his subjects' peculiarities. However, in the Regentesses (figure), he shows a neurologic condition—the blurred shoulder margin of the woman in the middle suggests trembling in a standing figure.1
Original Article: http://www.neurology.org/cgi/content/short/81/9/853?rss=1
BACKGROUND:Small, blister-like aneurysms (BLAs), by virtue of their unique morphology, are difficult to treat with conventional modalities. The use of oversized self-expanding stents as monotherapy for BLAs is a relatively new and promising concept that warrants further investigation. OBJECTIVE:To clarify the role of oversized self-expanding stents as monotherapy for BLAs. METHODS:Five consecutive patients were treated for BLAs with oversized self-expanding stents alone by the senior author (K.R.B.). We report on their clinical and radiographic outcomes. RESULTS:All 5 patients in our series were discharged in good clinical condition. Complete aneurysm occlusion was observed in all patients at the time of most recent radiographic follow-up. Mean follow-up time was 13.6 months (range, 1 month to 4.5 years). CONCLUSION:The use of oversized self-expanding stents to redirect flow away from aneurysms is an effective option for patients with BLAs. This approach represents an alternative to the use of flow diverters. ABBREVIATIONS:BLA, blister-like aneurysmCTA, computed tomography angiogramICA, internal carotid arterySAH, subarachnoid hemorrhageThe Neurosurgery Blog group is developing a series of apps dedicated to medicine and more specifically neuroscience.
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The post iPhone, iPad and Android apps for Neurosurgery appeared first on NEUROSURGERY BLOG.
Original Article: http://neurocirurgiabr.com/iphone-ipad-and-android-apps-for-neurosurgery/?utm_source=rss&utm_medium=rss&utm_campaign=iphone-ipad-and-android-apps-for-neurosurgery
BACKGROUND:Arteriovenous malformations (AVMs) in the basal ganglia, thalamus, and insula are considered inoperable given their depth, eloquence, and limited surgical exposure. Although many neurosurgeons opt for radiosurgery or observation, others have challenged the belief that deep AVMs are inoperable. Further discussion of patient selection, technique, and multimodality management is needed. OBJECTIVE:To describe and discuss the technical considerations of microsurgical resection for deep-seated AVMs. METHODS:Patients with deep AVMs who underwent surgery during a 14-year period were reviewed through the use of a prospective AVM registry. RESULTS:Microsurgery was performed in 48 patients with AVMs in the basal ganglia (n = 10), thalamus (n = 13), or insula (n = 25). The most common Spetzler-Martin grade was III− (68%). Surgical approaches included transsylvian (67%), transcallosal (19%), and transcortical (15%). Complete resection was achieved in 34 patients (71%), and patients with incomplete resection were treated with radiosurgery. Forty-five patients (94%) were improved or unchanged (mean follow-up, 1.6 years). CONCLUSION:This experience advances the notion that select deep AVMs may be operable lesions. Patients were highly selected for small size, hemorrhagic presentation, young age, and compactness—factors embodied in the Spetzler-Martin and Supplementary grading systems. Overall, 10 different approaches were used, exploiting direct, transcortical corridors created by hemorrhage or maximizing anatomic corridors through subarachnoid spaces and ventricles that minimize brain transgression. The same cautious attitude exercised in selecting patients for surgery was also exercised in deciding extent of resection, opting for incomplete resection and radiosurgery more than with other AVMs to prioritize neurological outcomes. ABBREVIATIONS:AVM, arteriovenous malformationMCA, middle cerebral arteryRS, Rankin Scale
BACKGROUND:Controversy remains about the optimal treatment for blood blister--like aneurysms (BBAs). OBJECTIVE:To evaluate clinical and angiographic outcomes after reconstructive treatment for BBA with stent and coil. METHODS:Thirty-four patients (6 men, 28 women; mean age, 47.3 years) with ruptured BBAs underwent reconstructive treatment with stent and coil. Posttreatment courses and outcomes were retrospectively evaluated. RESULTS:Initial treatments were ≥ 2 overlapping stents with or without coiling (n = 28) and single stent with coiling (n = 6). Three BBAs rebled on days 9, 11, and 15 after treatment, resulting in 1 death. Except for 3 patients who died early, 31 patients were followed up for 7 to 80 months (median, 32 months). One patient recovered completely but died of complications of systemic lupus erythematosus at 25 months. Of the remaining 30 patients, 25 had favorable outcomes (modified Rankin scale, 0-2) and 5 had unfavorable outcomes. Angiographic follow-up was available in the 32 BBAs. Eight (25.0%) recurred, all within 5 weeks. In the multiple stents group (n = 26), 22 BBAs showed improvement or complete healing, but 4 (15.4%, 2 rebleedings) had recurrence. In the single stent with coiling group (n = 6), 2 BBAs were stable but 4 (66.7%, 1 rebleeding) had recurrence. Single stent with coiling and Hunt and Hess grade ≥ 4 were 2 independent risk factors for recurrence (P < .05). CONCLUSION:Reconstructive treatment with stent and coil appears a viable option for BBAs. Single stent with coiling and Hunt and Hess grade ≥ 4 were 2 independent risk factors for recurrence. Follow-up angiography should be considered mandatory soon after treatment. ABBREVIATIONS:BBA, blood blister--like aneurysmICA, internal carotid arterymRS, modified Rankin ScaleSAH, subarachnoid hemorrhage
BACKGROUND:Intracranial aneurysms (IAs) occur more frequently at certain bifurcations than at others. Hemodynamic stress, which promotes aneurysm formation in animal models, also differs among bifurcations, depending on flow and vessel geometry. OBJECTIVE:To determine whether locations that are more likely to develop IAs experience different hemodynamic stresses that might contribute to higher IA susceptibility. METHODS:We characterized the hemodynamic microenvironment at 10 sites in or around the circle of Willis where IAs commonly occur and examined statistical relationships between hemodynamic factors and the tendency for a site to form IAs. The tendency for each site to develop IAs was quantified on the basis of the site distribution from systematic literature analysis of 19 reports including 26 418 aneurysms. Hemodynamic parameters for these sites were derived from image-based computational fluid dynamics of 114 cerebral bifurcations from 31 individuals. Wall shear stress and its spatial gradient were calculated in the impact zone surrounding the bifurcation apex. Linear and exponential regression analyses evaluated correlations between the tendency for IA formation and the typical hemodynamics of a site. RESULTS:IA susceptibility significantly correlated with the magnitudes of wall shear stress and positive wall shear stress gradient within the hemodynamic impact zone calculated for each site. CONCLUSION:IAs occur more frequently at cerebral bifurcations that typically experience higher hemodynamic shear stress and stronger flow acceleration, conditions previously shown to promote aneurysm initiation in animals. ABBREVIATIONS:CFD, computational fluid dynamicsIA, intracranial aneurysmMCA, middle cerebral arteryWSS, wall shear stressWSSG, wall shear stress gradient
BACKGROUND:The accurate localization of depth electrodes in epilepsy surgery is important for correct interpretation of stereoelectroencephalography recordings and neurosurgical resection. Unfortunately, image quality in postimplantation magnetic resonance imaging (MRI) is degraded by metal artifacts. The registration of postimplantation computed tomography (CT) or MRI to preimplantation (artifact-free) MRI facilitates electrode imaging and optimal visualization of brain anatomy. However, registration errors negatively affect electrode localization accuracy. OBJECTIVE:To compare the relative registration deviation between postimplantation CT and MRI with preimplantation MRI. METHODS:Retrospectively, 14 pharmacoresistant epilepsy patients were included who underwent stereotactic insertion of multiple depth electrodes and preimplantation and postimplantation MRI and postimplantation CT. Postimplantation MRI and CT image sets were registered to preimplantation MRI. The registration error between the registered postimplantation MRI and CT was quantified by measuring the geometrical distance between the electrodes of the registered postimplantation CT and the postimplantation MRI. RESULTS:The registration error of postimplantation imaging to preimplantation MRI was dependent on the algorithm used. After optimization, the smallest registration error was 1.22 ± 0.29 mm (mean ± SD) at the tip and 2.25 ± 1.18 mm at the base of the electrode. CONCLUSION:The good correspondence between the CT/MRI and the MRI/MRI registration suggests that either postimplantation MRI or CT is sufficient for accurate electrode localization. In case of postoperative morphological brain deformations, postimplantation MRI is still recommended. ABBREVIATIONS:MI, mutual informationNMI, normalized mutual information
BACKGROUND:Cerebral angiography is generally recommended in patients with subarachnoid hemorrhage (SAH) by positive lumbar puncture (LP) but negative findings on computed tomography (CT). Existing data on the yield of angiography in these patients are very limited. OBJECTIVE:To retrospectively assess the diagnostic yield of cerebral angiography in patients with CT−/LP+ SAH and to determine the clinical and laboratory predictors of a vascular abnormality on angiography. METHODS:A total of 35 patients with CT−/LP+ SAH underwent cerebral angiography at our institution between 2008 and 2011. Patient clinical characteristics and LP findings were entered into a multivariate logistic regression analysis to identify predictors of vascular abnormalities. RESULTS:Twenty-five patients (71.4%) were female and 10 (28.6%) were male, with a mean age of 53 years. Twenty-six patients (74.3%) had cerebrospinal fluid xanthochromia. Sixteen patients (45.7%) were found to have an aneurysm on cerebral angiography. The median CSF red blood cell count of both the first (7790/mm3 vs 4700/mm3), and last collection tubes (6800/mm3 vs 3219/mm3) were higher in patients with cerebral aneurysms vs those without aneurysms (P = .3). On multivariate analysis, there were no clinical or laboratory parameters that predicted the presence of aneurysm on cerebral angiography. CONCLUSION:The diagnostic yield of cerebral angiography is high (45.7%) in patients with CT−/LP+ SAH. Higher red blood cell counts were noted in patients with cerebral aneurysms but no clinical or laboratory parameter can reliably predict the presence of a vascular anomaly. Thus, it is reasonable to perform cerebral angiography in all patients with CT−/LP+ SAH. ABBREVIATIONS:CTA, computed tomography angiographyDSA, digital subtraction angiographyLP, lumbar punctureMRA, magnetic resonance angiographyRBC, red blood cellSAH, subarachnoid hemorrhageWBC, white blood cellMendez et al.1 found that distinguishing between pathologically confirmed bvFTD and AD can be determined by personality changes, problem-solving, and episodic memory deficits. This could have implications on future bvFTD diagnostic criteria. The higher incidence of episodic memory problems in AD raises the controversial issue: is a memory deficit a reliable diagnostic criterion in distinguishing between the pathologies? There is increasing evidence that an episodic memory deficit is a poor diagnostic predictor for bvFTD and AD, even in pathologically proven cases.2–5 Closer inspection of the authors' findings reveals that their neuropsychological memory measures confirm these findings by showing no episodic memory difference between bvFTD and AD. The authors based their recommendation on the binary informant-based decision of episodic memory deficits presence, which does not converge with their more objective neuropsychological findings. This discrepancy is concerning. The recommendation to discriminate between bvFTD and AD on the basis of memory deficits may not be warranted by their data. The authors should have mentioned this caveat in their publication.
Original Article: http://www.neurology.org/cgi/content/short/81/8/775?rss=1
Nature Reviews Neuroscience 14, 609 (2013). doi:10.1038/nrn3381
Authors: Scott J. Russo & Eric J. Nestler
Mood disorders are common and debilitating conditions characterized in part by profound deficits in reward-related behavioural domains. A recent literature has identified important structural and functional alterations within the brain's reward circuitry — particularly in the ventral tegmental area–nucleus accumbens pathway — that are associated
Original Article: http://feeds.nature.com/~r/nrn/rss/current/~3/VIOt4Tjj7LI/nrn3381
Nature Reviews Neuroscience 14, 609 (2013). doi:10.1038/nrn3381
Authors: Scott J. Russo & Eric J. Nestler
Mood disorders are common and debilitating conditions characterized in part by profound deficits in reward-related behavioural domains. A recent literature has identified important structural and functional alterations within the brain's reward circuitry — particularly in the ventral tegmental area–nucleus accumbens pathway — that are associated
Original Article: http://feeds.nature.com/~r/nrn/rss/current/~3/VIOt4Tjj7LI/nrn3381
Nature Reviews Neuroscience 14, 609 (2013). doi:10.1038/nrn3381
Authors: Scott J. Russo & Eric J. Nestler
Mood disorders are common and debilitating conditions characterized in part by profound deficits in reward-related behavioural domains. A recent literature has identified important structural and functional alterations within the brain's reward circuitry — particularly in the ventral tegmental area–nucleus accumbens pathway — that are associated
Original Article: http://feeds.nature.com/~r/nrn/rss/current/~3/VIOt4Tjj7LI/nrn3381
Nature Reviews Neuroscience 14, 659 (2013). doi:10.1038/nrn3578
Authors: Eric R. Kandel, Henry Markram, Paul M. Matthews, Rafael Yuste & Christof Koch
Despite cash-strapped times for research, several ambitious collaborative neuroscience projects have attracted large amounts of funding and media attention. In Europe, the Human Brain Project aims to develop a large-scale computer simulation of the brain, whereas in the United States, the Brain Activity Map is
Original Article: http://feeds.nature.com/~r/nrn/rss/current/~3/7StCxviOM2c/nrn3578
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Published online before print July 11, 2013, doi: 10.3174/ajnr.A3671
AJNR 2013
A.C. Mamourian
Department of Radiology, Neuroradiology
B.A. Pukenas
Department of Radiology, Neurointervention
Hospital of the University of Pennsylvania
Philadelphia, Pennsylvania
S.R. Satti
Department of Neurointerventional Surgery
Christiana Care Heath System
Wilmington, Delaware
After the editorial alarmingly entitled "Death by Nondiagnosis: Why Emergent CT Angiography Should Not Be Done for Patients with Subarachnoid Hemorrhage"1 in the American Journal of Neuroradiology (AJNR) in 2007, we were looking forward to an update in Dr Jayaraman's recent commentary, "Cerebral Angiography: Not Yet Ready to Join the Dinosaurs,"2 after 6 years of progress with CTA technology. On the basis of the title of the piece, we expected to read a commonsense plea for neuroradiologists to maintain their competence with catheters now that CTA has effectively become the first imaging test at many hospitals for patients presenting with nontraumatic subarachnoid hemorrhage. Therefore, we were surprised to read about his suggestion to bypass CTA altogether and go directly to DSA whenever possible, a point of view reminiscent of that 2007 editorial.
His commentary was in response to a scientific article in which Delgado Almandoz et al3 reported that 10%–20% of patients with acute subarachnoid hemorrhage but negative CTA or MRA had positive findings on DSA. This is of interest but not surprising and less so when one considers that only approximately 11 cases a year (18%) had negative CTA findings over the course of 5 years at their institution. In only approximately 3% (15% of 18%) of all the patients presenting to their hospital with subarachnoid hemorrhage, angiography was required to find the source of the hemorrhage. If we choose to look at the glass half full, in 97% of their patients CTA alone provided the correct diagnosis. That is better than most other diagnostic tests used routinely. Nevertheless, DSA was necessary to find that 3% in 18% of their patients, so let us say that CTA alone provided the correct diagnosis in approximately 80%.
He then cited another article that reported that even when the CTA findings are positive, the DSA examination changed the treatment plan in 20%–30% of patients.4 While that certainly would support his argument, some of the "changes" listed in that article would be insignificant in the setting of a patient with an acute subarachnoid hemorrhage. For example, a 4-mm anterior communicating artery aneurysm noted on CTA was 1 example of "change" when it was found to be to a 5-mm aneurysm on DSA. Acute subarachnoid hemorrhage was not required for inclusion in the study and, in both articles, MRA was lumped together with CTA in the pre-DSA group. That explains the title of the Delgado Almandoz3 article, "Diagnostic Yield of Catheter Angiography in Patients with Subarachnoid Hemorrhage and Negative Noninvasive Examinations" (italics ours). Therefore, while neither article directly addresses the question of CTA versus DSA in patients with subarachnoid hemorrhage, let us accept that there is something to what they say and call CTA diagnostic in only 70% of cases.
With these facts in hand, Dr Jayaraman goes on to remind the readers of their obligation as physicians to eliminate unnecessary costs to the health system and concludes: "As part of this cost containment, if we can eliminate a 'good' test (CTA) to go directly to the 'best' test (DSA), I believe that we should take this opportunity…. Doing so may decrease the cost and will also decrease patient radiation dose."2
"May" indeed. One might then ask on what basis? The commentary does not offer any numbers to support the advice to skip CTA. At our institution, the charge for DSA is approximately 5 times that of CTA. The difference may be even larger at other institutions, and that differential makes perfect sense considering that DSA is an invasive test (one that requires an hour or more to perform, catheters and the like, and with physicians in attendance) and should cost considerably more than CTA to perform. With regard to radiation dose, we rely on the report by Manninen et al,5 in which they used real measurements to show that CTA of the intracranial vessels has only one-fifth the effective dose of a DSA examination.
For keeping score, let us assign to CTA a relative cost value of 1 and the same for its dose. Using their relative values for a single brain DSA, we will assign a value of 5 for cost and 5 as well for dose. If we were to then choose to examine the next 100 patients who arrive at the emergency department with a subarachnoid hemorrhage with a DSA study as their only examination instead of a CTA, doing the "best" test first, as suggested in the commentary, the total cost in terms of our relative values would be 500 (5 x 100) for cost and 500 (5 x 100) for dose—that is, of course, assuming that there were no complications from the DSA, because they would certainly increase both the cost and dose of this approach. Now let us reset the counter and offer each patient a CTA at the time of presentation. The total cost for the CTA part of their work-up would then be 100, and their total dose, 100. Now then if we assume that 30% of the 100 had normal or less-thandefinitive CTA findings followed by DSA, if we used our relative-value scale, that would require an additional cost of 150 (30 x 5) and dose of 150 (30 x 5). The total then for the approach of using CTA followed by DSA in our group of 100 in total would add up to 250 for cost and 250 for dose compared with 500 and 500, respectively, for the DSA-only model. In short, using the DSA-first approach suggested by Dr Jayaraman would incur twice the cost and dose. While there may be flaws with this simple calculation, we believe, in broad strokes, that it is sound, and at least we offer an analysis to support the CTA-first approach.
What should be acknowledged at the outset is that in clinical practice, DSA is usually performed as part of the patient's endovascular procedure and not as a stand-alone diagnostic test. That is why this question of cost and dose is really quite complex. At most centers, CTA is used as a decision point on the way to surgical or, more frequently, endovascular treatment of an aneurysm. The benefit of endovascular treatment in this circumstance was recently reaffirmed by the Barrow Ruptured Aneurysm Trial from the Barrow Institute.6 Using CTA as the first examination is helpful in many ways: For example, it can determine whether the patient requires emergent surgery, it allows the family to understand the magnitude of the risks before any treatment, and it allows the interventionalist to limit the diagnostic portion of the endovascular procedure and decide how to best address the specifics of the aneurysm configuration before the procedure. Because diagnostic angiography is commonly performed without anesthesia but interventional procedures are not, one would have to consider the implications, in terms of cost, of performing a diagnostic DSA examination without anesthesia and then bringing in anesthesia, compared with the cost of doing all DSA examinations with anesthesia in anticipation of some going on to intervention. It is for these reasons that the impact of bypassing CTA goes well beyond any simple measure of sensitivity, because even a negative CTA finding in the middle of the night has a significant impact on patient care regardless of the results of the DSA that follows the next day.
We can all agree that CTA alone cannot address all the diagnostic questions for these patients with subarachnoid hemorrhage. Moreover, for those patients who need DSA for diagnosis, we wholeheartedly agree with Dr Jayaraman that neuroradiologists need to be well-trained and prepared to offer optimal DSA imaging with minimal risk whenever necessary. However, until real evidence is provided to the contrary, we believe that CTA remains the logical first examination for patients presenting with subarachnoid hemorrhage.
Published online before print July 11, 2013, doi: 10.3174/ajnr.A3703
AJNR 2013
M.V. Jayaraman
Departments of Diagnostic Imaging and Neurosurgery
Warren Alpert School of Medicine at Brown University
Providence, Rhode Island
I would like to thank Drs Mamourian, Pukenas, and Satti for their letter, "Should American Journal of Neuroradiology Commentary Be Evidence-Based?" I agree that commentary should indeed be evidence-based. However, with many studies, there can be more than one way to interpret the data.
I stated in my original letter that "we as radiologists should do our part to optimize patient care by eliminating redundant testing…."1 Recently, McDonald et al2 published an analysis of the relative use of CTA and DSA in patients with ruptured cerebral aneurysms. They showed that in a retrospective analysis of 4972 patients (3950 of whom were treated with endovascular coiling) spanning 2006–2011, the use of CTA increased from 20% in 2006 to 44% in 2011. Meanwhile, during the same time, the use of angiography remained unchanged at 94%–96%. This evidence seems to support the assertion that in patients with ruptured aneurysms, increasing use of CTA did not decrease the use of DSA. Certainly, this retrospective study has limitations, the most significant of which is that patients with nonaneurysmal subarachnoid hemorrhage were not included.
Mamourian et al also suggest that pretreatment CTA "is very helpful to determine whether the patient requires emergent surgery, it allows the family to understand the magnitude of the risks before any treatment, and it allows the interventionalist to limit the diagnostic portion of the endovascular procedure and plan before the procedure how to best address the specifics of the aneurysm configuration." However, there is no evidence that they can reference to support that claim. Where is the evidence showing that pretreatment CTA improves outcomes or patient safety among those who subsequently undergo endovascular therapy? Where is the evidence that a pretreatment CTA reduces procedural time or radiation exposure during diagnostic angiography?
Because they also state that CTA "remains the logical first examination for patients presenting with subarachnoid hemorrhage," I would suggest that they provide the evidence that supports this claim. Perhaps they should randomize all patients with SAH to either CTA first or DSA first. Then, when they can show that the CTA-first group had better outcomes and lower costs, they can support their logic. It may also have been logical to believe that endovascular therapy is better than the best medical therapy for intracranial atherosclerotic disease3 or that logically, endovascular therapy improves outcomes over IV thrombolysis alone in patients with acute ischemic stroke.4
I certainly believe that CTA has an important role in the emergent setting. Patients who are too unstable to undergo angiography or need emergent resection of an intracranial hematoma are excellent candidates for a CTA. In addition, those with low suspicion for aneurysmal hemorrhage can also often be managed with CTA alone. Indeed, the original article that started this discussion showed that in patients with isolated perimesencephalic hemorrhage, negative findings on noninvasive imaging would have been adequate.5 However, at the present time, there is inadequate evidence to imply that CTA as a first imaging technique on all patients with subarachnoid hemorrhage should be the standard of care.
The post Should American Journal of Neuroradiology Commentary be Evidence-Based? appeared first on AJNR Blog.
Original Article: http://www.ajnrblog.org/2013/08/15/should-american-journal-of-neuroradiology-commentary-be-evidence-based/
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