1. Berman JP, Norby FL, Mosley T, et al. Atrial Fibrillation and Brain Magnetic Resonance Imaging Abnormalities. Stroke. 2019:783-788. doi:10.1161/strokeaha.118.024143

Atrial fibrillation (AF) is associated with dementia independent of clinical stroke. The mechanisms underlying this association remain unclear. In a community-based cohort, the ARIC study (Atherosclerosis Risk in Communities), the authors evaluated (1) the longitudinal association of incident AF and (2) the cross-sectional association of prevalent AF with brain MRI abnormalities.

The longitudinal analysis included 963 participants (mean age, 73 years; 62% women; 51% black) without prevalent stroke or AF who underwent a brain MRI in 1993 to 1995 and a second MRI in 2004 to 2006 (mean, 10.6 years). Outcomes included subclinical cerebral infarctions, sulcal size, ventricular size, and, for the cross-sectional analysis, white matter hyperintensity volume and total brain volume.

In a population-based cohort, the authors found that participants who developed AF had adverse longitudinal changes in brain morphology on MRI. Compared with participants who did not develop AF, those who developed AF had an increase in subclinical cerebral infarctions on longitudinal brain MRIs. Additionally, participants who developed AF were also at higher risk of worsened ventricular grade and worsened sulcal grade—changes that are also associated with advanced aging and dementia. These associations remained significant after adjusting for age, sex, and cardiovascular risk factors. In cross-sectional analysis, they observed an association between AF and higher ventricular and sulcal grades. Importantly, even after excluding participants with subclinical cerebral infarctions in both longitudinal and cross-sectional analyses, they observed associations with worse sulcal and ventricular grade, albeit the associations were attenuated. Notably, there was no association with WMH volume or with total brain volume. Finally, they did not observe any significant sex- or race-based interactions with AF.

Infarcts were defined based on signal characteristics on T1, T2, and proton density images: bright on T2 and proton density and dark on T1 images. Infarcts were counted only if they were >3 mm in maximum diameter. All scans were subjected to double-reads for infarct scoring.

For each visit MRI, axial T1-weighted images were used for assessment of ventricular grade and sulcal grade using a 0 to 9 scale developed and validated by the Cardiovascular Health Study with 9 being the largest and the most abnormal. Variability between 2 independent neuroradiologists was tested for 26 scans and showed reliability coefficients of 0.87 and 0.63 for ventricular grade and sulcal grade, respectively.

3 Tables

2. Kaesmacher J, Chaloulos-Iakovidis P, Panos L, et al. Mechanical Thrombectomy in Ischemic Stroke Patients With Alberta Stroke Program Early Computed Tomography Score 0–5. Stroke. 2019;50(4):880-888. doi:10.1161/STROKEAHA.118.023465

Whether anterior circulation large vessel occlusion acute ischemic stroke patients presenting with ASPECTS 0–5 should be treated with mechanical thrombectomy remains unclear. The purpose of this study was to report on the outcome of patients with ASPECTS 0–5 treated with mechanical thrombectomy and to provide data regarding the effect of successful reperfusion on clinical outcomes and safety measures in these patients.

Two hundred thirty-seven of 2046 patients included in this registry presented with anterior circulation large vessel occlusion and ASPECTS 0–5. In this subgroup, the overall rates of favorable outcome and mortality at day 90 were 40.1% and 40.9%. Achieving successful reperfusion was independently associated with favorable outcome, functional independence, reduced mortality, and lower rates of symptomatic intracerebral hemorrhage.

Many limitations: ASPECTS scores were rated at each center and were not core-lab adjudicated. Hence, there is uncertainty because of interrater variability. In particular, this has to be kept in mind, as the interrater agreement for DWI-ASPECTS and CT-ASPECTS is only modest. This analysis, however, primarily used dichotomizations of ASPECTS 0–5, which will decrease the interrater variability to some extent. Furthermore, the low ASPECTS group is primarily supplied by 3 centers, limiting generalizability of the findings. Another limitation of the ASPECTS is that it fails to account for ischemia outside the middle cerebral artery territory, such as anterior cerebral artery and posterior cerebral artery infarcts in case of carotid-T occlusions.

Because of the retrospective, nonrandomized nature of the data and the lack of an untreated control group, these results should be viewed as hypothesis generating that suggest the need of a future randomized controlled trial. However, when considering that the outcome for unsuccessfully reperfused patients resembles the natural course of the disease, and may thus partially substitute for a control group, the current analysis supports the notion that rapid and complete reperfusion in these patients is beneficial. This deduction is limited by the fact that an unsuccessful procedure may actually harm the patient by, for example, complications and sedation. Hence, formal testing of the best treatment approach (ie, mechanical thrombectomy versus best medical treatment) in randomized controlled trial is warranted

They conclude that in patients presenting with ASPECTS 0–5, who were treated with mechanical thrombectomy, successful reperfusion was beneficial without increasing the risk of symptomatic intracerebral hemorrhage. Formal testing of mechanical thrombectomy versus best medical treatment in these patients in a randomized controlled trial is warranted.

3 figures, 3 tables, no imaging

3. Aslani S, Dayan M, Storelli L, et al. Multi-branch convolutional neural network for multiple sclerosis lesion segmentation. Neuroimage. 2019;196(March):1-15. doi:10.1016/j.neuroimage.2019.03.068

The authors present an automated approach for segmenting multiple sclerosis (MS) lesions from multi-modal brain magnetic resonance images.

The method is based on a deep end-to-end 2D convolutional neural network (CNN) for slice-based segmentation of 3D volumetric data.

Computer stuff:
The proposed CNN includes a multi-branch down sampling path, which enables the network to encode information from multiple modalities separately. Multi-scale feature fusion blocks are proposed to combine feature maps from different modalities at different stages of the network. Then, multi-scale feature up sampling blocks are introduced to upsize combined feature maps to leverage information from lesion shape and location.

Back to reality:
They trained and tested the proposed model using orthogonal plane orientations of each 3D modality to exploit the contextual information in all directions. The proposed pipeline was evaluated on two different datasets: a private dataset including 37 MS patients and a publicly available dataset known as the ISBI 2015 longitudinal MS lesion segmentation challenge dataset, consisting of 14 MS patients. Considering the ISBI challenge, at the time of submission, this method was amongst the top performing solutions. On the private dataset, using the same array of performance metrics as in the ISBI challenge, the proposed approach shows high improvements in MS lesion segmentation compared with other publicly available tools.

In summary, the main contributions in this work are:
A whole-brain slice-based approach to exploit the overall structural information, combined with a multi-plane strategy to take advantage of full contextual information.

A multi-level feature fusion and upsampling approach to exploit contextual information at multiple scales.

The evaluation of different versions of the proposed model so as to find the most performant combination of MRI modalities for MS lesion segmentation.

The demonstration of top performance on two different datasets.

9 Figures, 4 tables, a bunch of equations.

4. Andreiuolo F, Varlet P, Tauziède-Espariat A, et al. Childhood supratentorial ependymomas with YAP1-MAMLD1 fusion: an entity with characteristic clinical, radiological, cytogenetic and histopathological features. Brain Pathol. 2019;29(2):205-216. doi:10.1111/bpa.12659

Supratentorial ependymomas are heterogeneous from clinical, molecular and morphological perspectives. In 2014, two studies independently reported on recurrent C11orf95-RELA fusions as the most frequent recurrent genetic alteration in supratentorial ependymomas of childhood, occurring in more than 70% of cases. RELA fusion-positive ependymoma has already been included in the last amendment of the WHO classification of brain tumors as a novel, genetically defined disease entity. Most RELA fusion positive ependymomas have a characteristic morphological aspect, often displaying clear cells and branching capillaries, although some pleomorphic tumors can also be seen in this group. RELA fusions have been shown to be oncogenic by activation of the NFKB pathway. The tumors can be well detected by demonstration of the fusion or by immunohistochemistry for pathological accumulation of p65 RelA protein in the nucleus.

Recently, a tumor with fusion of YAP1 (YES-associated protein 1) and MAMLD1 genes in a female infant with supratentorial ependymoma was described. Another publication identified a group of tumors with characteristic methylation profiles and frequent copy number alterations in chromosome 11 at the YAP1 locus (9/13) and almost exclusive location in the supratentorial compartment (one lesion was identified in the posterior fossa).

YES-associated protein 1 (YAP1) is one of the main downstream effectors of the Hippo signaling pathway, a tumor suppressor pathway implicated in organ size control but which is also deregulated in different types of cancer such as ovarian carcinoma, non-small cell lung carcinoma, esophageal squamous cell carcinoma and hepatocellular carcinoma, and also associated with metastatic potential in breast carcinoma and melanoma among others.

The aim of the present study was to define clinical, molecular and morphological characteristics in a cohort of patients with YAP1-MAMLD1-fused ependymomas.

Fifteen cases of YAP1-MAMLD1 ependymomas were retrieved from the archives of the DGNN Reference Center for Brain Tumors at the Institute of Neuropathology at the University of Bonn, Ste Anne/Necker Hospitals in Paris, University of Vienna and Seoul National University Children’s hospital. The cases were identified by retrospective evaluation of supratentorial ependymomas of childhood and adolescents (0–21 years) and subsequent exclusion of RELA-related ependymomas; residual cases were checked for the presence of YAP1-MAMLD1 fusions. Ependymomas with YAP1-MAMLD1 fusions correspond to approximately 4% of all supratentorial ependymomas in the age range of 0–14 years in the series of the DGNN brain tumor reference center.

The results confirm some of the epidemiological findings described in retrospective cohorts, showing a predominance of ependymomas with YAP1-MAMLD1 fusion among young female children. In the present series, 13/15 patients were female and only 3/15 were older than 3 years at diagnosis.

As patients this series were analyzed retrospectively, and treated with different protocols it is hard to draw definitive conclusions on the behavior of the tumors. A striking finding this cohort was an excellent outcome with 100% of children alive at a median follow-up of 4.8 years, although one patient had to be reoperated and one patient was irradiated after tumor progression.

1 Tables, 5 figures, with one MR figure

5. Chan SM, Chodakiewitz YG, Maya MM, Schievink WI, Moser FG. Intracranial Hypotension and Cerebrospinal Fluid Leak. Neuroimaging Clin N Am. 2019;29(2):213-226. doi:10.1016/j.nic.2019.01.002

Nice review of all aspects of diagnosis and treatment of SIH.
Of particular interest to me was the authors use of DSM.
They note that DSM was formerly reserved for use in high volume CSF leaks, which benefit from the real time imaging capability of DSM, compared with the inherent time delay involved in post myelogram CT. In these rapid leaks, by the time CT is performed, the contrast often has already spread over many levels and the exact site of the dural tear remains unknown. At the authors institution, they have expanded use of DSM to detect and localize CSF leak beyond just those with high-volume leaks and now perform DSM in nearly all patients requiring leak detection and localization for targeted treatment, because it offers increased sensitivity for ventral leaks, CSF venous fistulas and offers superior localization capabilities in detecting the site of dural defect.
14 Figures

6. Lavelle WF, Riew KD, Levi AD, Florman JE. Ten-year Outcomes of Cervical Disc Replacement With the BRYAN Cervical Disc. Spine (Phila Pa 1976). 2019;44(9):601-608. doi:10.1097/BRS.0000000000002907

Cervical disc arthroplasty (CDA) has the potential to reduce the risk of adjacent level disc degeneration and segmental instability that may be seen after a cervical fusion. The BRYAN Cervical Disc (Medtronic) is one of several CDA devices that have undergone safety and effectiveness evaluation in the United States. It currently has one of the longest follow-up periods available for review. After in vitro and in vivo testing demonstrated feasibility and adequate durability, a European prospective clinical trial, which began in 2000, demonstrated acceptable results at 2- and 4-year follow-ups.

This is an analysis of a US Food and Drug Administration (FDA) investigation comparing Cervical disc arthroplasty with ACDF for single-level patients. Eligible patients were 21 years of age with symptomatic cervical disc disease who had failed conservative care. Patients were followed at regular intervals with the current data set at > 10 years. Protocol for overall success:  15-point improvement in NDI scores, maintenance or improvement in neurologic status, no serious adverse events related to implant or implant/surgical procedure, and no subsequent surgery or intervention classified as ‘‘failure.’’

At 10-year follow-up, 128 (CDA) and 104 (ACDF) patients were available for evaluation. Overall success rate was significantly higher for Cervical disc arthroplasty group (81.3% vs. 66.3%). The rate of second surgeries at adjacent levels was lower for Cervical disc arthroplasty group (9.7% vs. 15.8%).

Cervical disc arthroplasty can preserve and maintain motion in the long term compared with ACDF. There was a trend toward fewer adjacent segment surgeries for BRYAN disc that did not reach significance. Significant improvement in CDA NDI scores may suggest better long-term success for CDA as compared to fusion.

These potentially positive findings must be tempered by viewing the data in light of the noninferiority design of the study itself and the dropout rate in the follow-up at the 120-month follow-up time point. While there may be some convergence of clinical benefit over time, there is maintenance of advantage in preserved motion and rates of reoperation for CDA. Future studies will be valuable to differentiate advantages of different implants, as CDA continues to be more widely adopted. While the experience with the BRYAN disc likely serves as a positive bellwether, study of pooled data and registries will be necessary to expose the truly long-term reality of CDA. It must be remembered that the available data are limited in predicting the natural history of CDA over the many decades of anticipated life expectancy of the patients.

5 figures, no imaging

7. Dobrocky T, Grunder L, Breiding PS, et al. Assessing Spinal Cerebrospinal Fluid Leaks in Spontaneous Intracranial Hypotension With a Scoring System Based on Brain Magnetic Resonance Imaging Findings. JAMA Neurol. 2019;76(5):580-587. doi:10.1001/jamaneurol.2018.4921

This case-control study in consecutive patients investigated for SIH was conducted at a single hospital department from February 2013 to October 2017. Three blinded readers retrospectively reviewed the brain MRI scans of patients with SIH and a spinal CSF leak, patients with orthostatic headache without a CSF leak, and healthy control participants, evaluating 9 quantitative and 7 qualitative signs.

An updated literature review was performed to identify previously reported signs of intracranial hypotension on brain imaging. The authors then assessed 7 qualitative items (engorgement of venous sinus, distended inferior intercavernous sinus, pachymeningeal enhancement, midbrain descent [subjective], superficial siderosis, subdural fluid collection [present or absent], and superior surface of the pituitary [concave, flat, or convex]) and 9 quantitative signs (pituitary height, pontomesencephalic angle, suprasellar cistern, prepontine cistern, midbrain descent, venous-hinge angle, mamillopontine angle, tonsillar descent, and area cavum veli interpositi.

A predictive diagnostic score based on multivariable backward logistic regression analysis was then derived. Its performance was validated internally in a prospective cohort of patients who had clinical suspicion for SIH.

A total of 152 participants were studied which included 56 with SIH and a spinal CSF leak, 16 with orthostatic headache without a CSF leak, 60 control participants, and 20 patients in the validation cohort. Six imaging findings were included in the final scoring system. Three were weighted as major (2 points each): pachymeningeal enhancement, engorgement of venous sinus, and effacement of the suprasellar cistern of 4.0 mm or less. Three were considered minor (1 point each): subdural fluid collection, effacement of the prepontine cistern of 5.0 mm or less, and mamillopontine distance of 6.5 mm or less. Patients were classified into groups at low, intermediate, or high probability of having a spinal CSF leak, with total scores of 2 points or fewer, 3 to 4 points, and 5 points or more, respectively, on a scale of 9 points.

This 3-tier predictive scoring system is based on the 6 most relevant brain MRI findings and allows assessment of the likelihood (low, intermediate, or high) of a positive spinal imaging result in patients with SIH. It may be useful in identifying patients with SIH who are leak positive and in whom further myelographic examinations are warranted before considering targeted therapy.

3 Figures, 2 tables including graphics of findings, and MR imaging

8. Goyal A, Yolcu Y, Kerezoudis P, Alvi MA, Krauss WE, Bydon M. Intramedullary spinal cord metastases: an institutional review of survival and outcomes. J Neurooncol. 2019;142(2):347-354. doi:10.1007/s11060-019-03105-2

Intramedullary spinal cord metastases (ISCMs) comprise a rare but a devastating manifestation of systemic malignancy. Their incidence is estimated between 4.2 and 8.5% of all central nervous system (CNS) metastases and nearly 3.5% of all spinal metastases. Their incidence
at autopsy is estimated to be between 0.9 and 2.1% of all patients with cancer. They constitute 1–3% of all intramedullary tumors and 0.6% of all spinal cord tumors. However, due to therapeutic advances and improvement in cancer specific survival, their frequency of diagnosis is gradually increasing with a rise in the number of associated publications.

The authors retrospectively analyzed the medical records of patients diagnosed with intramedullary metastatic lesions at their institution between 1997 and 2016. They analyzed different approaches to management and factors influencing survival and neurologic outcomes. A total of 70 patients (86 lesions) were analyzed. Most lesions were found in thoracic spinal cord (50%) followed by cervical (34%) and conus medullaris (14%). Mean age at diagnosis was 55 years with 60% (n = 42) being females. Median survival was 104.5 days. Twenty-three patients (33%) received conservative management, 39 (56%) received palliative radiotherapy, whereas 8 (11%) underwent surgery with one patient receiving only a biopsy. Age, sex, presence of concomitant brain and other systemic metastasis didn’t influence survival. Patients with solitary metastases had longer survival compared to multiple lesions (3.6 vs. 2.2 mo). In patients with solitary lesions without brain metastasis, surgical resection was associated with significantly longer survival (6 months vs. 3 months). The overall survival in patients with intramedullary metastasis remains poor. Surgical management may contribute to improved survival and neurologic outcomes in selected patients.

3 Figures , 5 Tables with 1 MR figure and Kaplan Meier plots.