Editor’s Choices
Blood-Brain Barrier Permeability Assessed by Perfusion CT Predicts Symptomatic Hemorrhagic Transformation and Malignant Edema in Acute Ischemic Stroke • J. Hom, J.W. Dankbaar, B.P. Soares, T. Schneider, S.-C. Cheng, J. Bredno, B.C. Lau, W. Smith, W.P. Dillon, and M. Wintermark
Symptomatic hemorrhagic transformation and malignant edema are the most feared complications of cerebral infarction, particularly after systemic thrombolysis; why are patients prone to develop them? These investigators retrospectively analyzed data obtained from 32 patients and gave special attention to the permeability of the blood-brain barrier (as measured by perfusion CT). Six patients developed SHT and/or ME and most had received either intravenous or intra-arterial tPA plus mechanical clot retrieval. Abnormal admission BBB permeability measurements were 100% sensitive and 79% specific in identifying patients who developed these dreaded complications. Also, all of these patients were older than 65 years of age.
Proton MR Spectroscopy Provides Relevant Prognostic Information in High-Grade Astrocytomas • C. Majós, J. Bruna, M. Julià-Sapé, M. Cos, Á. Camins, M. Gil, J.J. Acebes, C. Aguilera, and C. Arús
The range of survival in patients with high-grade astrocytomas varies and cannot be explained based only on histology. We now know that this variation is accounted for in many tumors by their genetic differences. Here, the authors tried to assess the predictive value of single-voxel proton MR spectroscopy in high-grade astrocytomas and evaluated 180 patients using both short and long TE MRS. They then divided the patients into 2 simple groups: those above median survival were designated as having good survival and those below it as having poor survival (nearly equal numbers in both groups). For analysis, they chose 2 locations in each long and short TE study with the former corresponding to lipid resonances and the latter to lipids and possibly sugars (as well as other less well-defined metabolites). They also acknowledged some possible contributions of lactate, which is known to precede neovascular activity in high-grade astrocytoma. Basically, higher lipids and depletion of glucose indicated a poorer prognosis as both are related to more aggressive behavior. Another important observation was that even treated tumors showed the same spectroscopic behavior and a corresponding poor prognosis.
Does Current Practice in the United States of Carotid Artery Stent Placement Benefit Asymptomatic Octogenarians? • K.C. Young and B.S. Jahromi
For both of these interventions to be considered successful, the rate of death/stroke needs to be less than 3% in the 30 days that follow the procedures. Though endarterectomy for asymptomatic stenoses has been extensively assessed, many patients are choosing stenting, a less well-evaluated procedure. Morbidity and mortality are known to increase with age for both procedures and because our patient population is getting older, the authors decided to look into the benefits of carotid stenting in individuals older than 80 years. They studied more than 30,000 patients obtained via a Nationwide Inpatient Sample. Both complication and death (4.9% vs 3.8%) rates were higher for those treated by stenting than for patients who had open surgery. Cost was also higher for stenting than for surgery. The authors concluded that in octogenarians, stenting does not improve the natural history of the disease.
Fellows’ Journal Club
Cerebral Microhemorrhages Detected by Susceptibility-Weighted Imaging in Amateur Boxers • Z.I. Hasiloglu, S. Albayram, H. Selcuk, E. Ceyhan, S. Delil, B. Arkan, and L. Baskoy
Brain damage induced by contact sports, particularly football, has been the topic of several scientific and nonscientific publications lately. A few days ago, I was looking at some recent pictures of Muhammad Ali and they reminded me of this article. Chronic traumatic brain injury is probably due, at least partly, to axonal damage but is notoriously difficult to objectively document. Here, the authors used susceptibility-weighted imaging (and other sequences) to look for microbleeds in 21 boxers and a similar number of controls. Microhemorrhages were present in nearly 10% of boxers, but their numbers were not statistically different from those found in controls. These bleeds were not seen on T2 fast spin-echo and T2* sequences. Boxers did have a significantly higher incidence of perivascular spaces and of cavum septum but no more atrophy. So, something is happening to these brains but microhemorrhages as seen on SWI are not markers of disease.
Injury to the Vertebral Endplate-Disk Complex Associated with Osteoporotic Vertebral Compression Fractures • A.O. Ortiz and R. Bordia
Extensive attention has been given to the features of fractured vertebral bodies to determine if an injury is acute or chronic, but the disk itself has received little notice. Here, the authors performed a retrospective analysis of 211 acute compression vertebral body fractures as seen on MR imaging studies and noted the findings in the endplate and disks. Thirty percent of affected vertebrae showed injured endplates, more commonly the superior ones. Thirty-six percent of fractures showed injury to the superior disk and 15% to the inferior one. Abnormalities in the endplates and/or disks were not mentioned in any of the original reports. Vertebral endplate injury is commonly seen in osteoporotic vertebral compression fractures. Furthermore, this is frequently associated with injury to the adjacent intervertebral disk. These findings are often under-reported but should be described because they may have important implications for symptomatic presentation, patient management, and outcomes.
Posterior Circulation and High Prevalence of Ischemic Stroke among Young Pediatric Patients with Moyamoya Disease: Evidence of Angiography-Based Differences by Age at Diagnosis • S. Mugikura, S. Higano, R. Shirane, M. Fujimura, Y. Shimanuki, and S. Takahashi
We all know the infratentorial arteries are never involved in Moyamoya disease whereas the posterior cerebral ones are commonly affected. These authors sought to determine whether age-related differences in clinical manifestations were associated with age-related angiographic differences in 78 patients. In patients younger than 4 years of age, the prevalence of infarctions on MR images was highest, and along with severity of steno-occlusive lesions of the posterior cerebral artery, the prevalence was significantly higher than in older children (aged 4–7 years). The severity of steno-occlusive lesions in the internal carotid artery and the degree of transdural collaterals did not differ significantly. The prevalence of infarctions did not differ significantly in older children whereas ICA and PCA lesions and transdural collaterals correlated positively with diagnostic age. In conclusion, the high prevalence of infarctions diagnosed before 4 years of age and is associated with advanced steno-occlusive lesions of the PCA. In patients 4 years and older at diagnosis, transdural collaterals develop in parallel with advancement of ICA and PCA lesions, which may contribute to the nearly constant prevalence of completed strokes with permanent neurologic deficit.
