Hemorrhage and calcification are common pathologic components of many intracranial diseases. Reliable differentiation between hemorrhages and calcifications is crucial for accurate diagnosis, prognosis, and therapy optimization. For example, the presence of a hemorrhage may suggest a possible stroke, traumatic brain injury, or a malignant tumor, whereas the presence of calcifications is suggestive of different diseases, such as Sturge-Weber syndrome, tuberous sclerosis, neurocysticercosis, or craniopharyngiomas (1,2). The differentiation of intracranial microbleeds from multiple calcified cysticercus granulomas is essential for choosing an appropriate treatment for patients affected by both neurocysticercosis and hypertension (3).
OBJECTIVE. Spontaneous subarachnoid hemorrhage (SAH) typically prompts a search for an underlying ruptured saccular aneurysm, which is the most common nontraumatic cause. Depending on the clinical presentation and pattern of SAH, the differential diagnosis may include a diverse group of causes other than aneurysm rupture.
OBJECTIVE. The objective of this article is to describe an approach to imaging CSF shunts. Topics reviewed include the components and imaging appearances of the most common types of shunts and the utility of different imaging modalities for the evaluation of shunt failure. Complications discussed include mechanical failure, infection, ventricular loculation, overdrainage, and unique complications related to each shunt type.
OBJECTIVE. Varying anatomic characteristics and clinical and radiologic manifestations are diagnostic challenges in the evaluation of the cerebral vein and of venous sinus diseases. The purpose of this article is to introduce bone subtraction CT venography and review normal variations and diseases involving the cerebral veins and venous sinuses.
Background: Given the controversy regarding whether carotid endarterectomy (CEA) or carotid artery stenting (CAS) may be superior for stroke prevention, it is uncertain how recent clinical evidence, guidelines, and reimbursement policies have influenced the volume and outcomes after these procedures.
Objectives: This study sought to randomly compare cerebral protection with ANGIOGUARD (Cordis Corporation, Bridgewater, New Jersey) with Mo.Ma (Invatec/Medtronic Vascular Inc, Santa Rosa, California) during carotid artery stenting (CAS), using diffusion-weighted magnetic resonance imaging (DW-MRI) to detect new ischemic cerebral lesions. The number, size, and location of lesions were analyzed.
Objectives: The purpose of the prospective, multicenter, nonrandomized CABANA study was to evaluate periprocedural clinical outcomes in high surgical risk patients with carotid artery stenosis treated with the Carotid WALLSTENT plus FilterWire EZ Embolic Protection System by a diverse group of clinicians.
Background: Recurrent vascular events remain a major source of morbidity and mortality after stroke or transient ischemic attack (TIA). The IRIS Trial is evaluating an approach to secondary prevention based on the established association between insulin resistance and increased risk for ischemic vascular events. Specifically, IRIS will test the effectiveness of pioglitazone, an insulin-sensitizing drug of the thiazolidinedione class, for reducing the risk for stroke and myocardial infarction (MI) among insulin resistant, nondiabetic patients with a recent ischemic stroke or TIA.
Multiple randomized, controlled trials have shown the efficacy of the use of intravenous tissue plasminogen activator (t-PA), administered up to 4.5 hours after the onset of symptoms of acute ischemic stroke.1,2 However, the global effect of this therapy has been limited, largely because of the narrow time window available for treatment and the risk of symptomatic intracerebral hemorrhage. Although endovascular approaches, including thrombectomy devices, have been shown to achieve greater rates of recanalization than the use of intravenous t-PA, no randomized, controlled trial has been completed comparing clinical outcomes versus standard medical care. Moreover, the potential to benefit from interventions in late time windows (≥3 hours) may be increased when they are coupled with brain imaging to select patients who are the most likely to benefit.
Intravenous recombinant tissue plasminogen activator (t-PA) is the standard treatment for acute ischemic stroke, but more than half the treated patients do not recover completely or die.1 Alternative treatments, such as endovascular treatment, have been used for many years. As compared with endovascular treatment, intravenous thrombolysis is associated with a lower probability of recanalization2-9 (46% of cases with intravenous t-PA vs. >80% with endovascular treatment10-15). Nevertheless, the two approaches have not been directly compared, recanalization is not invariably associated with a favorable clinical outcome,16 and it is not known whether clinical outcomes are superior with endovascular therapy as compared with intravenous t-PA.
Intravenous alteplase administered within 4.5 hours after symptom onset is the only reperfusion therapy with proven efficacy in patients with acute ischemic stroke.1 However, well-recognized limitations of this therapy include the narrow therapeutic time window and contraindications such as recent surgery, coagulation abnormalities, and a history of intracranial hemorrhage.2 Moreover, intravenous alteplase appears to be much less effective at opening proximal occlusions of the major intracranial arteries, which account for more than one third of cases of acute anterior-circulation stroke.3,4 Early recanalization after intravenous alteplase is seen in only about one third of patients with an occlusion of the internal-carotid-artery terminus,5 and the prognosis without revascularization is generally poor for such patients.6 For these reasons, intraarterial treatment is regarded as a potentially important component of the therapeutic armamentarium.
Three-dimensional (3D) rotational digital subtraction angiography (DSA) currently is considered the “gold standard” for the detection of cerebral aneurysms (1,2). However the technique is invasive, time consuming, technically demanding, relatively expensive, and has a 0.12% rate of permanent neurologic complication according to results of a previous prospective, randomized trial (3). Thus, developing an accurate, noninvasive diagnostic imaging modality for aneurysms is an important issue.
Background—Meaningful delays occurred in the Interventional Management of Stroke (IMS) III trial. Analysis of the work flow will identify factors contributing to the in-hospital delays.
A blood clot in the veins that drain the blood from the brain is called a sinus or cerebral vein thrombosis. It is an uncommon type of clot, affecting about 1500 people in the United States per year.
Background—Limited long-term follow-up data exist on the impact of appropriate secondary prevention therapies on cognitive function in patients after first-ever stroke. The aim of this study is to determine the effect of secondary prevention of vascular events on cognitive function after stroke.
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