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22 October 2020, 2:05 pm
Agarwal, S., Conway, J., Nguyen, V., Dogra, S., Krieger, P., Zagzag, D., Lewis, A., Melmed, K., Galetta, S., Jain, R.
BACKGROUND AND PURPOSE:

Various patterns of leukoencephalopathy have been described in coronavirus disease 2019 (COVID-19). In this article, we aimed to describe the clinical and imaging features of acute disseminated leukoencephalopathy in critically ill patients with COVID-19 and the imaging evolution during a short-term follow-up.

MATERIALS AND METHODS:

We identified and reviewed the clinical data, laboratory results, imaging findings, and outcomes for 8 critically ill patients with COVID-19 with acute disseminated leukoencephalopathy.

RESULTS:

All patients demonstrated multiple areas of white matter changes in both cerebral hemispheres; 87.5% (7/8) of patients had a posterior predilection. Four patients (50%) had short-term follow-up imaging within a median of 17 days after the first MR imaging; they developed brain atrophy, and their white matter lesions evolved into necrotizing cystic cavitations. All (8/8) patients had inflammatory cytokine release syndrome as demonstrated by elevated interleukin-6, D-dimer, lactate dehydrogenase, erythrocyte sedimentation rate, C-reactive protein, and ferritin levels. Most (7/8; 87.5%) patients were on prolonged ventilator support (median, 44.5 days; interquartile range, 20.5 days). These patients had poor functional outcomes (6/8 [75%] patients were discharged with mRS 5) and high mortality (2/8, 25%).

CONCLUSIONS:

Critically ill patients with COVID-19 can develop acute disseminated leukoencephalopathy that evolves into cystic degeneration of white matter lesions with brain atrophy during a short period, which we dubbed virus-associated necrotizing disseminated acute leukoencephalopathy. This may be the result of COVID-19-related endothelial injury, cytokine storm, or thrombotic microangiopathy.


22 October 2020, 1:52 pm
Brinjikji, W., Cloft, H. J., Lanzino, G.
BACKGROUND AND PURPOSE:

The pseudophlebitic pattern is an increasingly recognized angiographic manifestation of chronic venous congestion in the setting of a cranial dural arteriovenous fistula. We sought to study the clinical and radiologic manifestations of patients with the pseudophlebitic pattern.

MATERIALS AND METHODS:

We retrospectively reviewed a cohort of patients with dural arteriovenous fistulas evaluated at our institution from 2008 to 2020. Angiograms were reviewed to classify dural arteriovenous fistulas and document the presence or absence of a pseudophlebitic pattern, defined as the presence of serpiginous and tortuous collateral, bridging, and cortical veins with an associated delay in circulation time of the normal brain. We then studied the association between the pseudophlebitic pattern and clinical presentation and MR imaging findings.

RESULTS:

Two hundred one patients were included. Patients with a pseudophlebitic pattern had more hemorrhage (22.8% versus 8.4%, P = .005), gait changes and ataxia (6.0% versus 0.0%, P = 0.002), cognitive changes (6.9% versus 1.4%, P = .04), and seizures (8.6% versus 2.1%, P = .03). On MR imaging, the pseudophlebitic pattern was associated with higher rates of cerebral edema (70.9% versus 2.9%, P < .0001), chronic hemosiderin deposition and microhemorrhage (17.3% versus 2.2%, P = .0002), and dilated transmedullary veins (47.1% versus 0.0%, P < .0001). When we considered only patients with malignant fistulas, there was no difference in hemorrhage at presentation between the 2 groups (22.6% versus 22.8%, P = .99). Patients with a pseudophlebitic pattern did have higher rates of nonhemorrhagic neurologic deficits (24.1% versus 9.4%, P = .03).

CONCLUSIONS:

The pseudophlebitic pattern was associated with high rates of brain parenchymal changes and neurologic symptoms in this cohort of patients with dural arteriovenous fistulas.


15 October 2020, 3:36 pm
Kim, Y. J., Jeong, W.- J., Bae, Y. J., Kim, H., Choi, B. S., Jung, Y. H., Baik, S. H., Sunwoo, L., Kim, J. H.
BACKGROUND AND PURPOSE:

Transoral robotic surgery is an emerging strategy for treating human papillomavirus–positive cancers, but the role of MR imaging in predicting the surgical outcome has not been established. We aimed to identify preoperative MR imaging characteristics that predispose the outcome of transoral robotic surgery toward an insecure (positive or close) surgical margin in human papillomavirus–positive tonsillar squamous cell carcinoma.

MATERIALS AND METHODS:

Between December 2012 and May 2019, sixty-nine patients underwent transoral robotic surgery at our institution. Among these, 29 who were diagnosed with human papillomavirus–positive tonsillar squamous cell carcinoma, did not receive neoadjuvant treatment, underwent preoperative 3T MR imaging, and had postoperative pathologic reports and were included in this retrospective study. Two neuroradiologists evaluated the preoperative MR imaging scans to determine the tumor spread through the pharyngeal constrictor muscle using a 5-point scale: 1, normal constrictor; 2, bulging constrictor; 3, thinning constrictor; 4, obscured constrictor; and 5, tumor protrusion into the parapharyngeal fat. The risk of an insecure surgical margin (involved or <1 mm) according to the MR imaging scores was predicted using logistic regression with the Firth correction.

RESULTS:

The interobserver agreement for the MR imaging scores was excellent ( = 0.955, P < .001). A score of ≥4 could predict an insecure margin with 87.5% sensitivity and 92.3% specificity (area under the curve = 0.899) and was the only significant factor associated with an insecure margin in the multivariable analysis (OR, 6.59; 95% CI, 3.11–22.28; P < .001).

CONCLUSIONS:

The pre-transoral robotic surgery MR imaging scoring system for the pharyngeal constrictor muscle is a promising predictor of the surgical margin in human papillomavirus–positive tonsillar squamous cell carcinoma.


15 October 2020, 3:01 pm
Aiken, A. H.

15 October 2020, 2:46 pm
Seyedsaadat, S. M., Neuhaus, A. A., Pederson, J. M., Brinjikji, W., Rabinstein, A. A., Kallmes, D. F.
BACKGROUND:

Weighting neuroimaging findings based on eloquence can improve the predictive value of ASPECTS, possibly aiding in informed treatment decisions for acute ischemic stroke.

PURPOSE:

Our aim was to study the contribution of region-specific ASPECTS infarction to acute ischemic stroke outcomes.

DATA SOURCES:

We searched MEDLINE and EMBASE for reports on ASPECTS in patients with acute ischemic stroke from 2000 to March 2019.

STUDY SELECTION:

Two investigators independently reviewed articles and extracted data. Three-month poor functional outcome defined as mRS >2 was the primary end point.

DATA ANALYSIS:

A random-effects meta-analysis was performed to compare the association between infarct and mRS >2 among ASPECTS regions. Subanalyses included the following: laterality of stroke (left/right), imaging technique (NCCT or advanced imaging with DWI, CTP, or CTA), and interventional technique (IV-tPA/conservative management or mechanical thrombectomy).

DATA SYNTHESIS:

M6 infarct was most associated with poor functional outcome (OR = 3.26; 95% CI, 2.21–4.80; P < .001). Pair-wise comparisons of ASPECTS regions regarding the association between infarct and mRS >2 were not significant, with the exception of M6 versus lentiform (P = .009). However, pair-wise comparisons among ASPECTS regions were not significant among subgroup analyses.

LIMITATIONS:

Limitations were the heterogeneity of time points, neuroimaging modalities, and interventional techniques; limited studies for inclusion; publication bias among some comparisons; and the retrospective nature of included studies.

CONCLUSIONS:

Our study indicated an unequal impact of some ASPECTS subregions in predicting outcomes of patients with acute ischemic stroke. Stroke laterality, imaging technique, and interventional technique subgroup analyses showed no differences among ASPECTS regions in predicting outcome. Investigation in larger cohorts is required to assess the association of ASPECTS with acute ischemic stroke outcome.