The Role of 3 Tesla MRA in the Detection of Intracranial Aneurysms

Intracranial aneurysms constitute a common pathological entity, affecting approximately 1–8% of the general population. Their early detection is essential for their prompt treatment. Digital subtraction angiography is considered the imaging method of choice. However, other noninvasive methodologies such as CTA and MRA have been employed in the investigation of patients with suspected aneurysms. MRA is a noninvasive angiographic modality requiring no radiation exposure. However, its sensitivity and diagnostic accuracy were initially inadequate. Several MRA techniques have been developed for overcoming all these drawbacks and for improving its sensitivity. 3D TOF MRA and contrast-enhanced MRA are the most commonly employed techniques. The introduction of 3 T magnetic field further increased MRA's sensitivity, allowing detection of aneurysms smaller than 3 mm. The development of newer MRA techniques may provide valuable information regarding the flow characteristics of an aneurysm. Meticulous knowledge of MRA's limitations and pitfalls is of paramount importance for avoiding any erroneous interpretation of its findings

Surgical Management of Patients with Chiari I Malformation

Chiari malformations (CMs) constitute a variety of four mainly syndromes (I, II, III, and IV), which describe the protrusion of brain tissue into the spinal canal through the foramen magnum. These malformations frequently occur in combination with other pathological entities such as myelomeningocele, hydrocephalus, and/or hydrosyringomyelia. The recent improvement of imaging techniques has increased not only the rate of CM diagnosis but also the necessity for its early treatment. Several different surgical techniques have been employed in the treatment of patients with symptomatic CM-I. In our current study, a systematic and critical review of the pertinent literature was made for identifying the most commonly employed surgical procedures in the management of these patients. Emphasis was given in outlining the advantages and disadvantages of each surgical approach. Moreover, an attempt was made for defining those parameters that may be prognostic factors for their surgical outcome. There is a consensus that surgical treatment is reserved only for symptomatic patients with CM-I. It has also been postulated that early surgically intervention is usually associated with better outcome. Despite the large number of previously published clinical series, further clinical research with large-scale studies is necessary for defining surgical treatment guidelines in these patients

Intradural extramedullary Ewing's sarcoma: A case report and review of the literature

Introduction Extra-skeletal Ewing's sarcomas are very rare lesions to the spine surgeon, with the intradural, extramedullary lesions being even rarer. Herein we present a patient with an intradural, extramedullary form of Ewing's sarcoma and review the relevant literature. The medical records, operative reports, radiographical studies and histological examinations of a single patient are retrospectively reviewed. Case report A 31-year old male presented with back-pain, right-leg progressive paraparesis, and inability to walk. Both motor and sensory disturbances were revealed on the right leg at the clinical examination. Lumbar MRI showed two lesions. The first one was an intradural, extramedullary lesion at the L2-L3 level, while the second was smaller, located at the bottom of the dural sac. The patient underwent gross total resection of the L2-L3 lesion after a bilateral laminectomy. Histological examination was compatible with Ewing's sarcoma, and was verified by molecular analysis. No other extra-skeletal or skeletal lesion was found. A chemotherapy scheme was tailored to the patients’ histological diagnosis. The patient presented with local recurrence and bone metastasis 2 years after his initial diagnosis. A second operation was performed and the follow up of the patient showed no disease progression 18 months after revision surgery. Conclusion The spine surgeon should be aware of the existence of such rare entities, in order to timely fulfill the staging process and institute the proper therapy. The management of patients with extra-skeletal Ewing's sarcomas involves professionals as members of a multidisciplinary team, all of which should co-operate for the patient's optimal outcome

A cervical ligamentum flavum cyst in an 82-year-old woman presenting with spinal cord compression: a case report and review of the literature

<p>Abstract</p> <p>Introduction</p> <p>We report on a very rare case of a cervical ligamentum flavum cyst, which presented with progressive myelopathy and radiculopathy. The cyst was radically extirpated and our patient showed significant recovery. A review of the relevant literature yielded seven cases.</p> <p>Case presentation</p> <p>An 82-year-old Greek woman presented with progressive bilateral weakness of her upper extremities and causalgia, cervical pain, episodes of upper extremity numbness and significant walking difficulties. Her neurological examination showed diffusely decreased motor strength in both her upper and lower extremities. Magnetic resonance imaging of her cervical spine demonstrated a large, well-demarcated cystic lesion on the dorsal aspect of her spinal cord at the C3 to C4 level, significantly compressing the spinal cord at this level, in close proximity to the yellow ligament and the C3 left lamina. The largest diameter of this lesion was 1.4 cm, and there was no lesion enhancement after the intravenous administration of a paramagnetic contrast. The lesion was surgically removed after a bilateral C3 laminectomy. The thick cystic wall was yellow and fibro-elastic in consistency, while its content was gelatinous and yellow-brownish. A postoperative cervical-spine magnetic resonance image was obtained before her discharge, demonstrating decompression of her spinal cord and dural expansion. Her six-month follow-up evaluation revealed complete resolution of her walking difficulties, improvement in the muscle strength of her arms (4+/5 in all the affected muscle groups), no causalgia and a significant decrease in her preoperative upper extremity numbness.</p> <p>Conclusion</p> <p>Cervical ligamentum flavum cysts are rare benign lesions, which should be included in the list of differential diagnosis of spinal cystic lesions. They can be differentiated from other intracanalicular lesions by their hypointense appearance on T₁-weighted and hyperintense appearance on T₂-weighted magnetic resonance images, with contrast enhancement of the cystic wall. Surgical extirpation of the cyst is required for symptom alleviation and decompression of the spinal cord. The outcome of these cysts is excellent with no risk of recurrence.</p

EndoVAscular treatment and ThRombolysis for Ischemic Stroke Patients (EVA-TRISP) registry: basis and methodology of a pan-European prospective ischaemic stroke revascularisation treatment registry.

PURPOSE The Thrombolysis in Ischemic Stroke Patients (TRISP) collaboration was a concerted effort initiated in 2010 with the purpose to address relevant research questions about the effectiveness and safety of intravenous thrombolysis (IVT). The collaboration also aims to prospectively collect data on patients undergoing endovascular treatment (EVT) and hence the name of the collaboration was changed from TRISP to EVA-TRISP. The methodology of the former TRISP registry for patients treated with IVT has already been published. This paper focuses on describing the EVT part of the registry. PARTICIPANTS All centres committed to collecting predefined variables on consecutive patients prospectively. We aim for accuracy and completeness of the data and to adapt local databases to investigate novel research questions. Herein, we introduce the methodology of a recently constructed academic investigator-initiated open collaboration EVT registry built as an extension of an existing IVT registry in patients with acute ischaemic stroke (AIS). FINDINGS TO DATE Currently, the EVA-TRISP network includes 20 stroke centres with considerable expertise in EVT and maintenance of high-quality hospital-based registries. Following several successful randomised controlled trials (RCTs), many important clinical questions remain unanswered in the (EVT) field and some of them will unlikely be investigated in future RCTs. Prospective registries with high-quality data on EVT-treated patients may help answering some of these unanswered issues, especially on safety and efficacy of EVT in specific patient subgroups. FUTURE PLANS This collaborative effort aims at addressing clinically important questions on safety and efficacy of EVT in conditions not covered by RCTs. The TRISP registry generated substantial novel data supporting stroke physicians in their daily decision making considering IVT candidate patients. While providing observational data on EVT in daily clinical practice, our future findings may likewise be hypothesis generating for future research as well as for quality improvement (on EVT). The collaboration welcomes participation of further centres willing to fulfill the commitment and the outlined requirements

THE CONTRIBUTION OF MRA IN THE EVALUATION OF TRANSIENT ISCHEMIC ATTACKS

TRANSIENT ISCHEMIC ATTACKS ARE ONE OF THE MOST COMMON CAUSES OF DEATH IN CIVILIZED POPULATIONS, 90% OF WHICH ARE DUE TO ATHEROSCLEROTIC ARTERIAL DISEASE. THEPREDILECTION OF ATHEROSCLEROTIC DISEASE IS VERY IMPORTANT. THE PURPOSE OF THIS STUDY WAS TO EVALUATE THE CONTRIBUTION OF MRA AS A NONINVASIVE METHOD IN THEDIAGNOSIS OF ATHEROSCLEROTIC DISEASE. THIS STUDY STARTED IN 1990 WHEN MRA WAS STILL IN THE BEGINNING. 40 PATIENTS (80 CAROTIDS) WERE EXAMINED WITH TIAS AND THEY UNDERWENT DOPPLER ULTRASOUND, MRA AND MRI AND 14 OF THEM ALSO UNDERWENT DSA. THESE PATIENTS HAD A MEAN AGE OF 59 YEARS. MRA CAN BE PERFORMED IN SHORT EXAMINATION TIMES TOGETHER WITH A ROUTINE MRI BRAIN STUDY AND IS SENSITIVE TO ATHEROSCLEROTIC DISEASE OF THE NECK VESSELS. MRA SHOWS POTENTIAL AS A NONINVASIVE SCREENING MODALITY OF ATHEROSCLEROTIC DISEASE OF THE CAROTID AND VERTEBRAL ARTERIES BUT ALSO FOR THE EVALUATION OF THE INTRACRANIAL VESSELS.Η ΙΣΧΑΙΜΙΚΗ ΕΓΚΕΦΑΛΙΚΗ ΑΠΟΠΛΗΞΙΑ ΟΦΕΙΛΕΤΑΙ ΚΑΤΑ 90% ΣΕ ΑΡΤΗΡΙΟΣΚΛΗΡΩΤΙΚΗ ΝΟΣΟ ΤΩΝ ΚΑΡΩΤΙΔΩΝ. Η ΑΠΕΙΚΟΝΙΣΗ ΤΩΝ ΑΓΓΕΙΩΝ ΓΙΝΕΤΑΙ ΜΕ ΕΠΕΜΒΑΤΙΚΕΣ ΚΑΙ ΜΗ ΕΠΕΜΒΑΤΙΚΕΣ ΜΕΘΟΔΟΥΣ. ΟΙ ΕΠΕΜΒΑΤΙΚΕΣ ΜΕΘΟΔΟΙ ΟΠΩΣ Η ΑΓΓΕΙΟΓΡΑΦΙΑ ΠΑΡΟΥΣΙΑΖΟΥΝ ΟΡΙΣΜΕΝΕΣΕΠΙΠΛΟΚΕΣ. ΣΚΟΠΟΣ ΤΗΣ ΠΑΡΟΥΣΑΣ ΜΕΛΕΤΗΣ ΕΙΝΑΙ ΝΑ ΑΞΙΟΛΟΓΗΣΕΙ ΤΗΝ ΣΥΜΒΟΛΗ ΤΗΣ ΜΑΓΝΗΤΙΚΗΣ ΑΓΓΕΙΟΓΡΑΦΙΑΣ ΩΣ ΜΕΘΟΔΟΥ ΜΗ ΕΠΕΜΒΑΤΙΚΗΣ, ΣΤΗΝ ΔΙΑΓΝΩΣΗ ΤΗΣ ΑΘΗΡΩΜΑΤΙΚΗΣ ΝΟΣΟΥ ΤΩΝ ΚΑΡΩΤΙΔΩΝ, ΣΥΓΚΡΙΝΟΝΤΑΣ ΤΑ ΕΥΡΗΜΑΤΑ ΤΗΣ ΜΕ ΑΥΤΑ ΤΟΥ ΥΠΕΡΗΧΟΓΡΑΦΗΜΑΤΟΣ ΕΞΕΤΑΖΟΝΤΑΣ 40 ΑΣΘΕΝΕΙΣ ΠΟΥ ΠΡΟΣΗΛΘΑΝ ΜΕ ΣΥΜΠΤΩΜΑΤΟΛΟΓΙΑ ΠΑΡΟΔΙΚΗΣ ΙΣΧΑΙΜΙΚΗΣ ΕΓΚΕΦΑΛΙΚΗΣ ΑΠΟΠΛΗΞΙΑΣ. ΚΑΤΑΛΗΓΟΥΜΕ ΣΤΟ ΟΤΙ Η ΥΠΕΡΗΧΗΤΙΚΗ ΑΡΤΗΡΙΟΓΡΑΦΙΑ ΑΝΑΔΕΙΚΝΥΕΙ ΣΑΦΩΣ ΤΟ ΒΑΘΜΟ ΣΤΕΝΩΣΗΣ ΚΑΙ ΤΗΝ ΥΦΗ ΤΗΣ ΑΘΗΡΩΜΑΤΙΚΗΣ ΠΛΑΚΑΣ. Η ΜΑΓΝΗΤΙΚΗ ΑΓΓΕΙΟΓΡΑΦΙΑ ΜΠΟΡΕΙ ΝΑ ΧΡΗΣΙΜΟΠΟΙΗΘΕΙ ΣΑΝ ΑΝΙΧΝΕΥΤΙΚΗ ΜΕΘΟΔΟΣ ΣΤΕΝΩΣΕΩΣ ΑΓΓΕΙΩΝ. ΑΠΟΤΕΛΕΙ ΜΙΑ ΑΞΙΟΠΙΣΤΗ ΜΗ ΕΠΕΜΒΑΤΙΚΗ ΤΕΧΝΙΚΗ ΓΙΑ ΤΗΝ ΑΠΕΙΚΟΝΙΣΗ ΤΩΝ ΕΞΩΚΡΑΝΙΩΝ ΚΑΙ ΕΝΔΟΚΡΑΝΙΩΝ ΑΓΓΕΙΩΝ. Ο ΣΥΝΔΥΑΣΜΟΣ ΤΗΣ ΜΑΓΝΗΤΙΚΗΣ ΑΓΓΕΙΟΓΡΑΦΙΑΣ ΚΑΙ ΤΗΣ ΥΠΕΡΗΧΗΤΙΚΗΣ ΑΡΤΗΡΙΟΓΡΑΦΙΑΣ ΜΠΟΡΕΙ ΝΑ ΕΛΑΧΙΣΤΟΠΟΙΗΣΟΥΝ ΤΗΝ ΑΝΑΓΚΗ ΓΙΑ ΕΝΔΑΡΤΗΡΙΑΚΗ ΨΗΦΙΑΚΗ ΕΚΛΕΚΤΙΚΗ ΑΓΓΕΙΟΓΡΑΦΙΑ, ΙΔΙΩΣ ΣΕ ΑΣΘΕΝΕΙΣ ΟΙ ΟΠΟΙΟΙ ΠΑΡΟΥΣΙΑΖΟΥΝ ΑΝΤΕΝΔΕΙΞΕΙΣ ΓΙΑ ΤΗΝ ΜΕΘΟΔΟ ΑΥΤΗ