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BACKGROUND Endovascular surgery is the first-line treatment for indirect cavernous carotid fistulae (CCFs). This study compares multiple treatment techniques. OBJECTIVE To compare endovascular techniques for indirect CCF treatment. METHODS Retrospective analysis was performed of prospectively maintained records at 4 centers, identifying patients undergoing indirect CCF embolization. Demographics, symptoms, and lesion characteristics were recorded. Medical records were reviewed for changes in symptoms, delayed complications, and angiographically proven recurrence. Univariate and multivariate analyses were performed to identify impacts of the above characteristics on outcomes. RESULTS Sufficient records were available for 267 patients treated between January 1987 and December 2016. Obliteration was achieved in 86.5% patients, occurring in 86.9% of exclusively transvenous treatments and 79.5% of other treatments. Obliteration rates were highest following transvenous embolization using coils compared to all other materials (likelihood ratio [LR] 5.0, P = .024). Complications were less common with coil embolization compared to other materials (LR 0.070, P < .001). Embolization with liquid embolics resulted in higher complication rates (LR 10.2, P = .002), although risk was reduced when used in conjunction with coils. Angiographically confirmed recurrence was more common following embolization with polyvinyl alcohol (LR 9.9, P = .004) and when multiple embolic agents were used (LR 6.6, P = .018). Delayed development of symptoms following embolization was less common following embolization with coils (LR 0.20, P = .030) and more common following embolization with liquids (LR 6.5, P = .014). CONCLUSION To treat indirect CCFs, transvenous coil embolization is the safest and most effective technique. Liquid embolics are less effective and have more complications and should be carefully considered only in extenuating circumstances.

Summary:Purpose: To examine the subgroup of patients with medically intractable epilepsy receiving temporal lobectomies who have pathologically verified mesial temporal sclerosis (MTS) and to determine the relation of demographic and clinical factors, results of diagnostic testing, and details of the surgical procedure with prognosis for achieving control of seizures.Methods: All patients receiving surgical treatment for intractable epilepsy between 1991 and 1998 at the University of Washington were reviewed. There were 118 patients who met inclusion criteria of adequate pathological analysis showing MTS without a progressive process and a minimum of 1-year follow-up.Results: Only personal history of status epilepticus demonstrated significant (p ‫ס‬ 0.0276) prediction of outcome, increasing the risk of surgical failure. No other factors were significant predictors of outcome, including history of febrile seizures, possible etiologic factors, EEG, magnetic resonance imaging (MRI) or neuropsychological testing results, or extent of resection.Conclusions: Many factors that have been previously described to predict favorable outcome in the overall group of patients receiving temporal lobe resections for intractable epilepsy are, in fact, predictors of MTS and lose their predictive value when the subgroup of patients with confirmed MTS is examined. Neurosurgical treatment of MTS can be very effective even in the presence of significant etiologic factors, or of bilateral or extratemporal abnormalities on EEG or MRI.

Background and Purpose Our goal is to determine the added value of intracranial vessel wall MRI (IVWI) in differentiating non-occlusive vasculopathies compared to luminal imaging alone. Methods We retrospectively reviewed images from patients with both luminal and IVWI to identify cases with clinically defined intracranial vasculopathies: atherosclerosis (ICAD), reversible cerebral vasoconstriction syndrome (RCVS) and inflammatory vasculopathy (IVas). Two neuroradiologists blinded to clinical data reviewed the luminal imaging of defined luminal stenoses/irregularities and evaluated the pattern of involvement to make a presumed diagnosis with diagnostic confidence. Six weeks later, the 2 raters re-reviewed the luminal imaging in addition to IVWI for the pattern of wall involvement, presence and pattern of post-contrast enhancement, and presumed diagnosis and confidence. Analysis was performed on a per-lesion and per-patient basis. Results 30 ICAD, 12 IVas and 12 RCVS patients with 201 lesions (90 ICAD, 64 RCVS and 47 IVas) were included. For both per-lesion and per-patient analyses, there was significant diagnostic accuracy improvement with luminal imaging+IVWI when compared to luminal imaging alone (per-lesion: 88.8% vs. 36.1%, p<.001, per-patient: 96.3% vs. 43.5%, p<.001), respectively. There was substantial inter-rater diagnostic agreement for luminal imaging+IVWI (κ 0.72) and only slight agreement for luminal imaging (κ 0.04). While there was a significant correlation for both luminal and IVWI pattern of wall involvement with diagnosis, there was a stronger correlation for IVWI finding of lesion eccentricity and ICAD diagnosis than for luminal imaging (κ 0.69 vs. 0.18, p<.001). Conclusion IVWI can significantly improve the differentiation of non-occlusive intracranial vasculopathies when combined with traditional luminal imaging modalities.

Background and Purpose Although studies have evaluated the differential imaging of moyamoya disease and atherosclerosis, none have investigated the added value of vessel-wall MRI. The current study evaluates the added diagnostic value of vessel-wall MRI in differentiating moyamoya disease (MMD), atherosclerotic-moyamoya syndrome (A-MMS) and vasculitic-moyamoya syndrome (V-MMS) with a multi-contrast protocol. Methods We retrospectively reviewed the carotid artery territories of patients with clinically defined vasculopathies (MMD, atherosclerosis, vasculitis) and steno-occlusive intracranial carotid disease. Two neuroradiologists, blinded to clinical data reviewed the luminal imaging of each carotid, evaluating collateral extent and making a presumed diagnosis with diagnostic confidence. After three weeks, the two readers reviewed the luminal imaging+vessel-wall MRI for presence, pattern and intensity of post-contrast enhancement, T2 signal characteristics, pattern of involvement, presumed diagnosis and confidence. Results Ten A-MMS, three V-MMS and eight MMD cases with 38 affected carotid segments were included. There was significant improvement in diagnostic accuracy with luminal imaging+vessel-wall MRI as compared to luminal imaging (87% vs. 32%, p<.001). The most common vessel-wall MRI findings for MMD were non-enhancing, non-remodeling lesions without T2 heterogeneity; for A-MMS eccentric, remodeling, and T2 heterogeneous lesions with mild/moderate and homogeneous/heterogeneous enhancement; and for V-MMS concentric lesions with homogeneous, moderate enhancement. Inter-reader agreement was moderate to substantial for all vessel-wall MRI characteristics (κ=0.46-0.86) and fair for collateral grading (κ=0.35). There was 11% inter-reader agreement for diagnosis on luminal imaging as compared to 82% for luminal imaging+vessel-wall MRI (p<.001). Conclusion Vessel-wall MRI can significantly improve the differentiation of moyamoya vasculopathies when combined with traditional imaging techniques.

Conclusion:The arterial phase of computed tomography (CT) imaging is not necessary for routine detection of endoleaks. This portion of CT evaluation after endovascular AAA repair can be eliminated, with a reduction in radiation exposure.Summary: This was a retrospective analysis performed of arterial and venous phases of CT scans evaluating for endoleak in patients with endovascular repair of an abdominal aortic aneurysm (AAA). The purpose was to determine if the arterial phase of CT scanning for evaluation of endoleak can be potentially eliminated, thus lowering radiation exposure. The authors analyzed 85 patients (66 men and 19 women; mean age, 66 years) who underwent endovascular repair of an AAA. There were 110 multidetector CT examinations available for analysis. The CT protocol for endoleak evaluation included first obtaining a noncontrast, enhanced set of CT images. After this, intravenous contrast material was administered, and both arterial and venous phase images were obtained.Nonenhanced and venous phase images were evaluated to determine if an endoleak was present. Arterial phase images were analyzed separately. It was then determined how often the arterial phase imaging contributed to the diagnosis of endoleak.A total of 28 type II endoleaks were detected with a combination of nonenhanced and venous phase CT acquisitions. Of these 28 endoleaks, 25 endoleaks were also visualized during the arterial phase of the CT scan, with three type II endoleaks only seen during the venous phase. No additional endoleaks were seen with the arterial phase. Seventy-eight scans from 67 patients revealed no endoleak during the venous phase; and in these scans, no endoleaks were discovered with the arterial phase images. The arterial phase of the CT scan was responsible for 36.5% of the radiation exposure during the combination of noncontrast, venous, and arterial phase images.Comment: The radiation administered during a diagnostic CT scan is associated with low, but not zero, health risk. This radiation has been linked to an increase in life-long risk of cancer (Radiology 2004;232:735-8). Because type II endoleaks are relatively benign, the increased radiation dose of arterial phase acquisitions does not seem warranted. Additional data are required to know whether the arterial phase acquisitions may, however, remain necessary to detect small type I or type III endoleaks.

The results of ARUBA-eligible and unruptured grade I/II patients overall show that excellent outcomes can be obtained in this subgroup of patients, especially with surgical management. Functional outcomes for ARUBA-eligible patients were similar to those of patients who were randomized to medical management in ARUBA. On the basis of these data, in appropriately selected patients, we recommend treatment for low-grade BAVMs.

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