Background and Purpose: Distal medium vessel occlusions (DMVOs) are increasingly considered for endovascular thrombectomy but are difficult to detect on computed tomography angiography (CTA). We aimed to determine whether time-to-maximum of tissue residue function ( Tmax ) maps, derived from CT perfusion, can be used as a triage screening tool to accurately and rapidly identify patients with DMVOs. Methods: Consecutive code stroke patients who underwent multimodal CT were screened retrospectively. Two experienced readers evaluated all patients’ Tmax maps in consensus for presence of delay in an arterial territory (territorial Tmax delay). The diagnostic accuracy of this surrogate for identifying DMVOs was determined using receiver-operating characteristic analysis. CTA, interpreted by 2 experienced neuroradiologists with access to all imaging data, served as the reference standard. Diagnostic performance of 4 other readers with different levels of experience for identifying DMVOs on Tmax versus CTA was also assessed. These readers independently assessed patients’ Tmax maps and CTAs in 2 separate timed sessions, and areas under the receiver-operating characteristic curves were compared using the DeLong algorithm. The Wilcoxon signed-rank test was used to comparatively assess diagnostic speed. Results: Three hundred seventy-three code stroke patients (median age, 70 years; 56% male, 70 with a DMVO) were included. Territorial Tmax delay had a sensitivity of 100% (CI 95 , 94.9%–100%) and specificity of 87.8% (CI 95 , 83.6%–91.3%) for presence of a DMVO, yielding an area under the receiver-operating characteristic curves of 0.939 (CI 95 , 0.920–0.957). All 4 readers achieved sensitivity >95% and specificity >84% for detecting DMVOs using Tmax maps, with diagnostic accuracy (area under the receiver-operating characteristic curves) and speed that were significantly ( P <0.001) higher than on CTA. Conclusions: Territorial Tmax delay had perfect sensitivity and high specificity for a DMVO. Tmax maps were accurately and rapidly interpreted by even inexperienced readers, and causes of false positives are easy to recognize and dismiss. These findings encourage the use of Tmax to identify patients with DMVOs.

BACKGROUND AND PURPOSE: Detecting intracranial distal arterial occlusions on CTA is challenging but increasingly relevant to clinical decision-making. Our purpose was to determine whether the use of CTP-derived time-to-maximum of the tissue residue function maps improves diagnostic performance for detecting these occlusions. MATERIALS AND METHODS:Seventy consecutive patients with a distal arterial occlusion and 70 randomly selected controls who underwent multimodal CT with CTA and CTP for a suspected acute ischemic stroke were included in this retrospective study. Four readers with different levels of experience independently read the CTAs in 2 separate sessions, with and without time-to-maximum of the tissue residue function maps, recording the presence or absence of an occlusion, diagnostic confidence, and interpretation time. Accuracy for detecting distal occlusions was assessed using receiver operating characteristic analysis, and areas under curves were compared to assess whether accuracy improved with use of time-to-maximum of the tissue residue function. Changes in diagnostic confidence and interpretation time were assessed using the Wilcoxon signed rank test. RESULTS:Mean sensitivity for detecting occlusions on CTA increased from 70.7% to 90.4% with use of time-to-maximum of the tissue residue function maps. Diagnostic accuracy improved significantly for the 4 readers (P , .001), with areas under the receiver operating characteristic curves increasing by 0.186, 0.136, 0.114, and 0.121, respectively. Diagnostic confidence and speed also significantly increased. CONCLUSIONS:All assessed metrics of diagnostic performance for detecting distal arterial occlusions improved with the use of time-to-maximum of the tissue residue function maps, encouraging their use to aid in interpretation of CTA by both experienced and inexperienced readers. These findings show the added diagnostic value of including CTP in the acute stroke imaging protocol. ABBREVIATIONS: ACA ¼ anterior cerebral artery; AUC ¼ area under the curve; DVO ¼ distal vessel occlusion; EVT ¼ endovascular thrombectomy; NECT ¼ nonenhanced CT; PCA ¼ posterior cerebral artery; ROC ¼ receiver operating characteristic; Tmax ¼ time to maximum of the tissue residue function; SCA ¼ Superior Cerebellar Artery

Radiology signs have long been described in ways that communicate the imagery around us to enhance our cognitive perception. Here, we describe the use and limitations of 10 such signs in neuroradiology, divided into three groups. The first are signs that are reliable for a specific diagnosis, such as the Medusa head sign indicating a developmental venous anomaly, or a racing car sign in agenesis of corpus callosum. The second group of signs helps us to diagnose rare conditions, such as the onion skin sign in Balo’s concentric sclerosis. The third group is of unreliable signs that may lead clinicians astray. For example, the absence of a swallow-tail sign in Parkinson’s disease or the presence of a hummingbird sign and Mickey Mouse sign in progressive supranuclear palsy. The appropriate use of these signs in clinical practice is essential.

Fig. 1. A) Axial MIP of an MR angiogram and B) 3D surface shaded render of a catheter angiogram showing a vessel (arrowhead) passing from the internal carotid artery (arrow) to the basilar artery (open arrow).

Dilated perivascular spaces in the brain have typical neuroimaging appearances. The classification of dilated perivascular spaces is based on their relationship to blood vessels and is divided into 3 subtypes. A fourth type has been described and termed “opercular perivascular space.” We report on an incidental finding of an opercular perivascular space on MR imaging. Dilated perivascular spaces are benign; it is important to be familiar with their characteristic appearance to prevent reporting them as a neoplasm.

Erratum to ''Is a trident or a bident? Appearance of a primitive trigeminal artery on sagittal views -Question and Is a trident or a bident? Appearance of a primitive trigeminal artery on sagittal views -Answer" [

Fig. 2. A) Lateral digitally subtracted catheter angiogram of a selected internal carotid artery (arrow) injection demonstrating the persistent trigeminal artery (arrowhead) passing posteriorly to join the basilar artery (open arrow). B) Cropped view of the painting ''Concilio degli dei" by Raffaello Sanzio da Urbino depicting Hades holding a bident (left), next to his brother Poseidon holding a trident (middle) [10]. Zeus (right) is also pictured, without a spear.