WEB Treatment of Ruptured Intracranial Aneurysms

Fellows’ Journal Club

This observational cohort study evaluated 32 patients with 32 acutely ruptured aneurysms endovascularly treated with the Woven EndoBridge (WEB) device. The mean aneurysm size was 4.9 mm, with 14 less than or equal to 4 mm, and most had a wide neck. All aneurysms were adequately occluded, and there were no procedural ruptures or complications related to the WEB device. No adjunctive stents or balloons were needed. Seven patients with poor clinical grade died during hospital admission due to the sequelae of their subarachnoid hemorrhage. The authors conclude that WEB treatment of small ruptured aneurysms was safe and effective without the need for anticoagulation, adjunctive stents, or balloons.


Figure 3 from paper
A 57-year-old woman with a ruptured anterior communicating artery aneurysm. A, 3D angiogram shows a small anterior communicating artery aneurysm. Note the spasm in the left A1. B, Measurement of the height (3.9 mm) and neck width (2.3 mm). C, Angiogram directly after placement of a 4-mm WEB-SLS. Note some opacification inside the WEB. D, Angiogram at 3 months demonstrates complete occlusion of the aneurysm.


The Woven EndoBridge (WEB) device was recently introduced for intrasaccular treatment of wide-neck aneurysms without the need for adjunctive support. We present our first experience in using the WEB for small ruptured aneurysms.


During 11 months, 32 of 71 (45%) endovascularly treated acutely ruptured aneurysms were treated with the WEB. The patients were 12 men and 20 women, with a mean age of 61 years (range, 34–84 years). The mean aneurysm size was 4.9 mm, and 14 were ≤4 mm. Of 32 aneurysms, 24 (75%) had a wide neck.


All 32 aneurysms were adequately occluded after WEB placement. There were no procedural ruptures and no complications related to the WEB device. No adjunctive stents or balloons

Quantitative Susceptibility Mapping and R2* Measured Changes during White Matter Lesion Development in Multiple Sclerosis: Myelin Breakdown, Myelin Debris Degradation and Removal, and Iron Accumulation

Editor’s Choice

The authors characterized lesion changes on quantitative susceptibility mapping and R2* at various gadolinium enhancement stages (nodular, shell-like, nonenhancing) in 64 patients with 203 lesions. They found that: 1) active MS lesions with nodular enhancement show R2* decrease but no quantitative susceptibility mapping change; 2) late active lesions with peripheral enhancement show R2* decrease and quantitative susceptibility mapping increase in the lesion center; and 3) nonenhancing lesions show both quantitative susceptibility mapping and R2* increase, reflecting iron accumulation.

Imaging of Cerebrovascular Disease: A Practical Guide

Runge VM. Imaging of Cerebrovascular Disease: A Practical Guide. Thieme; 2016; 160 pp; 711 ill; $79.99

Cover of Imaging of Cerebrovascular Disease

In a short, easy-to-read, soft-covered book, “Imaging of Cerebrovascular Disease: A Practical Guide,” Dr. Runge has compiled all the key points in CVD imaging without going into elaborate and unnecessary details. The reader will come away understanding how to acquire and interpret vascular disease imaging, including stroke, vascular malformations, and aneurysms. By providing an initial chapter on MR and CT techniques, Dr. Runge lays a foundation for the 5 chapters that follow. Nice comparisons both technique-wise and with images at 1.5 T and 3.0T scanners are described and illustrated.

Dr. Runge has previously published material on MR physics and on contrast material in MR imaging, so the first chapter is a summary of his experience as it relates to CVD. It is important to start with the reading of this chapter, but one must have a basic knowledge of MR to fully appreciate this material. The material is not intended for someone trying to understand the fundamentals of MR imaging. There is less time spent on CT, in part due to the fact that there are fewer variables to manipulate or consider; nonetheless, the underpinning of CT in CVD is explained.

The chapters on normal anatomy and hemorrhage are short and adequately illustrated.

The chapter on ischemia is one that should be made available to new residents rotating through neuroradiology and all neuroradiology fellows. It will serve to emphasize the appearance and evolution of strokes, using different MR parameters and different strength MR systems. It is noteworthy that when describing and illustrating infarcts, there is a mention of the particular part of the brain involved. Such inclusion in any radiology report makes it more meaningful and helps with the anatomic/clinical correlations. Parameter maps …

The Chronic Ear

Dornhoffer JL, Gluth MB, eds. The Chronic Ear. Thieme; 2016; 368 pp; 472 ill; $179.99

Cover of The Chronic Ear

If you ever thought that imaging of ear diseases (middle ear in particular) is challenging, then wait until you read this book. The Chronic Ear details the breadth of pathophysiology, clinical approach, and surgical management of chronic ear pathology.

The book is divided into eight sections. Section 1, “The Fundamentals of Chronic Ear Disease,” is dedicated to the fundamental principles of anatomy and physiology of ear disease. Section 2 details the clinical evaluation and office management of chronic ear disease, while Section 3 is dedicated to the various surgical techniques. In all these 3 sections, the chapters are didactic, detailed, and easy to follow. The anatomy, histology, and pathophysiology is exhaustive yet written in simple language. The pictures are very illustrative and descriptive, and the image quality is excellent. The radiographic evaluation is included in Section 2. The chapter is only a few pages but covers the most important aspects of radiologic anatomy, preoperative diagnosis, post-operative evaluation/complications, and surveillance. The figures are representative and clearly labeled, and the captions are comprehensive.

Sections 3 through 7 are dedicated to various treatment/surgical options and are presented in a round-table approach. In contradistinction to the first 3 sections, the chapters in these sections are shorter and more practical. Each section starts with a one-paragraph overview/introduction describing the issue at hand. This is followed by small subsections and short chapter discussions of the issue that include real-life cases, technique descriptions, and standardized approaches to patient selection/management. It is obvious that the editors chose a broad-minded approach in presenting the diverse literature.

Section 8 describes “Special Topics and New Horizons in Surgery for Chronic Ear Disease”. This is a very interesting part of this book. It describes new techniques …

“Recognizing Review”: Peer Review Week 2016 Celebrates the Heroes of Scientific Review

Publons_160_660_PRW1AJNR is proud to highlight our partnership with Publons during Peer Review Week 2016 as we showcase our commitment to honoring the efforts of our peer reviewers. These experts help ensure the publication of solid science that is relevant and robust before it gets communicated to the world. We encourage our reviewers to act upon this year’s theme of Recognizing Review and sign up for Publons now to effortlessly track, verify, and showcase every review they complete for AJNR and other Publons-affiliated journals. By registering, our reviewers will be eligible for Publons’ inaugural Sentinels of Science awards, paying homage to the most prolific heroes of peer review over the past year.

Follow the Twitter feed on this week’s activities at #PeerRevWk16 with @publons.…

Centripetal Propagation of Vasoconstriction at the Time of Headache Resolution in Patients with Reversible Cerebral Vasoconstriction Syndrome

Fellows’ Journal Club

In this retrospective cohort study, the authors evaluated 16 patients diagnosed with reversible cerebral vasoconstriction syndrome who underwent MR imaging, including MRA, within 72 hours of RCVS onset (initial MRA) and within 48 hours of thunderclap headache remission. In 14 of the 16 patients (87.5%), centripetal propagation of vasoconstriction occurred from the initial MRA to remission of thunderclap headache, with typical segmental vasoconstriction of major vessels (M1, P1, A1). The authors conclude that there is evidence of centripetal propagation of vasoconstriction on MRA performed at the time of remission of the thunderclap headache, and this time point may represent a useful opportunity to diagnose RCVS with greater confidence.


Figure 1 from paper
Images from a 28-year-old woman (case 6) with puerperium-related reversible cerebral vasoconstriction syndrome. The patient was admitted to the hospital 1 day after onset. A, The initial MRA obtained 1 day after the onset of thunderclap headache shows vasoconstrictions in the bilateral P2–3 portions of the posterior cerebral arteries (black arrows). B, MRA obtained at the time of TCH remission (12 days after onset) shows centripetal propagation of vasoconstriction in the bilateral P2 (black arrows) and P1 (white arrows) portions of the posterior cerebral arteries and bilateral A1 portions of the anterior cerebral arteries (black arrowheads).


Reversible cerebral vasoconstriction syndrome is characterized by thunderclap headache and diffuse segmental vasoconstriction that resolves spontaneously within 3 months. Previous reports have proposed that vasoconstriction first involves small distal arteries and then progresses toward major vessels at the time of thunderclap headache remission. The purpose of this study was to confirm centripetal propagation of vasoconstriction on MRA at the time of thunderclap headache remission compared with MRA at the time of reversible cerebral vasoconstriction syndrome onset.


Of the 39 patients diagnosed with reversible cerebral vasoconstriction syndrome

Association of Automatically Quantified Total Blood Volume after Aneurysmal Subarachnoid Hemorrhage with Delayed Cerebral Ischemia

Editor’s Choice

The authors retrospectively studied clinical and radiologic data of 333 consecutive patients with aneurysmal SAH between January 2009 and December 2011. Adjusted odds ratios werecalculated for the association between automatically quantified total blood volume on NCCT and delayed cerebral ischemia (clinical, radiologic, and both). The adjusted OR of total blood volume for delayed cerebral ischemia was 1.02 per milliliter of blood. They conclude that a higher total blood volume measured with the automated quantification method is significantly associated with delayed cerebral ischemia.

Journal Scan – This Month in Other Journals, September 2016

Gondi V, Yock TI, Mehta MP. Proton therapy for paediatric CNS tumours — improving treatment-related outcomes. Nat Rev Neurol. 2016;12(6):334–345. doi:10.1038/nrneurol.2016.70.

In this review, the authors provide an introduction to the types of pediatric CNS tumors for which proton therapy can be considered, and discuss the evidence that proton therapy limits toxicities and improves quality of life for patients. As you no doubt remember from your residency, a proton has a defined maximum penetration depth, called the Bragg peak, at which the majority of its energy is released over a few millimeters. The Bragg peak is determined by the energy of a proton, and can be shortened to match the distal edge of the target by placement of customized tissue-equivalent material in the beam path. Before reaching the Bragg peak, a proton loses only a small amount of its energy, so delivers a lower ‘entrance’ dose than does conventional X‑ray therapy. Beyond the Bragg peak, a proton has no energy, so delivers no ‘exit’ dose. The improvement in dose distribution achieved with proton therapy can meaningfully affect the risk of long-term radiotherapy effects, such as secondary malignancy, cognitive toxicity, endocrinopathy, hearing loss and vasculopathic effects. Despite its higher up front costs, proton therapy has been shown to be more cost effective than X ray therapy owing to the dramatic reduction in the excess costs of managing long-term toxicities. Keep in mind that randomized trials of proton ther¬apy versus X ray therapy are unlikely due to the rarity of the diseases involved and the ethical issues surrounding the enrollment of children into trials in which one arm is asso¬ciated with a greater likelihood of toxicity. Uncertainty about the biological effects of proton therapy on certain healthy tissue and the relative inaccessibility of proton therapy, especially in developing nations, pose …

Evaluation of Focal Cervical Spinal Cord Lesions in Multiple Sclerosis: Comparison of White Matter–Suppressed T1 Inversion Recovery Sequence versus Conventional STIR and Proton Density–Weighted Turbo Spin-Echo Sequences

Fellows’ Journal Club

The authors performed a retrospective blinded analysis of cervical cord MR imaging examinations of 50 patients with MS. In each patient, 2 neuroradiologists measured the number of focal lesions and overall lesion conspicuity in the STIR/proton density–weighted TSE and WM-suppressed T1 inversion recovery sequence groups. Substantial interreader agreement was noted on the WM-suppressed T1 inversion recovery sequence compared with STIR/proton density–weighted TSE. Average lesion conspicuity was better on the WM-suppressed T1 inversion recovery sequence. Additionally, spurious lesions were more common on STIR/proton density–weighted TSE than on the WM-suppressed T1 inversion recovery sequence. They conclude that the WM-suppressed T1 inversion recovery sequence could potentially be substituted for either STIR or proton density–weighted TSE sequences in routine clinical protocols.


Figure 2 from paper
Example of improved lesion conspicuity in a 45-year-old woman with a relapsing-remitting subtype of multiple sclerosis. Sagittal STIR (A) and PDWTSE (B) images show a focal lesion in the dorsum of the cord at the lower C2 level (arrow). Anterior to this lesion, there is linear hyperintensity in the center of the cord usually noted on the STIR/PDWTSE sequence group (arrowhead). The central canal is more homogeneous in signal intensity on sagittal WMS image (C); this feature improves the definition of the superior margin of the dorsal lesion. An additional focal lesion is noted in the ventral cord at the upper C2 level (open arrow), better identified on the WMS sequence (C).


Conventional MR imaging of the cervical spinal cord in MS is challenged by numerous artifacts and interreader variability in lesion counts. This study compares the relatively novel WM-suppressed T1 inversion recovery sequence with STIR and proton density–weighted TSE sequences in the evaluation of cervical cord lesions in patients with MS.


Retrospective blinded analysis of cervical cord MR imaging examinations of 50

Electrophysiologic Validation of Diffusion Tensor Imaging Tractography during Deep Brain Stimulation Surgery

Editor’s Choice

Eleven patients underwent subthalamic nucleus deep brain stimulation. DTI and high-resolution T1- and T2-weighted MRI were performed at 3T. The electrode positions and current amplitudes that elicited corticospinal tract effects during the operation were studied to determine relative corticospinal tract distance. The mean intraoperative electrophysiologic corticospinal tract distance was 3.0 mm +/- 0.6 mm; the mean image-derived corticospinal tract distance (DTI fiber tractography) was 3.0 mm +/- 1.3 mm. DTI fiber tractography depicted the medial corticospinal border in concordance with electrophysiology under 2 different conditions and modeling approaches. Under both conditions, the electrophysiologic measurements were clearly related to the DTI fiber tractography.