Journal Welcomes New Editors

Dr. Yvonne Lui

AJNR Senior Editor Dr. Jody Tanabe recently accepted a new assignment as Acting Chair at the University of Colorado School of Medicine and has ended her term after 3½ years of dedicated service to the Journal. Her role overseeing functional and advanced imaging submissions will be filled by Dr. Yvonne Lui, Associate Professor of Radiology and Chief of Neuroradiology at New York University School of Medicine. Dr. Lui is a graduate of Yale University School of Medicine and completed her radiology and neuroradiology training at NYU. Her interests are focused on advanced MR imaging of the central nervous system and she leads an NIH-funded research program on brain injury. Dr. Lui is a charter member of the NIH Scientific Review Committee for Medical Imaging, reviews for 7 other academic journals, and serves as the 2017 President of the New York Roentgen Society. She has also served as AJNR’s Podcast Editor since 2013.

Dr. Wende Gibbs

Dr. Wende Gibbs will be stepping into Dr. Lui’s role as AJNR’s Podcast Editor. She will be the host of the Journal’s monthly podcast, 1 of 3 episodes published each month. Dr. Gibbs is an Assistant Professor of Neuroradiology and Director of Spine Imaging and Intervention at the University of Southern California, Keck School of Medicine. She previously completed a 2-year fellowship at the Barrow Neurological Institute. Dr. Gibbs has authored a number of publications and book chapters and holds leadership and committee positions for the ASNR, ASSR, ARRS, WNRS, and ABR. She is a member of the AJNR Editorial Board and reviews for 7 journals. Her main interests are spine oncology, pain management, and patient-centered care.…

Baseline Survey of the Neuroradiology Work Environment in the United States with Reported Trends in Clinical Work, Nonclinical Work, Perceptions of Trainees, and Burnout Metrics

Fellows’ Journal Club

A voluntary survey was sent to practicing and out-of-training members of the ASNR. Four hundred thirty-two respondents across a broad range of experience reported: 93% with workdays extending at least 1 hour past expected; 71.9% reading more cases per hour compared with previous years; 79.5% sometimes-to-always interpreting cases faster than comfortable for optimal interpretation; and 67.8% sometimes or more often with inadequate time to discuss abnormal results. Burnout symptoms ranged between 49% and 75%. The trends and the correlations should be concerning to the leaders of radiology and warrant further monitoring.

The Use of Noncontrast Quantitative MRI to Detect Gadolinium-Enhancing Multiple Sclerosis Brain Lesions: A Systematic Review and Meta-Analysis

Editor’s Choice

The authors evaluated 37 journal articles that included 985 patients with MS who had MR imaging in which T1-weighted postcontrast sequences were compared with noncontrast sequences obtained during the same MR imaging examination by using ROI analysis of individual MS lesions. DTI-based fractional anisotropy values were significantly different between enhancing and nonenhancing lesions, with enhancing lesions showing decreased FA. None of the other most frequently studied MR imaging biomarkers (mean diffusivity, magnetization transfer ratio, or ADC) were significantly different between enhancing and nonenhancing lesions. They conclude that noncontrast MR imaging techniques, such as DTI-based FA, can assess MS lesion acuity without gadolinium.

Color Atlas of Brainstem Surgery

Spetzler RF, Kalani MYS, Nakaji P, Yagmurlu K. Color Atlas of Brainstem Surgery. Thieme; 2017; 416 pp; 850 ill; $249.99

cover of Spetzler

This recent publication is a unique work that emphasizes the structural and functional anatomy of the thalamus and brainstem and provides guidance for accessing these regions surgically for intrinsic lesions. The print atlas is accompanied by a large collection of online media, including animations and narrated surgical videos.

The book opens with an overview of anatomy, beginning with surface structures and perpendicular sections of whole fixed brains and progressing through focused dissections. To clarify specific relationships, it strategically incorporates diagrams of deep venous anatomy and cisterns around the brainstem. It summarizes the function and location of the long fiber tracts at the level of the cerebrum, midbrain, pons, medulla, and spinal cord, reviewing the clinically significant deficits incurred with lesions at each level. The discussion then integrates these concepts to introduce the safe entry zones of the brainstem, identifying both surface and deep structures that must be avoided. Fixed tissue dissections of varying depth demonstrate the three-dimensional relationships of adjacent tracts and nuclei. Full-color illustrations and dissection views of the associated vasculature are accompanied by axial slices depicting the territories of arterial supply. The combination of detailed sketches and meticulous dissections helps the reader bridge the conceptual gap between cross-sectional images and a surgeon’s view of the deeper structures that are imminently transgressed. The anatomy section finishes with a summary of the skull base foramina and traversing cranial nerves.

The next section of the book specifically describes the safe entry zones and nearby landmarks, with illustrations that depict the surface and cross-sectional anatomy of each zone. Some of this content is outlined in the preceding chapter, but this section provides a detailed rationale for the use of the safe …

Journal Scan – This Month in Other Journals, July 2017

Rabinstein AA. Treatment of Acute Ischemic Stroke. Continuum (Minneap Minn). 2017;23(1, Cerebrovascular Disease):62-81. doi:10.1212/CON.0000000000000420.

This is an excellent and comprehensive review of current acute stroke treatment.  The three main principles of acute stroke care are: (1) achieve timely recanalization of the occluded artery and reperfusion of the ischemic tissue, (2) optimize collateral flow, and (3) avoid secondary brain injury. The author states there is incontrovertible evidence that IV thrombolysis with rtPA and endovascular thrombectomy with a retrievable stent improve neurologic outcomes in patients with acute ischemic stroke. Both treatments should be administered as quickly as possible after stroke onset, can be combined, and are safe in appropriately selected candidates. IV thrombolysis with rtPA is proven to be effective in improving functional outcomes after an ischemic stroke up to 4.5 hours after symptom onset. IV rtPA infused within 3 hours of symptom onset increases the chances of functional independence at 3 months by one-third. The benefit is time dependent and much stronger when the drug is administered within the first 90 minutes after symptom onset.

Regarding mechanical thrombectomy, the six positive trials shared the requirement of CT angiograms for patient screening (only patients with documented internal carotid artery or proximal middle cerebral artery occlusions could be entered into the studies), emphasized the importance of prompt intervention, and almost exclusively used retrievable stents to achieve reperfusion. All of the trials enrolled patients with severe neurologic deficits and good prestroke functional status who presented mostly within 6 hours of symptom onset. Major early ischemic changes on the baseline CT scan were a reason for exclusion. Patients treated with mechanical thrombectomy had high rates of reperfusion and much better functional outcomes at 90 days. Mechanical thrombectomy was also proven to be quite safe, with a pooled rate of

Clinically Feasible Microstructural MRI to Quantify Cervical Spinal Cord Tissue Injury Using DTI, MT, and T2*-Weighted Imaging: Assessment of Normative Data and Reliability

Fellows’ Journal Club

Forty healthy subjects underwent T2WI, DTI, magnetization transfer, and T2*WI at 3T in <35 minutes using standard hardware and pulse sequences. Cross-sectional area, fractional anisotropy, magnetization transfer ratio, and T2*WI WM/GM signal intensity ratio were calculated. Reliable multiparametric assessment of spinal cord microstructure is possible by using clinically suitable methods. These results establish normalization procedures and pave the way for clinical studies.

Resting-State Seed-Based Analysis: An Alternative to Task-Based Language fMRI and Its Laterality Index

Editor’s Choice

Eighteen healthy right-handed volunteers were prospectively evaluated with resting-state fMRI and task-based fMRI to assess language networks. The laterality indices of Broca and Wernicke areas were calculated by using task-based fMRI via a voxel-value approach. The authors performed seed-based resting-state fMRI connectivity analysis together with parameters such as amplitude of low-frequency fluctuation and fractional amplitude of low-frequency fluctuation (fALFF). fALFF can be used as an alternative to task-based fMRI for assessing language laterality. There was a strong positive correlation between the fALFF of the Broca area of resting-state fMRI with the laterality index of task-based fMRI.

Chordomas: Technologies, Techniques and Treatment Strategies

Necmettin Pamir M, Al-Mefty O, Borba LAB. Chordomas: Technologies, Techniques and Treatment Strategies. Thieme; 2017; 256 pp; 400 ill; $199.99

Cover of Necmettin Pamir

When I was asked to review this book, I was a bit apprehensive. I questioned the rationale of reviewing an entire book dealing with a tumor I encounter only a handful of times a year. As a neuroradiologist with passion for skull base imaging, I would have found more practical use out of a book discussing more commonly encountered diagnoses such as schwannomas or meningiomas. However, to my pleasant surprise, this was an outstanding book to review and by far one of the best reads in the last few years.

The book, a product of the collaboration of over 50 contributors from 6 different countries, tackles a rare but challenging entity. It is a well-organized book that is divided into 4 parts.

Part 1. Definition, History, Demographics, Pathology and Pathogenesis: Eight chapters describe historic aspects of this disease and address a wide variety of topics ranging from descriptive epidemiology, to embryology of the notochord, to pathology, and even to cytogenetic and molecular biology of chordomas.

Part 2. Diagnosis of Chordomas: As a neuroradiologist, this was of specific interest to me. It consists of 3 chapters. The first 2 are about radiologic findings and differential diagnosis of chordomas at the skull base and spine, respectively. The third chapter deals with molecular imaging of chordomas.

Part 3. Surgical Treatment of Chordomas: This is the largest section of the book. It tackles the surgical techniques and approaches that are currently available, their indications, advantages, and limitations. Conventional techniques as well as new, innovative technologies are eloquently described.

Part 4. Special Topics in Chordomas: In this section, a variety of miscellaneous topics are discussed, including radiation therapy, recurrent tumor management, and even outcomes/quality …

Neurosonology and Neuroimaging of Stroke: A Comprehensive Reference, 2nd Edition

Valdueza JM, Schreiber SJ, Roehl J-E, Connolly F, Klingebiel R. Neurosonology and Neuroimaging of Stroke: A Comprehensive Reference. 2nd ed. Thieme; 2017; 768 pp; 1305 ill; $224.99

Cover of Valdueza

Neurosonology and Neuroimaging of Stroke, written by 4 neurologists and 1 neuroradiologist, is an exhaustive review of stroke imaging, with a special emphasis on vascular ultrasound. As stated in the preface, it is based on the combined teaching experience gained by the authors over the last 15 years.

The book is divided in 2 parts. “Part A: Principles and Rules,” the first third of the book, is dedicated to basic ultrasound principles, with a focus on ultrasound vascular anatomy, blood flow hemodynamics, stroke pathogenesis, and a comprehensive presentation of intracranial and extracranial vascular pathology. It ends with an overview of current neuroradiologic vascular imaging techniques such as DSA, MRA, and CTA. In each chapter, schematic diagrams, pictures, and multimodality images, which are thoughtfully labeled and adequately described, beautifully depict the subject matter. The supplemental online material includes high-quality videos that illustrate both arterial and venous ultrasound examinations.

“Part B: Case Histories” is a collection of 45 cases, each of which is presented in the same format: a case presentation, initial neuroradiologic findings, suspected diagnosis, questions to answer, initial neurosonologic findings, clinical course, final diagnosis, and discussion. The cases range from commonly encountered entities such as atherosclerotic disease, to rarer and more elusive diagnoses such as arteriovenous dural fistula, postpartum angiopathy, and diffuse cerebral angiomatosis. Each case is accompanied by high-resolution ultrasound images, which are exquisitely correlated to other cross-sectional modalities and are well-annotated. Finally, the discussions are well-written and thorough, with a strong emphasis on clinical management.

In the authors’ own words, this book is aimed at all doctors—in particular at neurologists, neurosurgeons, internists, angiologists, and neuroradiologists who treat neurologic or …

Large Basilar Apex Aneurysms Treated with Flow-Diverter Stents

Fellows’ Journal Club

The authors report their experience treating basilar apex aneurysms with flow-diverter stents and evaluate their efficacy and safety profile in this specific condition. Of the 175 aneurysms treated with flow-diverter stents at their institution, 5 patients received flow-diverter stents for basilar apex aneurysms. The mean follow-up after stent deployment was 21 months. They conclude that flow diversion is a feasible technique with an efficacy demonstrated at a midterm follow-up, especially in the case of basilar apex aneurysm recurrences after previous endovascular treatments.