The Neuroradiology Journal

Large vessel occlusions (LVO) are a common etiology of morbidity and mortality. The current literature lacks a synthesis of the landscape and trends in research.

We aimed to conduct a bibliometric analysis of the 100 most cited original articles on LVOs to assess the current state of research.

Scopus database was queried from inception to December 2022 to identify the most cited original articles from 4506 retrieved records on LVOs. Publication year, country of origin, total and average annual citation count, and type of study were collected for each article. The journal impact factor (JIF) was obtained from the Journal Citation Reports database.

The articles were published between 1994 and 2021, with most (n = 82) published during the 2011–2020 decade. The median total citation count was 108.5, with an interquartile range (IQR) of 81–149.5. The median (IQR) average annual citation count was 15.9 (11.5–22.9). Half of the articles were published in Stroke (n = 35) and Journal of NeuroInterventional Surgery (n = 15), with JIFs ranging from 1.8 to 202.7. The USA was the leading country in contributing to LVO research (n = 45). Most studies focused on the treatment (n = 63) and diagnosis (n = 22) of LVOs.

Most articles were published during the past decade, highlighting the impact of the clinical trials of endovascular treatment on the discipline. With several ongoing clinical trials on the horizon, continued growth of the field is anticipated in the upcoming decades.

Glioma is one of the most common primary brain tumors. The presence of the telomerase reverse transcriptase promoter (pTERT) mutation is associated with a better prognosis. This study aims to investigate the TERT mutation in patients with glioma using machine learning (ML) algorithms on radiographic imaging.

This study was prepared according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The electronic databases of PubMed, Embase, Scopus, and Web of Science were searched from inception to August 1, 2023. The statistical analysis was performed using the MIDAS package of STATA v.17.

A total of 22 studies involving 5371 patients were included for data extraction, with data synthesis based on 11 reports. The analysis revealed a pooled sensitivity of 0.86 (95% CI: 0.78–0.92) and a specificity of 0.80 (95% CI 0.72–0.86). The positive and negative likelihood ratios were 4.23 (95% CI: 2.99–5.99) and 0.18 (95% CI: 0.11–0.29), respectively. The pooled diagnostic score was 3.18 (95% CI: 2.45–3.91), with a diagnostic odds ratio 24.08 (95% CI: 11.63–49.87). The Summary Receiver Operating Characteristic (SROC) curve had an area under the curve (AUC) of 0.89 (95% CI: 0.86–0.91).

The study suggests that ML can predict TERT mutation status in glioma patients. ML models showed high sensitivity (0.86) and moderate specificity (0.80), aiding disease prognosis and treatment planning. However, further development and improvement of ML models are necessary for better performance metrics and increased reliability in clinical practice.

We aimed to investigate the external validation and performance of an FDA-approved deep learning model in labeling intracranial hemorrhage (ICH) cases on a real-world heterogeneous clinical dataset. Furthermore, we delved deeper into evaluating how patients’ risk factors influenced the model’s performance and gathered feedback on satisfaction from radiologists of varying ranks.

This prospective IRB approved study included 5600 non-contrast CT scans of the head in various clinical settings, that is, emergency, inpatient, and outpatient units. The patients’ risk factors were collected and tested for impacting the performance of DL model utilizing univariate and multivariate regression analyses. The performance of DL model was contrasted to the radiologists’ interpretation to determine the presence or absence of ICH with subsequent classification into subcategories of ICH. Key metrics, including accuracy, sensitivity, specificity, positive predictive value, and negative predictive value, were calculated. Receiver operating characteristics curve, along with the area under the curve, were determined. Additionally, a questionnaire was conducted with radiologists of varying ranks to assess their experience with the model.

The model exhibited outstanding performance, achieving a high sensitivity of 89% and specificity of 96%. Additional performance metrics, including positive predictive value (82%), negative predictive value (97%), and overall accuracy (94%), underscore its robust capabilities. The area under the ROC curve further demonstrated the model’s efficacy, reaching 0.954. Multivariate logistic regression revealed statistical significance for age, sex, history of trauma, operative intervention, HTN, and smoking.

Our study highlights the satisfactory performance of the DL model on a diverse real-world dataset, garnering positive feedback from radiology trainees.

To determine the frequency and accuracy of diffusion restriction (DR) of the retina and/or optic nerve (ON) detection on standard brain magnetic resonance diffusion-weighted imaging (DWI-MRI) in patients presenting with acute non-arteritic central retinal artery occlusion (CRAO).

This is a retrospective case-control study that includes all consecutive patients presenting to our tertiary academic center from 2013-2021 with acute non-arteritic CRAO (cases) or acute ischemic stroke syndrome (controls, age and gender-matched) that had brain MRI performed within 14 days from symptom onset. Two neurology residents (junior and senior), a vascular neurologist, and two neuroradiologists, blinded to the site of CRAO, independently reviewed the brain MRIs to assess for the presence of retina and ON DR. The consensus agreement between the two neuroradiologists was used to perform sensitivity and specificity analyses and calculate inter-rater reliability (prevalence-adjusted bias-adjusted kappa coefficient).

A total of 128 patients with acute non-arteritic CRAO (mean (SD) age 69 (14) years; 50% female; median time from CRAO to DW-MRI 2 days (IQR 1-5)) and 128 age and gender-matched controls with acute cerebral ischemia were included. After the neuroradiologist consensus, DR was correctly identified in the retina or ON in 51/128 (39.8%) CRAO cases, retina alone 27.3%, ON alone 24.2%, and both retina and ON 11.7%, with almost perfect neuroradiologists’ inter-rater reliability for retina (K = 0.91) and ON (K = 0.83). Among controls, the retina DR was identified in 1/128 (0.8%) and ON DR in 5/128 (3.9%). The sensitivity, specificity, positive predictive value, and negative predictive value were 28.1%, 99.2%, 97.3%, and 58.0% for retina DR, and 27.3%, 96.1%, 87.5%, and 56.9% for ON DR.

Though experienced neuroradiologists identified retina and ON DR with excellent inter-rater reliability, these are infrequent findings in real world CRAO practice, with excellent specificity but limited sensitivity. Prospective studies with larger cohort of patients, optimization of standardized orbit DWI-MRI protocols are needed to facilitate a more accurate and reliable identification of retina and ON DR in acute CRAO.

Platelet function testing using serial VerifyNow P2Y12 platelet reactivity units (PRUs) is established for guiding clopidogrel antiplatelet therapy in cerebral aneurysm stenting procedures. However, for ticagrelor, the impact of serial PRU testing and the identification of safe PRU ranges remains unexplored.

Flow diversion stenting (n = 232) and stent-assisted coiling procedures (n = 83) performed 05/2017–12/2021 were reviewed. Out of these, 31 flow diversion and 18 stent-coiling procedures were performed on 44 patients using ticagrelor. Baseline demographics, ticagrelor PRUs, and clinical outcomes were assessed.

Collectively, 257 ticagrelor P2Y12 PRUs were obtained. PRUs were <100 in 192/257 (74.7%) tests. Only 11/257 (4.3%) PRUs were >200. The overall median ticagrelor PRU was 38 (IQR 11–101). Among the 49 procedures, median PRUs before the procedure (25, IQR 10–67), on the day of the procedure (68, IQR 44–117), and on the day after the procedure (37, IQR 21–79) did not show the significant differences between the groups. A total of seven thromboembolic complications occurred. Median PRUs surrounding the thromboembolic complications (median 182, IQR 148–235) were significantly higher than preprocedural (p < .001), day of surgery (p < .01), and postprocedural PRUs (p < .01). All seven procedures harbored demographic, anatomic, or procedural features increasing the risk for thromboembolic complications.

The majority of periprocedural ticagrelor PRUs were <100. PRUs at the time point of thromboembolic complications were >120. Despite procedure-complicating features in each thromboembolic case, it raises the question whether safe ticagrelor PRU levels might be lower than those commonly applied for clopidogrel.

Our study aimed to investigate potential alterations in iron deposition within pulvinar, using susceptibility weighted imaging (SWI) MRI in epilepsy patients through a biomarker termed the “hypointense pulvinar sign.”

A full-text radiological information system search of radiological reports was performed for the term “epilepsy” between 2014 and 2022. Only patients with the diagnosis of epilepsy were included. SWI was assessed by two readers recording lateralization of an asymmetrically more hypointense pulvinar. Cohen’s kappa for inter-rater reliability was calculated. Fisher’s exact test was performed to assess for significance between groups.

Our epilepsy cohort comprised 105 patients with following diagnoses: 45 intra-axial tumor, 13 meningioma, 13 MRI negative, 12 encephalomalacia, seven siderosis, six cavernoma, five arteriovenous malformation, two acute demyelinating encephalomyelitis, one tuberous sclerosis, one giant aneurysm. The hypointense pulvinar sign was correct in 44% of cases. Notably, right hemispheric lesions exhibited a significantly higher proportion of correct hypointense pulvinar signs compared to the left hemisphere (46% vs 24%; p = 0.044). Inter-rater reliability was substantial at 0.62 (p < 0.001). Only two of 21 (10%) of healthy controls demonstrated a hypointense pulvinar sign, which was significantly different from the epilepsy cohort (p < 0.01).

The hypointense pulvinar sign has proven to be a reproducible, simple to use biomarker for iron deposition in epilepsy which could be considered for inclusion into multimodal precision medicine models.

Zoom reperfusion system (Imperative Care, CA) has proven to be promising for use in adult mechanical thrombectomies (MTs) but has not been described in pediatrics. We present two cases of a 14-year-old with acute right middle cerebral artery (MCA) syndrome and a 10-year old with acute left MCA syndrome who underwent MT using Zoom Reperfusion System safely with TICI 2B and TICI 3 recanalization, respectively.

Case report and literature review.

A 14-year-old healthy boy with right supraclinoid internal carotid artery (ICA) occlusion (case 1) and a 10-year-old boy with left hypoplastic heart syndrome and left ICA terminus occlusion (case 2) were taken for MT after receiving alteplase at our institution. Through femoral access, an 8-French sheath was introduced into the right femoral artery through which a Zoom 88 catheter was introduced and parked at the right petrous ICA segment in case 1 and left ophthalmic ICA segment in case 2. Angiogram demonstrated complete ICA occlusion just past the ophthalmic artery origin in case 1 and at the ICA terminus in case 2. Zoom system (88 and 71) was then navigated to the face of clot with vacuum manifold engaged with the clot. TICI 2B (with the help of Trevo stent retriever [Stryker]) and TICI 3 recanalization were achieved in cases 1 and 2, respectively.

The use of Zoom reperfusion system could potentially be feasible for use in pediatric age group. Larger pediatric patient population is needed to establish its safety.

Carotid artery stenting (CAS) is an established treatment for internal carotid artery stenosis (ICS). The Carotid Wallstent is commonly used as a stent device in CAS procedures. Rare complications associated with the use of the Carotid Wallstent in CAS procedures include delayed shortening and incomplete stent expansion due to displacement of a marker ring. However, there have been no previous reports of a stent holder becoming unpredictably detached from a Carotid Wallstent during a procedure, requiring the additional deployment of another Carotid Wallstent.

The case of a 72-year-old man with progressive ICS is described. Since the ICS was resistant to medical treatment, CAS was planned to prevent ischemic events. During the procedure, a Mo.Ma Ultra and a carotid guardwire were used for proximal and distal protection, respectively. Following the introduction of those protective devices, a Carotid Wallstent was deployed at the stenotic lesion of the ICS. After the deployment of the Carotid Wallstent, a stent holder unpredictably detached was identified in the lumen of the Carotid Wallstent. Since it was impossible to mechanically retrieve the detached stent holder, another Carotid Wallstent was deployed to trap the substance. Postoperatively, the substance was identified as a stent holder of the first Carotid Wallstent.

This is the first report of an extremely rare complication concerning a Carotid Wallstent in CAS.