Amy Rothman Schonfeld

Editor's Note: Do you refer stroke patients to registries? If not, why not? Do you agree with Dr. Connors' assertion that neurologists “do not believe in” interventions? Please write us at [email protected]

OLYMPIC VALLEY, CALIF. — Few neurologists have been enrolling patients in any of the three existing stroke registries, in large part because they do not know about them.

Dr. John J. Connors III, medical director of the NeuroVascular Research Foundation, noted that although many neurointerventionists may be aware of these registries, those who are on the front lines of stroke treatment are simply not aware of the registries or are reluctant to participate because of the time and diligence required. There are currently three registries enrolling patients.

The first, known as INSTOR (Interventional Stroke Therapy Outcomes Registry), was designed primarily to collect information on intra-arterial lysis for large-vessel occlusion. At first, 159 sites expressed interest in participating, but most have not entered any patients since INSTOR's launch in 2002. Nevertheless, 20 active sites have contributed 278 patients to date, making it the largest database in the world that focuses on this type of stroke treatment.

A second registry, INTRASTOR (Intracranial Angioplasty and Stenting Outcomes Registry), was created to evaluate whether angioplasty and stenting can prevent stroke by treating atherosclerotic disease in the brain. At a poster presented at the annual meeting of the Society of Neurointerventional Surgery, data from 199 patients with 201 lesions indicated that 89% (178) of patients had greater than 70% stenosis. In all, 90 patients were treated with angioplasty alone, 72 by primary stenting, and 29 by angioplasty followed by stenting. (Data were unavailable for the remaining eight patients.)

After treatment, 74% of patients had less than 33% residual stenosis, and 14% of patients had 34%–50% residual stenosis. Symptomatic complications included 10 patients with permanent neurologic deficits, 26 with minor complications that fully resolved, and 3 patients who died.

A third registry that was recently launched, known as INSTOR II, is designed to collect more complete information on the use of mechanical and combination interventions that are used to treat acute ischemic stroke. These interventions include mechanical retrievers and a device that delivers intracranial ultrasound-aided lysis.

“We need neurologists on board,” Dr. Connors said. “Although randomized control trial data are always preferable, any data are better than none. The INSTOR registries include [data on] patient selection, usually with [CT angiography] to choose patients with large-vessel occlusions. To this day, even with our ubiquitous neuroimaging tools, large stroke treatment trials [such as the Interventional Management of Stroke III trial] still use only patient selection no more sophisticated than that used 20 years ago. No oncology trial, for instance, would ever include all grades of breast cancer in a chemotherapy trial.”

Although larger numbers of patients are still needed, the registries are already revealing worthwhile information, Dr. Connors noted. For instance, the data from INSTOR I indicate that almost one-fifth of the 278 patient were on Coumadin, but 45 of these 53 patients had international normalized ratio levels lower than 2.0, indicating less-than-effective doses that might have allowed a cardiogenic embolus in a patient who was known to be at risk.

Other data suggest many of the patients were being treated with acetylsalicylic acid but had a presumed cardiogenic embolus and possibly should have been on Coumadin. Their average score on the National Institutes of Health Stroke Scale was 17, and 53% of patients had 3-month Rankin grades of 0–2 (though follow-up was incomplete).

“Registries are necessary for proof that neurointerventional procedures work. They are recommended by the Brain Attack Coalition in Comprehensive Stroke Centers. They are mandated by certain health care agencies, including the state of Florida, [and] by several medical societies, and will be mandated by upcoming stroke-treatment training guidelines. Decisions by [the Centers for Medicare and Medicaid Services] have been based upon registry data,” Dr. Connors said. “It is necessary for members of the endovascular societies that treat stroke to participate in this effort.”

Although most neurologists, particularly those in leadership, do not believe in these interventions, the data from the registries—if adequate numbers are achieved—should help remove any concerns that endovascular intervention for appropriately selected patients works.

“Collecting these data in the long run is beneficial for the science of endovascular stroke therapy and prevention, but requires the commitment of both individual physicians and medical leadership,” Dr. Connors said. In the long run, these data are good not only for the patient, but also for the cerebrovascular/stroke business, he added.

For more information about enrollment instructions, equipment, and obtaining Institutional Review Board support for the registries, visit www.strokeregistry.org

Editor's Note: Do you refer stroke patients to registries? If not, why not? Do you agree with Dr. Connors' assertion that neurologists “do not believe in” interventions? Please write us at [email protected]

OLYMPIC VALLEY, CALIF. — Few neurologists have been enrolling patients in any of the three existing stroke registries, in large part because they do not know about them.

Dr. John J. Connors III, medical director of the NeuroVascular Research Foundation, noted that although many neurointerventionists may be aware of these registries, those who are on the front lines of stroke treatment are simply not aware of the registries or are reluctant to participate because of the time and diligence required. There are currently three registries enrolling patients.

The first, known as INSTOR (Interventional Stroke Therapy Outcomes Registry), was designed primarily to collect information on intra-arterial lysis for large-vessel occlusion. At first, 159 sites expressed interest in participating, but most have not entered any patients since INSTOR's launch in 2002. Nevertheless, 20 active sites have contributed 278 patients to date, making it the largest database in the world that focuses on this type of stroke treatment.

A second registry, INTRASTOR (Intracranial Angioplasty and Stenting Outcomes Registry), was created to evaluate whether angioplasty and stenting can prevent stroke by treating atherosclerotic disease in the brain. At a poster presented at the annual meeting of the Society of Neurointerventional Surgery, data from 199 patients with 201 lesions indicated that 89% (178) of patients had greater than 70% stenosis. In all, 90 patients were treated with angioplasty alone, 72 by primary stenting, and 29 by angioplasty followed by stenting. (Data were unavailable for the remaining eight patients.)

After treatment, 74% of patients had less than 33% residual stenosis, and 14% of patients had 34%–50% residual stenosis. Symptomatic complications included 10 patients with permanent neurologic deficits, 26 with minor complications that fully resolved, and 3 patients who died.

A third registry that was recently launched, known as INSTOR II, is designed to collect more complete information on the use of mechanical and combination interventions that are used to treat acute ischemic stroke. These interventions include mechanical retrievers and a device that delivers intracranial ultrasound-aided lysis.

“We need neurologists on board,” Dr. Connors said. “Although randomized control trial data are always preferable, any data are better than none. The INSTOR registries include [data on] patient selection, usually with [CT angiography] to choose patients with large-vessel occlusions. To this day, even with our ubiquitous neuroimaging tools, large stroke treatment trials [such as the Interventional Management of Stroke III trial] still use only patient selection no more sophisticated than that used 20 years ago. No oncology trial, for instance, would ever include all grades of breast cancer in a chemotherapy trial.”

Although larger numbers of patients are still needed, the registries are already revealing worthwhile information, Dr. Connors noted. For instance, the data from INSTOR I indicate that almost one-fifth of the 278 patient were on Coumadin, but 45 of these 53 patients had international normalized ratio levels lower than 2.0, indicating less-than-effective doses that might have allowed a cardiogenic embolus in a patient who was known to be at risk.

Other data suggest many of the patients were being treated with acetylsalicylic acid but had a presumed cardiogenic embolus and possibly should have been on Coumadin. Their average score on the National Institutes of Health Stroke Scale was 17, and 53% of patients had 3-month Rankin grades of 0–2 (though follow-up was incomplete).

“Registries are necessary for proof that neurointerventional procedures work. They are recommended by the Brain Attack Coalition in Comprehensive Stroke Centers. They are mandated by certain health care agencies, including the state of Florida, [and] by several medical societies, and will be mandated by upcoming stroke-treatment training guidelines. Decisions by [the Centers for Medicare and Medicaid Services] have been based upon registry data,” Dr. Connors said. “It is necessary for members of the endovascular societies that treat stroke to participate in this effort.”

Although most neurologists, particularly those in leadership, do not believe in these interventions, the data from the registries—if adequate numbers are achieved—should help remove any concerns that endovascular intervention for appropriately selected patients works.

“Collecting these data in the long run is beneficial for the science of endovascular stroke therapy and prevention, but requires the commitment of both individual physicians and medical leadership,” Dr. Connors said. In the long run, these data are good not only for the patient, but also for the cerebrovascular/stroke business, he added.

For more information about enrollment instructions, equipment, and obtaining Institutional Review Board support for the registries, visit www.strokeregistry.org

Editor's Note: Do you refer stroke patients to registries? If not, why not? Do you agree with Dr. Connors' assertion that neurologists “do not believe in” interventions? Please write us at [email protected]

OLYMPIC VALLEY, CALIF. — Few neurologists have been enrolling patients in any of the three existing stroke registries, in large part because they do not know about them.

Dr. John J. Connors III, medical director of the NeuroVascular Research Foundation, noted that although many neurointerventionists may be aware of these registries, those who are on the front lines of stroke treatment are simply not aware of the registries or are reluctant to participate because of the time and diligence required. There are currently three registries enrolling patients.

The first, known as INSTOR (Interventional Stroke Therapy Outcomes Registry), was designed primarily to collect information on intra-arterial lysis for large-vessel occlusion. At first, 159 sites expressed interest in participating, but most have not entered any patients since INSTOR's launch in 2002. Nevertheless, 20 active sites have contributed 278 patients to date, making it the largest database in the world that focuses on this type of stroke treatment.

A second registry, INTRASTOR (Intracranial Angioplasty and Stenting Outcomes Registry), was created to evaluate whether angioplasty and stenting can prevent stroke by treating atherosclerotic disease in the brain. At a poster presented at the annual meeting of the Society of Neurointerventional Surgery, data from 199 patients with 201 lesions indicated that 89% (178) of patients had greater than 70% stenosis. In all, 90 patients were treated with angioplasty alone, 72 by primary stenting, and 29 by angioplasty followed by stenting. (Data were unavailable for the remaining eight patients.)

After treatment, 74% of patients had less than 33% residual stenosis, and 14% of patients had 34%–50% residual stenosis. Symptomatic complications included 10 patients with permanent neurologic deficits, 26 with minor complications that fully resolved, and 3 patients who died.

A third registry that was recently launched, known as INSTOR II, is designed to collect more complete information on the use of mechanical and combination interventions that are used to treat acute ischemic stroke. These interventions include mechanical retrievers and a device that delivers intracranial ultrasound-aided lysis.

“We need neurologists on board,” Dr. Connors said. “Although randomized control trial data are always preferable, any data are better than none. The INSTOR registries include [data on] patient selection, usually with [CT angiography] to choose patients with large-vessel occlusions. To this day, even with our ubiquitous neuroimaging tools, large stroke treatment trials [such as the Interventional Management of Stroke III trial] still use only patient selection no more sophisticated than that used 20 years ago. No oncology trial, for instance, would ever include all grades of breast cancer in a chemotherapy trial.”

Although larger numbers of patients are still needed, the registries are already revealing worthwhile information, Dr. Connors noted. For instance, the data from INSTOR I indicate that almost one-fifth of the 278 patient were on Coumadin, but 45 of these 53 patients had international normalized ratio levels lower than 2.0, indicating less-than-effective doses that might have allowed a cardiogenic embolus in a patient who was known to be at risk.

Other data suggest many of the patients were being treated with acetylsalicylic acid but had a presumed cardiogenic embolus and possibly should have been on Coumadin. Their average score on the National Institutes of Health Stroke Scale was 17, and 53% of patients had 3-month Rankin grades of 0–2 (though follow-up was incomplete).

“Registries are necessary for proof that neurointerventional procedures work. They are recommended by the Brain Attack Coalition in Comprehensive Stroke Centers. They are mandated by certain health care agencies, including the state of Florida, [and] by several medical societies, and will be mandated by upcoming stroke-treatment training guidelines. Decisions by [the Centers for Medicare and Medicaid Services] have been based upon registry data,” Dr. Connors said. “It is necessary for members of the endovascular societies that treat stroke to participate in this effort.”

Although most neurologists, particularly those in leadership, do not believe in these interventions, the data from the registries—if adequate numbers are achieved—should help remove any concerns that endovascular intervention for appropriately selected patients works.

“Collecting these data in the long run is beneficial for the science of endovascular stroke therapy and prevention, but requires the commitment of both individual physicians and medical leadership,” Dr. Connors said. In the long run, these data are good not only for the patient, but also for the cerebrovascular/stroke business, he added.

For more information about enrollment instructions, equipment, and obtaining Institutional Review Board support for the registries, visit www.strokeregistry.org

NEW ORLEANS — The combination of magnetic resonance spectroscopy with magnetic resonance imaging significantly improved the pretherapeutic diagnostic accuracy for pediatric brain tumors, according to findings from a retrospective study.

In a review of 122 children with newly detected brain tumors, Dr. Mark S. Shiroishi compared imaging reports with histopathologic findings. He found that the correct diagnosis was made 63% of the time (38/60) with contrast-enhanced magnetic resonance imaging (MRI). When magnetic resonance spectroscopy (MRS) was combined with contrast-enhanced MRI, the accuracy rate increased to 87% (54/62). MRI led to a partially correct diagnosis in 10% of cases (6/60), a rate that fell to 5% (3/62) when MRS was added.

Importantly, 27% of tumors (16/60) were incorrectly diagnosed with MRI alone, compared with 8% of those (5/62) who also underwent MRS. The difference in diagnostic accuracy between the two groups was statistically significant (P less than .01), said Dr. Shiroishi, a neuroradiologist at Childrens Hospital Los Angeles.

MR spectroscopy is a noninvasive way of monitoring the biochemical components of normal and abnormal brain tissue in vivo. MRS uses the same principles as MRI, but in MRS, a plot representing the chemical make-up of a region (rather than an image) is generated. MRS has proved useful in imaging tumors, infarcts, and epileptic foci.

“Spectroscopy allows us to readily distinguish … medulloblastomas, pilocytic astrocytomas, choroid plexus papillomas, and choroid plexus carcinomas,” said Dr. Shiroishi when he presented his findings at the annual meeting of the American Society of Neuroradiology.

“There is still a gray zone overlapping between anaplastic and regular astrocytomas and ependymomas,” he noted.

NEW ORLEANS — The combination of magnetic resonance spectroscopy with magnetic resonance imaging significantly improved the pretherapeutic diagnostic accuracy for pediatric brain tumors, according to findings from a retrospective study.

In a review of 122 children with newly detected brain tumors, Dr. Mark S. Shiroishi compared imaging reports with histopathologic findings. He found that the correct diagnosis was made 63% of the time (38/60) with contrast-enhanced magnetic resonance imaging (MRI). When magnetic resonance spectroscopy (MRS) was combined with contrast-enhanced MRI, the accuracy rate increased to 87% (54/62). MRI led to a partially correct diagnosis in 10% of cases (6/60), a rate that fell to 5% (3/62) when MRS was added.

Importantly, 27% of tumors (16/60) were incorrectly diagnosed with MRI alone, compared with 8% of those (5/62) who also underwent MRS. The difference in diagnostic accuracy between the two groups was statistically significant (P less than .01), said Dr. Shiroishi, a neuroradiologist at Childrens Hospital Los Angeles.

MR spectroscopy is a noninvasive way of monitoring the biochemical components of normal and abnormal brain tissue in vivo. MRS uses the same principles as MRI, but in MRS, a plot representing the chemical make-up of a region (rather than an image) is generated. MRS has proved useful in imaging tumors, infarcts, and epileptic foci.

“Spectroscopy allows us to readily distinguish … medulloblastomas, pilocytic astrocytomas, choroid plexus papillomas, and choroid plexus carcinomas,” said Dr. Shiroishi when he presented his findings at the annual meeting of the American Society of Neuroradiology.

“There is still a gray zone overlapping between anaplastic and regular astrocytomas and ependymomas,” he noted.

NEW ORLEANS — The combination of magnetic resonance spectroscopy with magnetic resonance imaging significantly improved the pretherapeutic diagnostic accuracy for pediatric brain tumors, according to findings from a retrospective study.

In a review of 122 children with newly detected brain tumors, Dr. Mark S. Shiroishi compared imaging reports with histopathologic findings. He found that the correct diagnosis was made 63% of the time (38/60) with contrast-enhanced magnetic resonance imaging (MRI). When magnetic resonance spectroscopy (MRS) was combined with contrast-enhanced MRI, the accuracy rate increased to 87% (54/62). MRI led to a partially correct diagnosis in 10% of cases (6/60), a rate that fell to 5% (3/62) when MRS was added.

Importantly, 27% of tumors (16/60) were incorrectly diagnosed with MRI alone, compared with 8% of those (5/62) who also underwent MRS. The difference in diagnostic accuracy between the two groups was statistically significant (P less than .01), said Dr. Shiroishi, a neuroradiologist at Childrens Hospital Los Angeles.

MR spectroscopy is a noninvasive way of monitoring the biochemical components of normal and abnormal brain tissue in vivo. MRS uses the same principles as MRI, but in MRS, a plot representing the chemical make-up of a region (rather than an image) is generated. MRS has proved useful in imaging tumors, infarcts, and epileptic foci.

“Spectroscopy allows us to readily distinguish … medulloblastomas, pilocytic astrocytomas, choroid plexus papillomas, and choroid plexus carcinomas,” said Dr. Shiroishi when he presented his findings at the annual meeting of the American Society of Neuroradiology.

“There is still a gray zone overlapping between anaplastic and regular astrocytomas and ependymomas,” he noted.

NEW ORLEANS — Functional MRI seems to be a reliable, safe, and effective technique to guide preoperative planning of brain tumor resection from eloquent cortex when used in conjunction with intraoperative stereotactic guidance, according to Kristin Houseknecht.

One benefit of using functional MRI (fMRI) preoperatively is that surgeons can avoid extensive intraoperative maneuvers such as awake craniotomy and cortical mapping.

“Awake craniotomy has the advantage of allowing real-time evaluation of function. However, there are unique intraoperative risks associated with awake craniotomy, and it also requires a willing and compliant patient,” noted Ms. Houseknecht, who is a fourth-year medical student at the University of South Florida, Tampa.

In this large series gathered as a retrospective chart review, 209 patients were identified who had undergone fMRI and then resective craniotomy under general anesthesia for either primary or secondary brain tumor in eloquent cortex between July 2002 and December 2005.

Postoperatively, 53% were neurologically stable, 30% showed neurologic improvement, and 17% experienced a decline in neurologic function.

Of those who had postoperative impairment, deficits were transient in about 30% and permanent in 13%.

Most patients in this group recovered rapidly and were discharged from the hospital within 2 days.

Tumors were located in the frontal (31%), parietal (20%), and temporal (11%) lobes, mostly within a single lobe.

Pathologically, 34% of tumors were glioblastoma, 12% grade 3 glioma, and 7% grade 2 glioma, and in a large number of patients, the brain tumors were secondary to cancer in other regions.

About half of the group had presented with motor deficits, 8% had speech deficits, and 11% had cognitive problems.

fMRI paradigms were chosen according to the function of the eloquent cortex in proximity to the brain tumor.

A test of foot flexion and extension or finger tapping was used to evaluate motor cortex and a number counting paradigm was employed to test the speech cortex.

“The majority of patients were able to satisfactorily complete the fMRI paradigms,” Ms. Houseknecht said.

Intraoperative somatosensory evoked potential monitoring was used to confirm sensory and motor cortex in some patients.

“Currently most tumors in eloquent cortex are referred to tertiary or quaternary referral centers because traditionally these cases are treated with an awake craniotomy to minimize postoperative neurologic deficits,” according to Dr. Nicolas Arredondo, a neurosurgery chief resident at the University of South Florida and one of the coinvestigators of the study.

“These preliminary data suggest that with preoperative fMRI and meticulous surgical technique, comparable outcomes may be possible in some cases without all of the resources that are required to successfully perform an awake craniotomy,” he commented.

Since the close of the enrollment date for this study, several hundred more patients with brain tumors have undergone fMRI, Ms. Houseknecht said at the American Society of Neuroradiology annual meeting.

“These results are just the tip of the iceberg,” he said.

Right motor strip (red shading) activated when the patient moved her left hand; at 1 month post resection of lesion, the patient was neurologically stable. Courtesy Dr. F. Reed Murtagh

NEW ORLEANS — Functional MRI seems to be a reliable, safe, and effective technique to guide preoperative planning of brain tumor resection from eloquent cortex when used in conjunction with intraoperative stereotactic guidance, according to Kristin Houseknecht.

One benefit of using functional MRI (fMRI) preoperatively is that surgeons can avoid extensive intraoperative maneuvers such as awake craniotomy and cortical mapping.

“Awake craniotomy has the advantage of allowing real-time evaluation of function. However, there are unique intraoperative risks associated with awake craniotomy, and it also requires a willing and compliant patient,” noted Ms. Houseknecht, who is a fourth-year medical student at the University of South Florida, Tampa.

In this large series gathered as a retrospective chart review, 209 patients were identified who had undergone fMRI and then resective craniotomy under general anesthesia for either primary or secondary brain tumor in eloquent cortex between July 2002 and December 2005.

Postoperatively, 53% were neurologically stable, 30% showed neurologic improvement, and 17% experienced a decline in neurologic function.

Of those who had postoperative impairment, deficits were transient in about 30% and permanent in 13%.

Most patients in this group recovered rapidly and were discharged from the hospital within 2 days.

Tumors were located in the frontal (31%), parietal (20%), and temporal (11%) lobes, mostly within a single lobe.

Pathologically, 34% of tumors were glioblastoma, 12% grade 3 glioma, and 7% grade 2 glioma, and in a large number of patients, the brain tumors were secondary to cancer in other regions.

About half of the group had presented with motor deficits, 8% had speech deficits, and 11% had cognitive problems.

fMRI paradigms were chosen according to the function of the eloquent cortex in proximity to the brain tumor.

A test of foot flexion and extension or finger tapping was used to evaluate motor cortex and a number counting paradigm was employed to test the speech cortex.

“The majority of patients were able to satisfactorily complete the fMRI paradigms,” Ms. Houseknecht said.

Intraoperative somatosensory evoked potential monitoring was used to confirm sensory and motor cortex in some patients.

“Currently most tumors in eloquent cortex are referred to tertiary or quaternary referral centers because traditionally these cases are treated with an awake craniotomy to minimize postoperative neurologic deficits,” according to Dr. Nicolas Arredondo, a neurosurgery chief resident at the University of South Florida and one of the coinvestigators of the study.

“These preliminary data suggest that with preoperative fMRI and meticulous surgical technique, comparable outcomes may be possible in some cases without all of the resources that are required to successfully perform an awake craniotomy,” he commented.

Since the close of the enrollment date for this study, several hundred more patients with brain tumors have undergone fMRI, Ms. Houseknecht said at the American Society of Neuroradiology annual meeting.

“These results are just the tip of the iceberg,” he said.

Right motor strip (red shading) activated when the patient moved her left hand; at 1 month post resection of lesion, the patient was neurologically stable. Courtesy Dr. F. Reed Murtagh

NEW ORLEANS — Functional MRI seems to be a reliable, safe, and effective technique to guide preoperative planning of brain tumor resection from eloquent cortex when used in conjunction with intraoperative stereotactic guidance, according to Kristin Houseknecht.

One benefit of using functional MRI (fMRI) preoperatively is that surgeons can avoid extensive intraoperative maneuvers such as awake craniotomy and cortical mapping.

“Awake craniotomy has the advantage of allowing real-time evaluation of function. However, there are unique intraoperative risks associated with awake craniotomy, and it also requires a willing and compliant patient,” noted Ms. Houseknecht, who is a fourth-year medical student at the University of South Florida, Tampa.

In this large series gathered as a retrospective chart review, 209 patients were identified who had undergone fMRI and then resective craniotomy under general anesthesia for either primary or secondary brain tumor in eloquent cortex between July 2002 and December 2005.

Postoperatively, 53% were neurologically stable, 30% showed neurologic improvement, and 17% experienced a decline in neurologic function.

Of those who had postoperative impairment, deficits were transient in about 30% and permanent in 13%.

Most patients in this group recovered rapidly and were discharged from the hospital within 2 days.

Tumors were located in the frontal (31%), parietal (20%), and temporal (11%) lobes, mostly within a single lobe.

Pathologically, 34% of tumors were glioblastoma, 12% grade 3 glioma, and 7% grade 2 glioma, and in a large number of patients, the brain tumors were secondary to cancer in other regions.

About half of the group had presented with motor deficits, 8% had speech deficits, and 11% had cognitive problems.

fMRI paradigms were chosen according to the function of the eloquent cortex in proximity to the brain tumor.

A test of foot flexion and extension or finger tapping was used to evaluate motor cortex and a number counting paradigm was employed to test the speech cortex.

“The majority of patients were able to satisfactorily complete the fMRI paradigms,” Ms. Houseknecht said.

Intraoperative somatosensory evoked potential monitoring was used to confirm sensory and motor cortex in some patients.

“Currently most tumors in eloquent cortex are referred to tertiary or quaternary referral centers because traditionally these cases are treated with an awake craniotomy to minimize postoperative neurologic deficits,” according to Dr. Nicolas Arredondo, a neurosurgery chief resident at the University of South Florida and one of the coinvestigators of the study.

“These preliminary data suggest that with preoperative fMRI and meticulous surgical technique, comparable outcomes may be possible in some cases without all of the resources that are required to successfully perform an awake craniotomy,” he commented.

Since the close of the enrollment date for this study, several hundred more patients with brain tumors have undergone fMRI, Ms. Houseknecht said at the American Society of Neuroradiology annual meeting.

“These results are just the tip of the iceberg,” he said.

Right motor strip (red shading) activated when the patient moved her left hand; at 1 month post resection of lesion, the patient was neurologically stable. Courtesy Dr. F. Reed Murtagh

NEW ORLEANS — With visualization of dynamic airway motion in children with severe obstructive sleep apnea, cine MRI supplies unique information that enhances diagnosis, targets treatment and, in some cases, prevents unnecessary surgeries, according to findings presented at annual meeting of the American Society of Neuroradiology.

Likely candidates for cine MRI evaluation are children who have obstructive sleep apnea (OSA) and have undergone adenoidectomy or tonsillectomy and have failed using continuous positive airway pressure (CPAP). Many have congenital disorders such as Beckwith Weidemann syndrome, trisomy 21, midfacial hypoplasia, and cleft palate. “We do not use cine MRI for the typical patient who has sleep apnea and enlarged tonsils and would respond to conservative management,” said Dr. H. Coleman Herrod, of the University of Utah, Salt Lake City.

For the cine MRI, the patient is deeply sedated using propofol and then monitored for airway obstruction. During imaging, the airway is not secured, in order to elicit the obstructive pathophysiology. This requires close monitoring by the anesthesiologist to foster physiologic sleep respiratory patterns, and technologists who know exactly what they are doing to ensure the child's safety, Dr. Herrod said. Patients are imaged on a 1.5-T magnet through several different sequences.

In 29 cases, sleep was successfully induced with no adverse events. Airway obstruction was visualized in most patients. The remaining patients were found to have patent airways throughout the exam with no clinical evidence of apnea.

Cause of obstruction visible on cine imaging included macroglossia, glossoptosis, micrognathia, palatine elongation or coaptation with posterior pharynx, tonsillar hypertrophy, and dynamic multilevel airway collapse. In several cases, more than one site appeared obstructed.

The findings directed the need for surgery and the type of procedure in several cases. For example, in one case, an enlarged tongue was shown to be obstructing the airway. Subsequently, tongue reduction surgery led to a decline in the OSA score from 50.1 to 4.4. In a second case, the patient underwent Le Fort maxillary retrusion—an operation for reconstruction of the midface in which the teeth-bearing part of the maxilla is separated from its bony attachments and repositioned—to correct the problem. In at least two cases, physicians decided against surgery after reviewing the results of the cine MRI.

Traditional imaging for the evaluation of OSA in children includes radiographic, CT, and fluoroscopic imaging. Static imaging may show anatomic details but yields no information regarding dynamic airway motion. Fluoroscopy can show dynamic changes but at the risk of ionizing radiation exposure. Cine MRI adds to the traditional work-up of OSA for those patients with more severe disease, said Dr. Herrod, who added that he is getting positive feedback from referring clinicians.

NEW ORLEANS — With visualization of dynamic airway motion in children with severe obstructive sleep apnea, cine MRI supplies unique information that enhances diagnosis, targets treatment and, in some cases, prevents unnecessary surgeries, according to findings presented at annual meeting of the American Society of Neuroradiology.

Likely candidates for cine MRI evaluation are children who have obstructive sleep apnea (OSA) and have undergone adenoidectomy or tonsillectomy and have failed using continuous positive airway pressure (CPAP). Many have congenital disorders such as Beckwith Weidemann syndrome, trisomy 21, midfacial hypoplasia, and cleft palate. “We do not use cine MRI for the typical patient who has sleep apnea and enlarged tonsils and would respond to conservative management,” said Dr. H. Coleman Herrod, of the University of Utah, Salt Lake City.

For the cine MRI, the patient is deeply sedated using propofol and then monitored for airway obstruction. During imaging, the airway is not secured, in order to elicit the obstructive pathophysiology. This requires close monitoring by the anesthesiologist to foster physiologic sleep respiratory patterns, and technologists who know exactly what they are doing to ensure the child's safety, Dr. Herrod said. Patients are imaged on a 1.5-T magnet through several different sequences.

In 29 cases, sleep was successfully induced with no adverse events. Airway obstruction was visualized in most patients. The remaining patients were found to have patent airways throughout the exam with no clinical evidence of apnea.

Cause of obstruction visible on cine imaging included macroglossia, glossoptosis, micrognathia, palatine elongation or coaptation with posterior pharynx, tonsillar hypertrophy, and dynamic multilevel airway collapse. In several cases, more than one site appeared obstructed.

The findings directed the need for surgery and the type of procedure in several cases. For example, in one case, an enlarged tongue was shown to be obstructing the airway. Subsequently, tongue reduction surgery led to a decline in the OSA score from 50.1 to 4.4. In a second case, the patient underwent Le Fort maxillary retrusion—an operation for reconstruction of the midface in which the teeth-bearing part of the maxilla is separated from its bony attachments and repositioned—to correct the problem. In at least two cases, physicians decided against surgery after reviewing the results of the cine MRI.

Traditional imaging for the evaluation of OSA in children includes radiographic, CT, and fluoroscopic imaging. Static imaging may show anatomic details but yields no information regarding dynamic airway motion. Fluoroscopy can show dynamic changes but at the risk of ionizing radiation exposure. Cine MRI adds to the traditional work-up of OSA for those patients with more severe disease, said Dr. Herrod, who added that he is getting positive feedback from referring clinicians.

NEW ORLEANS — With visualization of dynamic airway motion in children with severe obstructive sleep apnea, cine MRI supplies unique information that enhances diagnosis, targets treatment and, in some cases, prevents unnecessary surgeries, according to findings presented at annual meeting of the American Society of Neuroradiology.

Likely candidates for cine MRI evaluation are children who have obstructive sleep apnea (OSA) and have undergone adenoidectomy or tonsillectomy and have failed using continuous positive airway pressure (CPAP). Many have congenital disorders such as Beckwith Weidemann syndrome, trisomy 21, midfacial hypoplasia, and cleft palate. “We do not use cine MRI for the typical patient who has sleep apnea and enlarged tonsils and would respond to conservative management,” said Dr. H. Coleman Herrod, of the University of Utah, Salt Lake City.

For the cine MRI, the patient is deeply sedated using propofol and then monitored for airway obstruction. During imaging, the airway is not secured, in order to elicit the obstructive pathophysiology. This requires close monitoring by the anesthesiologist to foster physiologic sleep respiratory patterns, and technologists who know exactly what they are doing to ensure the child's safety, Dr. Herrod said. Patients are imaged on a 1.5-T magnet through several different sequences.

In 29 cases, sleep was successfully induced with no adverse events. Airway obstruction was visualized in most patients. The remaining patients were found to have patent airways throughout the exam with no clinical evidence of apnea.

Cause of obstruction visible on cine imaging included macroglossia, glossoptosis, micrognathia, palatine elongation or coaptation with posterior pharynx, tonsillar hypertrophy, and dynamic multilevel airway collapse. In several cases, more than one site appeared obstructed.

The findings directed the need for surgery and the type of procedure in several cases. For example, in one case, an enlarged tongue was shown to be obstructing the airway. Subsequently, tongue reduction surgery led to a decline in the OSA score from 50.1 to 4.4. In a second case, the patient underwent Le Fort maxillary retrusion—an operation for reconstruction of the midface in which the teeth-bearing part of the maxilla is separated from its bony attachments and repositioned—to correct the problem. In at least two cases, physicians decided against surgery after reviewing the results of the cine MRI.

Traditional imaging for the evaluation of OSA in children includes radiographic, CT, and fluoroscopic imaging. Static imaging may show anatomic details but yields no information regarding dynamic airway motion. Fluoroscopy can show dynamic changes but at the risk of ionizing radiation exposure. Cine MRI adds to the traditional work-up of OSA for those patients with more severe disease, said Dr. Herrod, who added that he is getting positive feedback from referring clinicians.

NEW ORLEANS — A sudden decrease in cerebral blood flow at age 12 may reflect underlying neurophysiologic processes heralding the onset of behavioral and cognitive changes that define adolescence.

Whereas previous studies have documented gradual age-associated decreases in cerebral blood flow in normal subjects, by studying a large sample size investigators were able to pinpoint precisely a time of rapid change. The sample included 380 subjects retrospectively identified from a pool of more than 8,000 who had MRI exams with arterial spin labeling perfusion imaging, said Dr. Christopher T. Whitlow, a neuroradiologist at Wake Forest University, Winston-Salem, N.C., who presented his findings at the American Society of Neuroradiology meeting.

Three trends were found after analysis of mean rates of cerebral blood flow (CBF) per year, coinvestigator Dr. Joseph Maldjian, director of the advanced neuroscience imaging research Laboratory at Wake Forest University said in an interview. The first 3 years of life are characterized by a rapid increase in rates of cerebral perfusion.

Dr. Whitlow said the majority of preadolescent subjects (aged 4-11 years) demonstrated whole-brain gray matter perfusion rates greater than 90 mL/100 g per minute. At that pivotal point, things appear to suddenly and rapidly change, so that by age 12-13 whole-brain gray matter perfusion is less than 90 mL/100 g per minute.

Compared with those of children 4-11 years of age, mean rates of CBF were significantly reduced by 27% among adolescents 12-19 years of age and 31% among young adults 20-30 years of age. There were no statistically significant differences, however, in rates of CBF between the adolescent and young adult age subgroups.

“The relatively rapid changes in cerebral perfusion that correspond to the onset of adolescence may help to explain the sudden nonlinear nature of marked shifts in emotional, motivational, and cognitive processes associated with this period of development,” said Dr. Whitlow.

He plans to explore age-related regional changes in CBF and to correlate CBF changes with hormone status.

Mean CBF rates were 27% lower among teens than children 4-11 years of age. The Advanced Neuroscience Imaging Research Laboratory/Department of Radiology/Wake Forest University School of Medicine

NEW ORLEANS — A sudden decrease in cerebral blood flow at age 12 may reflect underlying neurophysiologic processes heralding the onset of behavioral and cognitive changes that define adolescence.

Whereas previous studies have documented gradual age-associated decreases in cerebral blood flow in normal subjects, by studying a large sample size investigators were able to pinpoint precisely a time of rapid change. The sample included 380 subjects retrospectively identified from a pool of more than 8,000 who had MRI exams with arterial spin labeling perfusion imaging, said Dr. Christopher T. Whitlow, a neuroradiologist at Wake Forest University, Winston-Salem, N.C., who presented his findings at the American Society of Neuroradiology meeting.

Three trends were found after analysis of mean rates of cerebral blood flow (CBF) per year, coinvestigator Dr. Joseph Maldjian, director of the advanced neuroscience imaging research Laboratory at Wake Forest University said in an interview. The first 3 years of life are characterized by a rapid increase in rates of cerebral perfusion.

Dr. Whitlow said the majority of preadolescent subjects (aged 4-11 years) demonstrated whole-brain gray matter perfusion rates greater than 90 mL/100 g per minute. At that pivotal point, things appear to suddenly and rapidly change, so that by age 12-13 whole-brain gray matter perfusion is less than 90 mL/100 g per minute.

Compared with those of children 4-11 years of age, mean rates of CBF were significantly reduced by 27% among adolescents 12-19 years of age and 31% among young adults 20-30 years of age. There were no statistically significant differences, however, in rates of CBF between the adolescent and young adult age subgroups.

“The relatively rapid changes in cerebral perfusion that correspond to the onset of adolescence may help to explain the sudden nonlinear nature of marked shifts in emotional, motivational, and cognitive processes associated with this period of development,” said Dr. Whitlow.

He plans to explore age-related regional changes in CBF and to correlate CBF changes with hormone status.

Mean CBF rates were 27% lower among teens than children 4-11 years of age. The Advanced Neuroscience Imaging Research Laboratory/Department of Radiology/Wake Forest University School of Medicine

NEW ORLEANS — A sudden decrease in cerebral blood flow at age 12 may reflect underlying neurophysiologic processes heralding the onset of behavioral and cognitive changes that define adolescence.

Whereas previous studies have documented gradual age-associated decreases in cerebral blood flow in normal subjects, by studying a large sample size investigators were able to pinpoint precisely a time of rapid change. The sample included 380 subjects retrospectively identified from a pool of more than 8,000 who had MRI exams with arterial spin labeling perfusion imaging, said Dr. Christopher T. Whitlow, a neuroradiologist at Wake Forest University, Winston-Salem, N.C., who presented his findings at the American Society of Neuroradiology meeting.

Three trends were found after analysis of mean rates of cerebral blood flow (CBF) per year, coinvestigator Dr. Joseph Maldjian, director of the advanced neuroscience imaging research Laboratory at Wake Forest University said in an interview. The first 3 years of life are characterized by a rapid increase in rates of cerebral perfusion.

Dr. Whitlow said the majority of preadolescent subjects (aged 4-11 years) demonstrated whole-brain gray matter perfusion rates greater than 90 mL/100 g per minute. At that pivotal point, things appear to suddenly and rapidly change, so that by age 12-13 whole-brain gray matter perfusion is less than 90 mL/100 g per minute.

Compared with those of children 4-11 years of age, mean rates of CBF were significantly reduced by 27% among adolescents 12-19 years of age and 31% among young adults 20-30 years of age. There were no statistically significant differences, however, in rates of CBF between the adolescent and young adult age subgroups.

“The relatively rapid changes in cerebral perfusion that correspond to the onset of adolescence may help to explain the sudden nonlinear nature of marked shifts in emotional, motivational, and cognitive processes associated with this period of development,” said Dr. Whitlow.

He plans to explore age-related regional changes in CBF and to correlate CBF changes with hormone status.

Mean CBF rates were 27% lower among teens than children 4-11 years of age. The Advanced Neuroscience Imaging Research Laboratory/Department of Radiology/Wake Forest University School of Medicine

CHICAGO — No new cases of progressive multifocal leukoencephalopathy were reported among 36,700 patients with multiple sclerosis treated with natalizumab since the summer of 2006.

Similarly, no drug-related deaths have been reported. And the incidence of adverse events (AEs) has been low, despite the fact that many patients have been using the drug for longer than 1 year to treat multiple sclerosis (MS), said Dr. Carmen M. Bozic, vice president for drug safety at Biogen Idec Inc., which markets natalizumab as Tysabri.

“The TOUCH [prescribing program], TYGRIS [safety study], and pregnancy registry will constitute the largest long-term follow-up undertaken by any sponsor for a single therapy for multiple sclerosis,” said Dr. Bozic at the annual meeting of the American Academy of Neurology.

Hepatic events occurred in less than 1/1,000 patients and were mostly reversible, she said. Less than 20% discontinued the drug.

The JC virus (JCV), which lies dormant in about 80% of adults whether they have MS or not, causes PML. When Dr. Bozic examined data from 2,370 MS patients who had undergone JCV testing, 5 had detectable plasma levels of JCV, including 3 from the placebo group.

At the time of the presentation, 2,752 physicians were registered with TOUCH and 17,863 patients were receiving natalizumab. About 18% previously had been treated with natalizumab, with a median of seven infusions. About 5,600 patients were treated for at least 1 year. Four percent were treatment naive, 65% switched from another disease-modifying therapy, 13% switched from other therapies, and a few were “returning quitters.”

As of February 2008, about 2,100 patients were enrolled in the TYGRIS study. The incidence of serious adverse events was 2.6%. The most frequent adverse events were hypersensitivity reactions (0.6%) and infections (0.6%), the latter being “garden variety” upper respiratory infections, she said. There were no reports of PML. Two deaths unrelated to treatment were documented.

Thirty-six pregnant patients were enrolled in the pregnancy registry, with 20 ongoing pregnancies. There were no reports of adverse pregnancy outcomes.

A second presentation focused on the experiences of patients with MS who resumed natalizumab after voluntary discontinuation. While the overall incidence of hypersensitivity reactions or infusion reactions was low, the risks were elevated for patients who had only one or two prior infusions, said Dr. Paul W. O'Connor of St. Michael's Hospital, Toronto.

Dr. O'Connor scrutinized the records of 1,089 MS patients who had completed natalizumab pivotal clinical trials but stopped and restarted treatment. Of this group, 384 had formerly received placebo and 705 had been treated with natalizumab. All had been treated for about a year and a half, had received a median of seven infusions, and had MS for about 8 years.

Most (87%) had one or more AEs. About 55 (5%) had a serious AE, most commonly an MS relapse (2%). Overall rates of infusion reactions (5%) and hypersensitivity reactions (less than 1%) were low, and there were no opportunistic infections.

When the group was stratified by the number of prior infusions, the risk of infusion reactions or hypersensitivity reactions jumped to 24.1% and 7.4%, respectively, for those who had only one or two previous treatments.

Testing of over 6,000 plasma samples resulted in less than 1% (6/1,089 samples) with detectable JCV DNA, and these findings were not associated with PML, said Dr. O'Connor. Of the six positive samples, five had become JCV positive while on natalizumab and one was positive at baseline and became negative upon retesting.

Dr. Bozic is an employee of Biogen Idec and holds stock options in the company. Dr. O'Connor has received compensation for activities related to Biogen Idec and research support from them.

JCV testing of more than 6,000 plasma samples resulted in less than 1% with detectable JCV DNA. DR. O'CONNOR

CHICAGO — No new cases of progressive multifocal leukoencephalopathy were reported among 36,700 patients with multiple sclerosis treated with natalizumab since the summer of 2006.

Similarly, no drug-related deaths have been reported. And the incidence of adverse events (AEs) has been low, despite the fact that many patients have been using the drug for longer than 1 year to treat multiple sclerosis (MS), said Dr. Carmen M. Bozic, vice president for drug safety at Biogen Idec Inc., which markets natalizumab as Tysabri.

“The TOUCH [prescribing program], TYGRIS [safety study], and pregnancy registry will constitute the largest long-term follow-up undertaken by any sponsor for a single therapy for multiple sclerosis,” said Dr. Bozic at the annual meeting of the American Academy of Neurology.

Hepatic events occurred in less than 1/1,000 patients and were mostly reversible, she said. Less than 20% discontinued the drug.

The JC virus (JCV), which lies dormant in about 80% of adults whether they have MS or not, causes PML. When Dr. Bozic examined data from 2,370 MS patients who had undergone JCV testing, 5 had detectable plasma levels of JCV, including 3 from the placebo group.

At the time of the presentation, 2,752 physicians were registered with TOUCH and 17,863 patients were receiving natalizumab. About 18% previously had been treated with natalizumab, with a median of seven infusions. About 5,600 patients were treated for at least 1 year. Four percent were treatment naive, 65% switched from another disease-modifying therapy, 13% switched from other therapies, and a few were “returning quitters.”

As of February 2008, about 2,100 patients were enrolled in the TYGRIS study. The incidence of serious adverse events was 2.6%. The most frequent adverse events were hypersensitivity reactions (0.6%) and infections (0.6%), the latter being “garden variety” upper respiratory infections, she said. There were no reports of PML. Two deaths unrelated to treatment were documented.

Thirty-six pregnant patients were enrolled in the pregnancy registry, with 20 ongoing pregnancies. There were no reports of adverse pregnancy outcomes.

A second presentation focused on the experiences of patients with MS who resumed natalizumab after voluntary discontinuation. While the overall incidence of hypersensitivity reactions or infusion reactions was low, the risks were elevated for patients who had only one or two prior infusions, said Dr. Paul W. O'Connor of St. Michael's Hospital, Toronto.

Dr. O'Connor scrutinized the records of 1,089 MS patients who had completed natalizumab pivotal clinical trials but stopped and restarted treatment. Of this group, 384 had formerly received placebo and 705 had been treated with natalizumab. All had been treated for about a year and a half, had received a median of seven infusions, and had MS for about 8 years.

Most (87%) had one or more AEs. About 55 (5%) had a serious AE, most commonly an MS relapse (2%). Overall rates of infusion reactions (5%) and hypersensitivity reactions (less than 1%) were low, and there were no opportunistic infections.

When the group was stratified by the number of prior infusions, the risk of infusion reactions or hypersensitivity reactions jumped to 24.1% and 7.4%, respectively, for those who had only one or two previous treatments.

Testing of over 6,000 plasma samples resulted in less than 1% (6/1,089 samples) with detectable JCV DNA, and these findings were not associated with PML, said Dr. O'Connor. Of the six positive samples, five had become JCV positive while on natalizumab and one was positive at baseline and became negative upon retesting.

Dr. Bozic is an employee of Biogen Idec and holds stock options in the company. Dr. O'Connor has received compensation for activities related to Biogen Idec and research support from them.

JCV testing of more than 6,000 plasma samples resulted in less than 1% with detectable JCV DNA. DR. O'CONNOR

CHICAGO — No new cases of progressive multifocal leukoencephalopathy were reported among 36,700 patients with multiple sclerosis treated with natalizumab since the summer of 2006.

Similarly, no drug-related deaths have been reported. And the incidence of adverse events (AEs) has been low, despite the fact that many patients have been using the drug for longer than 1 year to treat multiple sclerosis (MS), said Dr. Carmen M. Bozic, vice president for drug safety at Biogen Idec Inc., which markets natalizumab as Tysabri.

“The TOUCH [prescribing program], TYGRIS [safety study], and pregnancy registry will constitute the largest long-term follow-up undertaken by any sponsor for a single therapy for multiple sclerosis,” said Dr. Bozic at the annual meeting of the American Academy of Neurology.

Hepatic events occurred in less than 1/1,000 patients and were mostly reversible, she said. Less than 20% discontinued the drug.

The JC virus (JCV), which lies dormant in about 80% of adults whether they have MS or not, causes PML. When Dr. Bozic examined data from 2,370 MS patients who had undergone JCV testing, 5 had detectable plasma levels of JCV, including 3 from the placebo group.

At the time of the presentation, 2,752 physicians were registered with TOUCH and 17,863 patients were receiving natalizumab. About 18% previously had been treated with natalizumab, with a median of seven infusions. About 5,600 patients were treated for at least 1 year. Four percent were treatment naive, 65% switched from another disease-modifying therapy, 13% switched from other therapies, and a few were “returning quitters.”

As of February 2008, about 2,100 patients were enrolled in the TYGRIS study. The incidence of serious adverse events was 2.6%. The most frequent adverse events were hypersensitivity reactions (0.6%) and infections (0.6%), the latter being “garden variety” upper respiratory infections, she said. There were no reports of PML. Two deaths unrelated to treatment were documented.

Thirty-six pregnant patients were enrolled in the pregnancy registry, with 20 ongoing pregnancies. There were no reports of adverse pregnancy outcomes.

A second presentation focused on the experiences of patients with MS who resumed natalizumab after voluntary discontinuation. While the overall incidence of hypersensitivity reactions or infusion reactions was low, the risks were elevated for patients who had only one or two prior infusions, said Dr. Paul W. O'Connor of St. Michael's Hospital, Toronto.

Dr. O'Connor scrutinized the records of 1,089 MS patients who had completed natalizumab pivotal clinical trials but stopped and restarted treatment. Of this group, 384 had formerly received placebo and 705 had been treated with natalizumab. All had been treated for about a year and a half, had received a median of seven infusions, and had MS for about 8 years.

Most (87%) had one or more AEs. About 55 (5%) had a serious AE, most commonly an MS relapse (2%). Overall rates of infusion reactions (5%) and hypersensitivity reactions (less than 1%) were low, and there were no opportunistic infections.

When the group was stratified by the number of prior infusions, the risk of infusion reactions or hypersensitivity reactions jumped to 24.1% and 7.4%, respectively, for those who had only one or two previous treatments.

Testing of over 6,000 plasma samples resulted in less than 1% (6/1,089 samples) with detectable JCV DNA, and these findings were not associated with PML, said Dr. O'Connor. Of the six positive samples, five had become JCV positive while on natalizumab and one was positive at baseline and became negative upon retesting.

Dr. Bozic is an employee of Biogen Idec and holds stock options in the company. Dr. O'Connor has received compensation for activities related to Biogen Idec and research support from them.

JCV testing of more than 6,000 plasma samples resulted in less than 1% with detectable JCV DNA. DR. O'CONNOR

CHICAGO — Analysis of EEG patterns in a group of drug-naive children diagnosed with absence seizures found that although 80% of individuals demonstrated consistent patterns, only 18% of this group demonstrated the classic pattern commonly described in textbooks, according to Dr. Yoshimi Sogawa.

“Textbooks will tell you that absence bursts are characterized by 3-Hz spike and wave discharges, are nonevolving, and start and end abruptly. What we are finding is that is not true,” said Dr. Sogawa, a neurologist at the Children's Hospital at Montefiore, New York.

The study participants, part of the largest cohort gathered to date of children with absence seizures (n = 400), were enrolled in the National Institutes of Health Childhood Absence Epilepsy Trial. Dr. Sogawa analyzed the EEGs of 103 drug-naive children. Of this group, 80 children showed a consistent EEG pattern while 23 who showed intraindividual variability were excluded from further analysis. Making an analogy to a musical sonata, Dr. Sogawa subdivided the 3-Hz spike-wave discharges into multiple components.

Within a burst, she identified five components:

▸ Introduction (I): initial change from baseline, consisting of irregular slowing with or without spikes.

▸ Exposition (E): the characteristic 3-Hz spike-wave discharge.

▸ Development (D): variations on the 3-Hz pattern.

▸ Recapitulation (R): reemergence of the E-like pattern.

▸ Coda (C): combination of rhythmic slow activity.

With these elements, Dr. Sogawa found that three predominant patterns emerge. The most frequent combination was the I-E-D-C pattern (59%), followed by the semiclassic I-E-D-R pattern (23.8%), and then the “classic” I-E-C pattern (17%).

“These patterns bring up the question: What is childhood absence epilepsy? It is not a single entity. There are so many variations,” according to Dr. Sogawa. This variability certainly brings into question the diagnostic value of the classic EEG pattern.

Dr. Sogawa suggested that the distribution of a particular EEG component may reflect genetic variability, perhaps related to calcium channel function, and may underlie the differences in sensitivity to antiepileptic medications that she often sees. Speaking at the annual meeting of the American Academy of Neurology, Dr. Sogawa said genetic analyses are underway to see how different EEG patterns correlate with drug response and comorbidity.

Dr. Sogawa said she had nothing to disclose.

CHICAGO — Analysis of EEG patterns in a group of drug-naive children diagnosed with absence seizures found that although 80% of individuals demonstrated consistent patterns, only 18% of this group demonstrated the classic pattern commonly described in textbooks, according to Dr. Yoshimi Sogawa.

“Textbooks will tell you that absence bursts are characterized by 3-Hz spike and wave discharges, are nonevolving, and start and end abruptly. What we are finding is that is not true,” said Dr. Sogawa, a neurologist at the Children's Hospital at Montefiore, New York.

The study participants, part of the largest cohort gathered to date of children with absence seizures (n = 400), were enrolled in the National Institutes of Health Childhood Absence Epilepsy Trial. Dr. Sogawa analyzed the EEGs of 103 drug-naive children. Of this group, 80 children showed a consistent EEG pattern while 23 who showed intraindividual variability were excluded from further analysis. Making an analogy to a musical sonata, Dr. Sogawa subdivided the 3-Hz spike-wave discharges into multiple components.

Within a burst, she identified five components:

▸ Introduction (I): initial change from baseline, consisting of irregular slowing with or without spikes.

▸ Exposition (E): the characteristic 3-Hz spike-wave discharge.

▸ Development (D): variations on the 3-Hz pattern.

▸ Recapitulation (R): reemergence of the E-like pattern.

▸ Coda (C): combination of rhythmic slow activity.

With these elements, Dr. Sogawa found that three predominant patterns emerge. The most frequent combination was the I-E-D-C pattern (59%), followed by the semiclassic I-E-D-R pattern (23.8%), and then the “classic” I-E-C pattern (17%).

“These patterns bring up the question: What is childhood absence epilepsy? It is not a single entity. There are so many variations,” according to Dr. Sogawa. This variability certainly brings into question the diagnostic value of the classic EEG pattern.

Dr. Sogawa suggested that the distribution of a particular EEG component may reflect genetic variability, perhaps related to calcium channel function, and may underlie the differences in sensitivity to antiepileptic medications that she often sees. Speaking at the annual meeting of the American Academy of Neurology, Dr. Sogawa said genetic analyses are underway to see how different EEG patterns correlate with drug response and comorbidity.

Dr. Sogawa said she had nothing to disclose.

CHICAGO — Analysis of EEG patterns in a group of drug-naive children diagnosed with absence seizures found that although 80% of individuals demonstrated consistent patterns, only 18% of this group demonstrated the classic pattern commonly described in textbooks, according to Dr. Yoshimi Sogawa.

“Textbooks will tell you that absence bursts are characterized by 3-Hz spike and wave discharges, are nonevolving, and start and end abruptly. What we are finding is that is not true,” said Dr. Sogawa, a neurologist at the Children's Hospital at Montefiore, New York.

The study participants, part of the largest cohort gathered to date of children with absence seizures (n = 400), were enrolled in the National Institutes of Health Childhood Absence Epilepsy Trial. Dr. Sogawa analyzed the EEGs of 103 drug-naive children. Of this group, 80 children showed a consistent EEG pattern while 23 who showed intraindividual variability were excluded from further analysis. Making an analogy to a musical sonata, Dr. Sogawa subdivided the 3-Hz spike-wave discharges into multiple components.

Within a burst, she identified five components:

▸ Introduction (I): initial change from baseline, consisting of irregular slowing with or without spikes.

▸ Exposition (E): the characteristic 3-Hz spike-wave discharge.

▸ Development (D): variations on the 3-Hz pattern.

▸ Recapitulation (R): reemergence of the E-like pattern.

▸ Coda (C): combination of rhythmic slow activity.

With these elements, Dr. Sogawa found that three predominant patterns emerge. The most frequent combination was the I-E-D-C pattern (59%), followed by the semiclassic I-E-D-R pattern (23.8%), and then the “classic” I-E-C pattern (17%).

“These patterns bring up the question: What is childhood absence epilepsy? It is not a single entity. There are so many variations,” according to Dr. Sogawa. This variability certainly brings into question the diagnostic value of the classic EEG pattern.

Dr. Sogawa suggested that the distribution of a particular EEG component may reflect genetic variability, perhaps related to calcium channel function, and may underlie the differences in sensitivity to antiepileptic medications that she often sees. Speaking at the annual meeting of the American Academy of Neurology, Dr. Sogawa said genetic analyses are underway to see how different EEG patterns correlate with drug response and comorbidity.

Dr. Sogawa said she had nothing to disclose.

CHICAGO – Older adults with normal cognition who engaged in a mental fitness program for 1 hour a day, 5 days a week for 8 weeks demonstrated significant improvements in memory and nonmemory tasks, according to data presented at the annual meeting of the American Academy of Neurology.

Gains were documented in standard neuropsychological tests that measured auditory memory, digit processing, letter-number sequencing, learning, delayed recall, and list memory, according to Dr. Kristine Yaffe, professor of psychiatry, neurology, and epidemiology and biostatistics at the University of California, San Francisco.

The randomized, double-blind trial, known as IMPACT, included 437 adults with a mean age of 75 years and Mini-Mental State Examination scores of 26 or higher. Of the total number of participants, 215 were assigned to the Brain Fitness Program, a cognitive training program designed to augment brain plasticity (Posit Science Corp., San Francisco), and 222 were assigned to an active control group that engaged in a more standard computer-based educational program. Each group underwent about 40 hours of training.

In the primary outcome measure–the Repeatable Battery for the Assessment of Neuropsychological Status [RBANS] GlobalAuditory Memory score–those in the experimental group demonstrated an average improvement of 3.66 points, compared with 1.30 points for those in the control group (P = .01). The training did not improve scores on the visual memory component of the RBANS.

In addition to the performance demonstrated on the objective test, the mental fitness buffs reported that their cognition had improved on a self-report questionnaire.

“'Use it or lose it' makes a lot of sense, but there [are] not a lot of data,” said Dr. Yaffe, who is also chief of geriatric psychiatry and director of the memory disorders clinic at the San Francisco VA Medical Center.

She categorized the risk factors for dementia and cognitive decline according to whether or not they can be modified. Although age and family history are unchangeable, for example, cardiovascular disease, obesity, metabolic dysregulation, depression, and physical and intellectual inactivity are risk factors that are amenable to intervention and modification, she noted.

With these risk factors in mind, Dr. Yaffe suggested the following strategies to prevent cognitive decline and dementia:

▸ Screen for depression and institute effective treatment promptly.

▸ Reduce cardiovascular risk factors, such as hypertension, metabolic syndrome, hypercholesterolemia, diabetes, and obesity, especially during midlife.

▸ Prevent head trauma.

▸ Promote mental activity, including lifelong education.

▸ Encourage physical activity.

Dr. Yaffe has served as a consultant to Posit Science Corporation. Her coauthors received personal compensation for activities with Posit Science as consultants.

CHICAGO – Older adults with normal cognition who engaged in a mental fitness program for 1 hour a day, 5 days a week for 8 weeks demonstrated significant improvements in memory and nonmemory tasks, according to data presented at the annual meeting of the American Academy of Neurology.

Gains were documented in standard neuropsychological tests that measured auditory memory, digit processing, letter-number sequencing, learning, delayed recall, and list memory, according to Dr. Kristine Yaffe, professor of psychiatry, neurology, and epidemiology and biostatistics at the University of California, San Francisco.

The randomized, double-blind trial, known as IMPACT, included 437 adults with a mean age of 75 years and Mini-Mental State Examination scores of 26 or higher. Of the total number of participants, 215 were assigned to the Brain Fitness Program, a cognitive training program designed to augment brain plasticity (Posit Science Corp., San Francisco), and 222 were assigned to an active control group that engaged in a more standard computer-based educational program. Each group underwent about 40 hours of training.

In the primary outcome measure–the Repeatable Battery for the Assessment of Neuropsychological Status [RBANS] GlobalAuditory Memory score–those in the experimental group demonstrated an average improvement of 3.66 points, compared with 1.30 points for those in the control group (P = .01). The training did not improve scores on the visual memory component of the RBANS.

In addition to the performance demonstrated on the objective test, the mental fitness buffs reported that their cognition had improved on a self-report questionnaire.

“'Use it or lose it' makes a lot of sense, but there [are] not a lot of data,” said Dr. Yaffe, who is also chief of geriatric psychiatry and director of the memory disorders clinic at the San Francisco VA Medical Center.

She categorized the risk factors for dementia and cognitive decline according to whether or not they can be modified. Although age and family history are unchangeable, for example, cardiovascular disease, obesity, metabolic dysregulation, depression, and physical and intellectual inactivity are risk factors that are amenable to intervention and modification, she noted.

With these risk factors in mind, Dr. Yaffe suggested the following strategies to prevent cognitive decline and dementia:

▸ Screen for depression and institute effective treatment promptly.

▸ Reduce cardiovascular risk factors, such as hypertension, metabolic syndrome, hypercholesterolemia, diabetes, and obesity, especially during midlife.

▸ Prevent head trauma.

▸ Promote mental activity, including lifelong education.

▸ Encourage physical activity.

Dr. Yaffe has served as a consultant to Posit Science Corporation. Her coauthors received personal compensation for activities with Posit Science as consultants.

CHICAGO – Older adults with normal cognition who engaged in a mental fitness program for 1 hour a day, 5 days a week for 8 weeks demonstrated significant improvements in memory and nonmemory tasks, according to data presented at the annual meeting of the American Academy of Neurology.

Gains were documented in standard neuropsychological tests that measured auditory memory, digit processing, letter-number sequencing, learning, delayed recall, and list memory, according to Dr. Kristine Yaffe, professor of psychiatry, neurology, and epidemiology and biostatistics at the University of California, San Francisco.

The randomized, double-blind trial, known as IMPACT, included 437 adults with a mean age of 75 years and Mini-Mental State Examination scores of 26 or higher. Of the total number of participants, 215 were assigned to the Brain Fitness Program, a cognitive training program designed to augment brain plasticity (Posit Science Corp., San Francisco), and 222 were assigned to an active control group that engaged in a more standard computer-based educational program. Each group underwent about 40 hours of training.

In the primary outcome measure–the Repeatable Battery for the Assessment of Neuropsychological Status [RBANS] GlobalAuditory Memory score–those in the experimental group demonstrated an average improvement of 3.66 points, compared with 1.30 points for those in the control group (P = .01). The training did not improve scores on the visual memory component of the RBANS.

In addition to the performance demonstrated on the objective test, the mental fitness buffs reported that their cognition had improved on a self-report questionnaire.

“'Use it or lose it' makes a lot of sense, but there [are] not a lot of data,” said Dr. Yaffe, who is also chief of geriatric psychiatry and director of the memory disorders clinic at the San Francisco VA Medical Center.

She categorized the risk factors for dementia and cognitive decline according to whether or not they can be modified. Although age and family history are unchangeable, for example, cardiovascular disease, obesity, metabolic dysregulation, depression, and physical and intellectual inactivity are risk factors that are amenable to intervention and modification, she noted.

With these risk factors in mind, Dr. Yaffe suggested the following strategies to prevent cognitive decline and dementia:

▸ Screen for depression and institute effective treatment promptly.

▸ Reduce cardiovascular risk factors, such as hypertension, metabolic syndrome, hypercholesterolemia, diabetes, and obesity, especially during midlife.

▸ Prevent head trauma.

▸ Promote mental activity, including lifelong education.

▸ Encourage physical activity.

Dr. Yaffe has served as a consultant to Posit Science Corporation. Her coauthors received personal compensation for activities with Posit Science as consultants.

CHICAGO – Poor gait and balance in the elderly correlated with white matter abnormalities in the genu of the corpus callosum, according to data presented at the American Society of Neuroradiology meeting. This was independent of age, arthritis, neuropathy, stroke, or brain atrophy.

Dr. Rafeeque A. Bhadelia studied 166 elderly individuals (123 females, mean age 74 years). Using diffusion tensor imaging (DTI), he found highly significant links between fractional anisotropy (FA) in the genu of the corpus callosum and Tenetti scores of gait (r = 0.31) and balance (r = 0.27). There were no correlations between FA in the splenium of the corpus callosum and gait or balance scores. “This is not surprising,” said Dr. Bhadelia, clinical operations chief in neuroradiology at Beth Israel Deaconess Medical Center, Boston. That's because the genu of the corpus callosum connects both frontal lobes; other studies show ties between gait, balance, and frontal lobe function.

MR DTI gives a detailed view of white matter fiber tracts and direction. FA reflects directional brain organization, which is influenced by the magnitude and orientation of white matter tracts.

Since gait and balance dysfunction can be caused by other factors (deconditioning, arthritis, degenerative disease, stroke, etc.), a multivariate analysis was performed. Correlations between FA in the genu and gait (r = 0.24) and balance (r = 0.30) were still highly significant independent of age, gender, arthritis, neuropathy, stroke, or brain atrophy. DTI can therefore distinguish individuals whose balance problems derive from white matter dysfunction from those whose poor mobility has other causes.

On DTI, white matter fibers are green, red, or blue, depending on their direction. Courtesy Dr. Rafeeque A. Bhadelia

CHICAGO – Poor gait and balance in the elderly correlated with white matter abnormalities in the genu of the corpus callosum, according to data presented at the American Society of Neuroradiology meeting. This was independent of age, arthritis, neuropathy, stroke, or brain atrophy.

Dr. Rafeeque A. Bhadelia studied 166 elderly individuals (123 females, mean age 74 years). Using diffusion tensor imaging (DTI), he found highly significant links between fractional anisotropy (FA) in the genu of the corpus callosum and Tenetti scores of gait (r = 0.31) and balance (r = 0.27). There were no correlations between FA in the splenium of the corpus callosum and gait or balance scores. “This is not surprising,” said Dr. Bhadelia, clinical operations chief in neuroradiology at Beth Israel Deaconess Medical Center, Boston. That's because the genu of the corpus callosum connects both frontal lobes; other studies show ties between gait, balance, and frontal lobe function.

MR DTI gives a detailed view of white matter fiber tracts and direction. FA reflects directional brain organization, which is influenced by the magnitude and orientation of white matter tracts.

Since gait and balance dysfunction can be caused by other factors (deconditioning, arthritis, degenerative disease, stroke, etc.), a multivariate analysis was performed. Correlations between FA in the genu and gait (r = 0.24) and balance (r = 0.30) were still highly significant independent of age, gender, arthritis, neuropathy, stroke, or brain atrophy. DTI can therefore distinguish individuals whose balance problems derive from white matter dysfunction from those whose poor mobility has other causes.

On DTI, white matter fibers are green, red, or blue, depending on their direction. Courtesy Dr. Rafeeque A. Bhadelia

CHICAGO – Poor gait and balance in the elderly correlated with white matter abnormalities in the genu of the corpus callosum, according to data presented at the American Society of Neuroradiology meeting. This was independent of age, arthritis, neuropathy, stroke, or brain atrophy.

Dr. Rafeeque A. Bhadelia studied 166 elderly individuals (123 females, mean age 74 years). Using diffusion tensor imaging (DTI), he found highly significant links between fractional anisotropy (FA) in the genu of the corpus callosum and Tenetti scores of gait (r = 0.31) and balance (r = 0.27). There were no correlations between FA in the splenium of the corpus callosum and gait or balance scores. “This is not surprising,” said Dr. Bhadelia, clinical operations chief in neuroradiology at Beth Israel Deaconess Medical Center, Boston. That's because the genu of the corpus callosum connects both frontal lobes; other studies show ties between gait, balance, and frontal lobe function.

MR DTI gives a detailed view of white matter fiber tracts and direction. FA reflects directional brain organization, which is influenced by the magnitude and orientation of white matter tracts.

Since gait and balance dysfunction can be caused by other factors (deconditioning, arthritis, degenerative disease, stroke, etc.), a multivariate analysis was performed. Correlations between FA in the genu and gait (r = 0.24) and balance (r = 0.30) were still highly significant independent of age, gender, arthritis, neuropathy, stroke, or brain atrophy. DTI can therefore distinguish individuals whose balance problems derive from white matter dysfunction from those whose poor mobility has other causes.

On DTI, white matter fibers are green, red, or blue, depending on their direction. Courtesy Dr. Rafeeque A. Bhadelia

DANA POINT CALIF. — Aneurysms that develop in children differ in distribution and etiology, compared with those in adults, but they can often be treated effectively, safely, and durably by surgery, embolization, or combination therapy, according to Dr. Steven Hetts, who presented his findings at the American Society of Interventional and Therapeutic Neuroradiology annual meeting.

Aneurysms occur rarely in children, with only 2%–5% of all aneurysms found in people age 19 years or younger. Nevertheless, when an aneurysm is discovered in a child, clinicians are faced with questions such as what is the risk of aneurysm rupture, whether to treat, and what treatment options are best.

By examining retrospective and prospective medical records, MRIs, and intracranial angiograms, Dr. Hetts was able to collect data on 75 children with 101 aneurysms who had been treated at the University of California, San Francisco, School of Medicine between 1981 and 2006. The children ranged in age from 3 months to 18 years, and the mean follow-up time was 45 months.

Headache, the most common symptom at presentation, was reported by 34 of the children.

Other symptoms include cranial neuropathy (12), nausea and vomiting (11), changes in vision (10), trauma (9), seizures (3,) and pulsatile tinnitus (1). Five children were asymptomatic. Twenty-four children presented with subarachnoid hemorrhage (SAH).

When Dr. Hetts analyzed aneurysm morphology, he found that 46% of the 101 aneurysms were saccular and 31% were fusiform. Twelve percent of the aneurysms were associated with infection, and 14% were thought to have a traumatic etiology. The mean maximal diameter was 12 mm and 11% were considered to be “giant” (greater than 25 mm) aneurysms. Sixteen percent of patients had multiple aneurysms.

In this sample, one child died, indicating 1.3% mortality. Four of 75 children (5%) manifested a new infarction and 1 in 75 children (1.3%) developed new-onset seizures. Twenty-four aneurysms ruptured, according to Dr. Hetts.

In the sample, saccular lesions were associated with a higher risk of rupture: 19 of the 46 saccular aneurysms ruptured, compared with only 2 of the 12 infectious and 3 of the 31 fusiform aneurysms. None of the traumatic aneurysms presented with hemorrhage.

“This may be because UCSF is not a regional trauma center, and the patients may not have survived before reaching us,” explained Dr. Hetts.

Of the 75 children, 17 patients were managed conservatively with close follow-up and serial imaging for an average observation time of 41 months.

The mean aneurysm size was 6 mm. These patients tended to have long segment vascular dysplasia involving multiple territories.

None of the patients required treatment, none of the aneurysms bled, and two patients showed minimal aneurysm enlargement.

Other patients underwent surgery, embolization, or combination therapy. Nineteen patients had their aneurysms surgically clipped (mean size 12 mm, mean age 12 years).

Thirteen of these patients had presented with SAH. After clipping, two patients required retreatment (with coiling). Complications of clipping included one ventriculitis, one proximal clip occlusion, one symptomatic infarct, and one brainstem infarct.

Nineteen other patients were treated with endovascular coiling (mean size 14 mm, mean age 10 years). Six had SAH, and four required retreatment. Complications included one rupture with infarct and one de novo hemorrhage in a patient with AIDS.

Thirteen patients underwent carotid occlusion (mean size 26 mm, mean age 14 years). Of these, one patient had SAH, and two required retreatment because of development of new aneurysms.

The charts contained no reports of major complications, and one new vertebral aneurysm was assigned to observation.

A fourth group of 10 patients had bypass/trapping of their aneurysms (mean size 12 mm, mean age 12 years). In this group, three patients had SAH, and two required retreatment. The complication rate was low, with ventriculitis reported in one patient and a new seizure disorder in another.

Dr. Hetts described the case of a 12-year-old boy who presented with acute onset of double vision.

A head CT revealed a giant aneurysm adjacent to and impressing upon his right cerebral peduncle and he was admitted to the hospital. A catheter angiogram demonstrated a fusiform partly thrombosed aneurysm of the right posterior cerebral artery, which at the same session was treated successfully with endovascular coiling.

The patient did well postprocedurally and was discharged home on hospital day 3 with improving double vision. “Aneurysms in children can be considered as a chronic disease.

“They should be carefully monitored, with the recognition that new aneurysms can arise,” said Dr. Hetts.

“Given that most aneurysms can be successfully treated with minimally invasive endovascular coiling or with surgery, we recommend that children with aneurysms be evaluated at centers with multidisciplinary collaborative teams of neurologists, neurosurgeons, and interventional neuroradiologists where a comprehensive plan for management can be formulated and carried out,” he said.

Angiography shows an untreated giant aneurysm in a 12-year-old child.

The same untreated lesion is shown in axial contrast computed tomography.

Coronal computed tomography shows the same untreated giant aneurysm.

Angiography shows resolution of the aneurysm after treatment with coiling.

A pretreatment sagittal noncontrast CT scan shows the same child.

An axial contrast computed tomography shows the child, pretreatment.

Lateral angiograph of the child shows a vertebral artery injection, precoiling.

Lateral angiograph of the child shows a vertebral artery injection after coiling. Photos courtesy Dr. Steven Hetts

DANA POINT CALIF. — Aneurysms that develop in children differ in distribution and etiology, compared with those in adults, but they can often be treated effectively, safely, and durably by surgery, embolization, or combination therapy, according to Dr. Steven Hetts, who presented his findings at the American Society of Interventional and Therapeutic Neuroradiology annual meeting.

Aneurysms occur rarely in children, with only 2%–5% of all aneurysms found in people age 19 years or younger. Nevertheless, when an aneurysm is discovered in a child, clinicians are faced with questions such as what is the risk of aneurysm rupture, whether to treat, and what treatment options are best.

By examining retrospective and prospective medical records, MRIs, and intracranial angiograms, Dr. Hetts was able to collect data on 75 children with 101 aneurysms who had been treated at the University of California, San Francisco, School of Medicine between 1981 and 2006. The children ranged in age from 3 months to 18 years, and the mean follow-up time was 45 months.

Headache, the most common symptom at presentation, was reported by 34 of the children.

Other symptoms include cranial neuropathy (12), nausea and vomiting (11), changes in vision (10), trauma (9), seizures (3,) and pulsatile tinnitus (1). Five children were asymptomatic. Twenty-four children presented with subarachnoid hemorrhage (SAH).

When Dr. Hetts analyzed aneurysm morphology, he found that 46% of the 101 aneurysms were saccular and 31% were fusiform. Twelve percent of the aneurysms were associated with infection, and 14% were thought to have a traumatic etiology. The mean maximal diameter was 12 mm and 11% were considered to be “giant” (greater than 25 mm) aneurysms. Sixteen percent of patients had multiple aneurysms.

In this sample, one child died, indicating 1.3% mortality. Four of 75 children (5%) manifested a new infarction and 1 in 75 children (1.3%) developed new-onset seizures. Twenty-four aneurysms ruptured, according to Dr. Hetts.

In the sample, saccular lesions were associated with a higher risk of rupture: 19 of the 46 saccular aneurysms ruptured, compared with only 2 of the 12 infectious and 3 of the 31 fusiform aneurysms. None of the traumatic aneurysms presented with hemorrhage.

“This may be because UCSF is not a regional trauma center, and the patients may not have survived before reaching us,” explained Dr. Hetts.

Of the 75 children, 17 patients were managed conservatively with close follow-up and serial imaging for an average observation time of 41 months.

The mean aneurysm size was 6 mm. These patients tended to have long segment vascular dysplasia involving multiple territories.

None of the patients required treatment, none of the aneurysms bled, and two patients showed minimal aneurysm enlargement.

Other patients underwent surgery, embolization, or combination therapy. Nineteen patients had their aneurysms surgically clipped (mean size 12 mm, mean age 12 years).

Thirteen of these patients had presented with SAH. After clipping, two patients required retreatment (with coiling). Complications of clipping included one ventriculitis, one proximal clip occlusion, one symptomatic infarct, and one brainstem infarct.

Nineteen other patients were treated with endovascular coiling (mean size 14 mm, mean age 10 years). Six had SAH, and four required retreatment. Complications included one rupture with infarct and one de novo hemorrhage in a patient with AIDS.

Thirteen patients underwent carotid occlusion (mean size 26 mm, mean age 14 years). Of these, one patient had SAH, and two required retreatment because of development of new aneurysms.

The charts contained no reports of major complications, and one new vertebral aneurysm was assigned to observation.

A fourth group of 10 patients had bypass/trapping of their aneurysms (mean size 12 mm, mean age 12 years). In this group, three patients had SAH, and two required retreatment. The complication rate was low, with ventriculitis reported in one patient and a new seizure disorder in another.

Dr. Hetts described the case of a 12-year-old boy who presented with acute onset of double vision.

A head CT revealed a giant aneurysm adjacent to and impressing upon his right cerebral peduncle and he was admitted to the hospital. A catheter angiogram demonstrated a fusiform partly thrombosed aneurysm of the right posterior cerebral artery, which at the same session was treated successfully with endovascular coiling.

The patient did well postprocedurally and was discharged home on hospital day 3 with improving double vision. “Aneurysms in children can be considered as a chronic disease.

“They should be carefully monitored, with the recognition that new aneurysms can arise,” said Dr. Hetts.

“Given that most aneurysms can be successfully treated with minimally invasive endovascular coiling or with surgery, we recommend that children with aneurysms be evaluated at centers with multidisciplinary collaborative teams of neurologists, neurosurgeons, and interventional neuroradiologists where a comprehensive plan for management can be formulated and carried out,” he said.

Angiography shows an untreated giant aneurysm in a 12-year-old child.

The same untreated lesion is shown in axial contrast computed tomography.

Coronal computed tomography shows the same untreated giant aneurysm.

Angiography shows resolution of the aneurysm after treatment with coiling.

A pretreatment sagittal noncontrast CT scan shows the same child.

An axial contrast computed tomography shows the child, pretreatment.

Lateral angiograph of the child shows a vertebral artery injection, precoiling.

Lateral angiograph of the child shows a vertebral artery injection after coiling. Photos courtesy Dr. Steven Hetts

DANA POINT CALIF. — Aneurysms that develop in children differ in distribution and etiology, compared with those in adults, but they can often be treated effectively, safely, and durably by surgery, embolization, or combination therapy, according to Dr. Steven Hetts, who presented his findings at the American Society of Interventional and Therapeutic Neuroradiology annual meeting.

Aneurysms occur rarely in children, with only 2%–5% of all aneurysms found in people age 19 years or younger. Nevertheless, when an aneurysm is discovered in a child, clinicians are faced with questions such as what is the risk of aneurysm rupture, whether to treat, and what treatment options are best.

By examining retrospective and prospective medical records, MRIs, and intracranial angiograms, Dr. Hetts was able to collect data on 75 children with 101 aneurysms who had been treated at the University of California, San Francisco, School of Medicine between 1981 and 2006. The children ranged in age from 3 months to 18 years, and the mean follow-up time was 45 months.

Headache, the most common symptom at presentation, was reported by 34 of the children.

Other symptoms include cranial neuropathy (12), nausea and vomiting (11), changes in vision (10), trauma (9), seizures (3,) and pulsatile tinnitus (1). Five children were asymptomatic. Twenty-four children presented with subarachnoid hemorrhage (SAH).

When Dr. Hetts analyzed aneurysm morphology, he found that 46% of the 101 aneurysms were saccular and 31% were fusiform. Twelve percent of the aneurysms were associated with infection, and 14% were thought to have a traumatic etiology. The mean maximal diameter was 12 mm and 11% were considered to be “giant” (greater than 25 mm) aneurysms. Sixteen percent of patients had multiple aneurysms.

In this sample, one child died, indicating 1.3% mortality. Four of 75 children (5%) manifested a new infarction and 1 in 75 children (1.3%) developed new-onset seizures. Twenty-four aneurysms ruptured, according to Dr. Hetts.

In the sample, saccular lesions were associated with a higher risk of rupture: 19 of the 46 saccular aneurysms ruptured, compared with only 2 of the 12 infectious and 3 of the 31 fusiform aneurysms. None of the traumatic aneurysms presented with hemorrhage.

“This may be because UCSF is not a regional trauma center, and the patients may not have survived before reaching us,” explained Dr. Hetts.

Of the 75 children, 17 patients were managed conservatively with close follow-up and serial imaging for an average observation time of 41 months.

The mean aneurysm size was 6 mm. These patients tended to have long segment vascular dysplasia involving multiple territories.

None of the patients required treatment, none of the aneurysms bled, and two patients showed minimal aneurysm enlargement.

Other patients underwent surgery, embolization, or combination therapy. Nineteen patients had their aneurysms surgically clipped (mean size 12 mm, mean age 12 years).

Thirteen of these patients had presented with SAH. After clipping, two patients required retreatment (with coiling). Complications of clipping included one ventriculitis, one proximal clip occlusion, one symptomatic infarct, and one brainstem infarct.

Nineteen other patients were treated with endovascular coiling (mean size 14 mm, mean age 10 years). Six had SAH, and four required retreatment. Complications included one rupture with infarct and one de novo hemorrhage in a patient with AIDS.

Thirteen patients underwent carotid occlusion (mean size 26 mm, mean age 14 years). Of these, one patient had SAH, and two required retreatment because of development of new aneurysms.

The charts contained no reports of major complications, and one new vertebral aneurysm was assigned to observation.

A fourth group of 10 patients had bypass/trapping of their aneurysms (mean size 12 mm, mean age 12 years). In this group, three patients had SAH, and two required retreatment. The complication rate was low, with ventriculitis reported in one patient and a new seizure disorder in another.

Dr. Hetts described the case of a 12-year-old boy who presented with acute onset of double vision.

A head CT revealed a giant aneurysm adjacent to and impressing upon his right cerebral peduncle and he was admitted to the hospital. A catheter angiogram demonstrated a fusiform partly thrombosed aneurysm of the right posterior cerebral artery, which at the same session was treated successfully with endovascular coiling.

The patient did well postprocedurally and was discharged home on hospital day 3 with improving double vision. “Aneurysms in children can be considered as a chronic disease.

“They should be carefully monitored, with the recognition that new aneurysms can arise,” said Dr. Hetts.

“Given that most aneurysms can be successfully treated with minimally invasive endovascular coiling or with surgery, we recommend that children with aneurysms be evaluated at centers with multidisciplinary collaborative teams of neurologists, neurosurgeons, and interventional neuroradiologists where a comprehensive plan for management can be formulated and carried out,” he said.

Angiography shows an untreated giant aneurysm in a 12-year-old child.

The same untreated lesion is shown in axial contrast computed tomography.

Coronal computed tomography shows the same untreated giant aneurysm.

Angiography shows resolution of the aneurysm after treatment with coiling.

A pretreatment sagittal noncontrast CT scan shows the same child.

An axial contrast computed tomography shows the child, pretreatment.

Lateral angiograph of the child shows a vertebral artery injection, precoiling.

Lateral angiograph of the child shows a vertebral artery injection after coiling. Photos courtesy Dr. Steven Hetts