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Fredric B. Meyer, John Huston III and Stephen S. Riederer

✓ The internal flow dynamics were assessed in 16 cerebral aneurysms by cine phase-contrast magnetic resonance (MR) angiography. Six of the aneurysms were associated with subarachnoid hemorrhage and 10 were unruptured. The ruptured aneurysms demonstrated a 51% ± 10% increase in volume between systole and diastole, while the increase in volume of the unruptured aneurysms was 17.6% ± 8.9% (p < 0.005). The ruptured aneurysms demonstrated an approximate 1.0- to 1.5-mm increase in diameter in at least one dimension during systole. There was no relationship between aneurysm size and volumetric increases. These findings suggest that cine phase-contrast MR angiography can detect structural weakness in the aneurysmal wall. Imaging techniques that can evaluate aneurysmal wall dynamics may be useful in therapeutic planning.

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Yoshihiro Yamamoto, Dudley H. Davis, Todd B. Nippoldt, William F. Young Jr., John Huston III and Joseph E. Parisi

✓ Inferior petrosal sinus sampling (IPSS) for adrenocorticotropic hormone (ACTH) levels in patients with Cushing's syndrome has become a useful method to distinguish ACTH-secreting pituitary tumors (Cushing's disease) from other causes of the syndrome, principally ectopic adrenocorticotropin secretion by an occult tumor. Although the test is generally regarded as highly specific, the authors recently encountered two patients whose IPSS measurements were false-positive for Cushing's disease. The results of IPSS suggested a pituitary origin of ACTH secretion in both patients, but transsphenoidal surgery failed to disclose a pituitary adenoma or to improve postoperative plasma cortisol levels. Both patients subsequently were found to have an ACTH-secreting carcinoid tumor of the lung. The false-positive IPSS studies were due to periodic hormonogenesis. The patients must be hypercortisolemic at the time IPSS is performed for the study to be valid.

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Wouter I. Schievink, John Huston III, Vicente E. Torres and W. Richard Marsh

✓ Autosomal dominant polycystic kidney disease (ADPKD) is a systemic disorder well known for its association with intracranial aneurysms. A series of patients with ADPKD who were screened for the presence of an intracranial aneurysm were reviewed and found to include an unexpectedly high number with intracranial arachnoid cysts.

Among 247 patients with ADPKD who underwent magnetic resonance imaging (180 cases) or high-resolution contrastenhanced computerized tomography (67 cases), there were 151 women and 96 men with a mean age of 44 years. Intracranial arachnoid cysts were found in 20 patients (8.1%) with ADPKD compared to two (0.8%) in a control group without ADPKD matched for age, sex, and method of imaging (p < 0.0001). Multiple intracranial arachnoid cysts were found in two patients. Polycystic liver disease was present in 17 (85.0%) of the 20 patients with intracranial arachnoid cysts compared to 119 (52.4%) of the 227 patients without (p < 0.004). Pineal cysts were found in two patients (0.8%) and choroid plexus cysts were found in three patients (1.2%) but this was not different from the control population. None of the intracranial cysts was symptomatic and none was treated surgically.

Intracranial arachnoid cysts are a relatively frequent incidental finding in patients with ADPKD, providing further support for the systemic nature of this disease. In the authors' experience with approximately 1500 patients with ADPKD, no complication has been encountered from an intracranial arachnoid cyst, suggesting that asymptomatic intracranial arachnoid cysts in patients with ADPKD require no treatment.

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Bruce E. Pollock and John Huston III

Object. To determine the natural history of colloid cysts of the third ventricle in patients in whom the cysts were incidentally discovered, the authors retrospectively reviewed cases observed during the modern neuroimaging era (1974–1998).

Methods. During this 25-year interval, 162 patients with colloid cysts were examined and cared for at our center. Sixty-eight patients (42%) were thought to be asymptomatic with regard to their colloid cyst and observation with serial neuroimaging was recommended. The mean patient age was 57 years at the time of diagnosis (range 7–88 years) and the mean cyst size was 8 mm (range 4–18 mm). Computerized tomography scanning revealed a hyperdense cyst in 49 (84%) of 58 patients. Three patients were excluded from the study because they died of unrelated causes within 6 months of scanning and seven patients were lost to follow-up review. Clinical follow-up evaluation was available at a mean of 79 months (range 7–268 months) in the remaining 58 patients. The numbers of patients who participated in follow-up review at 2, 5, and 10 years after diagnosis were 40, 28, and 14, respectively. The incidences of symptomatic progression related to the cyst were 0%, 0%, and 8% at 2, 5, and 10 years, respectively. No patient died suddenly during the follow-up interval. Two (6%) of 34 patients in whom follow-up imaging was performed either exhibited cyst growth (one patient) or experienced hydrocephalus (one patient) at a mean of 41 months after diagnosis (range 4–160 months).

Conclusions. Patients in whom asymptomatic colloid cysts are diagnosed can be cared for safely with observation and serial neuroimaging. If a patient becomes symptomatic, the cyst enlarges, or hydrocephalus develops, prompt neurosurgical intervention is necessary to prevent the occurrence of neurological decline from these benign tumors.

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Editorial

Unruptured aneurysms

David O. Wiebers, David G. Piepgras, Robert D. Brown Jr., Irene Meissner, James Torner, Neal F. Kassell, Jack P. Whisnant, John Huston III and Douglas A. Nichols

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Thanh G. Phan, John Huston III, Robert D. Brown Jr., David O. Wiebers and David G. Piepgras

Object. The goal of this study was to determine the frequency of enlargement of unruptured intracranial aneurysms by using serial magnetic resonance (MR) angiography and to investigate whether aneurysm characteristics and demographic factors predict changes in aneurysm size.

Methods. A retrospective review of MR angiograms obtained in 57 patients with 62 unruptured, untreated saccular aneurysms was performed. Fifty-five of the 57 patients had no history of subarachnoid hemorrhage. The means of three measurements of the maximum diameters of these lesions on MR source images defined the aneurysm size. The median follow-up period was 47 months (mean 50 months, range 17–90 months).

No aneurysm ruptured during the follow-up period. Four patients (7%) harbored aneurysms that had increased in size. No aneurysms smaller than 9 mm in diameter grew larger, whereas four (44%) of the nine aneurysms with initial diameters of 9 mm or larger increased in size. Factors that predicted aneurysm growth included the size of the lesion (p < 0.001) and the presence of multiple lobes (p = 0.021). The location of the aneurysm did not predict an increased risk of enlargement.

Conclusions. Patients with medium-sized or large aneurysms and patients harboring aneurysms with multiple lobes may be at increased risk for aneurysm growth and should be followed up with MR imaging if the aneurysm is left untreated.

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Bryce Weir

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Kelly D. Flemming, David O. Wiebers, Robert D. Brown Jr., Michael J. Link, Hirofumi Nakatomi, John Huston III, Robyn McClelland and Teresa J. H. Christianson

Object. Nonsaccular intracranial aneurysms (NIAs) are characterized by dilation, elongation, and tortuosity of intracranial arteries. Dilemmas in management exist due to the limited regarding the natural history of this disease entity. The objective of this study was to determine the prospective risk of subarachnoid hemorrhage (SAH) in patients with vertebrobasilar NIAs.

Methods. All patients with vertebrobasilar fusiform or dolichoectatic aneurysms that had been radiographically demonstrated between 1989 and 2001 were identified. These patients' medical records were retrospectively reviewed. A prospective follow-up survey was sent and death certificates were requested. Based on results of neuroimaging studies, the maximal diameter of the involved artery, presence of SAH, and measurements of arterial tortuosity were recorded. Nonsaccular intracranial aneurysms were classified according to their radiographic appearance: fusiform, dolichoectatic, and transitional. Dissecting aneurysms were excluded. The aneurysm rupture rate was calculated based on person-years of follow up. Predictive factors for rupture were evaluated using univariate analysis (p < 0.05). One hundred fifty-nine patients, 74% of whom were men, were identified. The mean age at diagnosis was 64 years (range 20–87 years). Five patients (3%) initially presented with hemorrhage; four of these patients died during follow up. The mean duration of follow up was 4.4 years (692 person-years). Nine patients (6%) experienced hemorrhage after presentation; six hemorrhages were definitely related to the NIA. The prospective annual rupture rate was 0.9% (six patients/692 person-years) overall and 2.3% in those with transitional or fusiform aneurysm subtypes. Evidence of aneurysm enlargement or transitional type of NIA was a significant predictor of lesion rupture. Six patients died within 1 week of experiencing lesion rupture.

Conclusions. Risk of hemorrhage in patients harboring vertebrobasilar NIAs is more common in those with evidence of aneurysm enlargement or a transitional type of aneurysm and carries a significant risk of death.