Single versus bilateral external ventricular drainage for intraventricular fibrinolysis in severe ventricular haemorrhage

BACKGROUND

Intraventricular fibrinolysis (IVF) through bilateral external ventricular drains (EVD) may provide better access of the thrombolytic agent to the intraventricular clot, potentially influencing clot clearance and outcome.

METHODS

Patients with spontaneous ganglionic intracerebral haemorrhage (ICH)<40 cm(3) and intraventricular haemorrhage (IVH) with acute hydrocephalus have been treated with IVF. The decision for placement of one or two EVDs has been left to the discretion of the treating physician. CT volumetry, the effects on cerebrospinal fluid (CSF) circulation and outcome at 3 months have been analysed for patients with one (group I, n = 13) or two EVDs (group II, n = 14).

RESULTS

No difference was found in clot resolution between the two groups (clot half life 2.1 (SD 1.2) vs 2.4 (1.3) days). A separate analysis of the third and fourth ventricle clearance was similar (1.6 (0.6) versus 1.8 (0.8) days), indicating no difference in reconstitution of CSF circulation. A trend towards a longer EVD duration and higher infection rate was found in the bilateral EVD group. No difference was found in outcome at 3 months.

CONCLUSIONS

Our results do not support the use of bilateral EVDs for IVF in patients with severe IVH.

Autosomal dominant nemaline myopathy caused by a novel alpha-tropomyosin 3 mutation

Nemaline myopathy (NM) is a genetically and clinically heterogenous muscle disorder, which is myopathologically characterized by nemaline bodies. Mutations in six genes have been reported to cause NM: Nebulin (NEB Pelin 1999), alpha-skeletal muscle actin (ACTA1 Nowak 1999), alpha-slow tropomyosin (TPM3 Laing 1995), beta-tropomyosin (TPM2 Donner 2002), slow troponin T (TNNT1 Johnston 2000) and cofilin 2 (CFL2 Agrawal 2007). The majority of cases are due to mutation in NEB and ACTA1. We report on the clinical, myopathological and muscle MRI findings in a German family with autosomal dominant NM due to a novel pathogenic TPM3 mutation (p.Ala156Thr).

In vivo imaging of MSCT and micro-CT: a comparison

PURPOSE

To evaluate the potential of MSCT and a novel AmicroCT system to assess the volume of malignant brain tumors in rats compared to histology.

MATERIALS AND METHODS

Fourteen rats underwent stereotactic implantation of GFP-marked F 98-glioma cells. On day 10 after implantation, animals received double-dose contrast-enhanced AmicroCT and MSCT imaging using Iomeprol. MSCT- and AmicroCT-derived tumor volumes were calculated and compared to histology (fluorescence staining) as the gold standard.

RESULTS

There was good correlation between the AmicroCT-derived tumor volume (69 A+ or - 23 mm(3)) and histology (81 A + or - 14 mm(3); p > 0.14). MSCT, however, showed significantly smaller tumor volumes (55 A + or - 25 mm(3)) compared to histology (p < 0.01) but was able to detect the tumors in all animals.

CONCLUSION

AmicroCT allows in vivo imaging of the contrast-enhancing parts of experimental gliomas with high correlation to histology. Although MSCT is less suitable for assessing exact tumor volume, this method reliably detects tumors in rats. Due to the high spatial resolution, AmicroCT-systems could play an important role for fusion imaging, e. g. to assess experimental brain gliomas with multimodal AmicroCT/PET- or AmicroCT/MRI-fusion images.

Coil migration after endovascular coil occlusion of internal carotid artery pseudoaneurysms within the sphenoid sinus

INTRODUCTION

We report two cases of coil migration after endovascular treatment of pseudoaneurysm of the internal carotid artery within the sphenoid sinus with coils and noncovered stents.

CASE REPORTS

Two patients underwent sphenoid sinus exposure for pituitary adenoma and chronic infection, respectively. As a complication pseudoaneurysms of the internal carotid artery within the sphenoid sinus developed. One patient was treated with stent and coils, the second with coils alone. Both patients experienced coil migration after 9 and 26 months, respectively, with the necessity for further treatment. Imaging was performed using flat detector computed tomography (FD-CT). Literature review revealed two additional cases of coil migration and four patients with the same treatment in stable condition.

CONCLUSION

Pseudoaneurysms of the internal carotid artery are a special entity and the environment of the aneurysm within the sphenoid sinus may change over a long time. Coil embolization may lead to the late onset complication of coil migration with the possible risk of acute epistaxis. As a consequence, these patients need a careful and prolonged follow up. FD-CT is an appropriate technique to visualize the implanted coils and if present the migration of coil material.

Rotational flat-panel computed tomography in diagnostic and interventional neuroradiology

Originally aimed at improving standard radiography by providing higher absorption efficiency and a wider dynamic range than available with X-ray film or film-screen combinations, flat-panel detector technology has become widely accepted for neuroangiographic imaging. In particular flat-panel detector computed tomography (FD-CT) which uses rotational C-arm-mounted flat-panel detector technology is capable of volumetric imaging with high spatial resolution. As "Angiographic CT" FD-CT may be helpful during many diagnostic and neurointerventional procedures, i.e. intracranial stenting for cerebrovascular stenoses, stent-assisted coil embolization of wide-necked cerebral aneurysms and embolizations of arteriovenous malformations. By providing morphologic, CT-like images of the brain within the angio suite, FD-CT is able to rapidly visualize periprocedural hemorrhage and may thus improve rapid complication management without the need for patient transfer. In addition, myelography and postmyelographic FD-CT imaging can be carried out using a single machine. Spinal interventions, such as kyphoplasty or vertebroplasty might also benefit from FD-CT. This paper briefly reviews the technical principles of FD technology and then focuses on possible applications in diagnostic and interventional neuroradiology.

Safety and outcome after thrombolysis in stroke patients with mild symptoms

BACKGROUND

Thrombolytic therapy is frequently withheld in patients with minor stroke symptoms. However, recent studies demonstrate that a substantial proportion of these patients dies or remains permanently disabled because of underestimation of symptom severity at baseline or secondary deterioration. We aimed to assess the safety and outcome of thrombolysis therapy in patients with minor but disabling stroke symptoms.

METHODS

32 patients presenting with mild symptoms were treated with intravenous recombinant tissue-type plasminogen activator between April 2006 and April 2008. Data were extracted from a prospectively collected database. Baseline demographic data, and clinical, laboratory and imaging findings were analyzed. Outcome was assessed using the modified Rankin Scale (mRS) score at 3 months and was dichotomized into favorable (mRS 0-1) versus unfavorable (mRS 2-6).

RESULTS

In the majority of patients, the left hemisphere was affected, with aphasia representing the most common symptom leading to treatment decision. The frequency of perfusion lesion (46%) and vessel occlusion (35%) at baseline was high but had no effect on the outcome at 3 months in our series of treated patients. Outcome was favorable in 94% of patients, and 47% recovered without any persisting symptom. Only one asymptomatic and no symptomatic hemorrhage was observed.

CONCLUSION

Our data support current guidelines and international licenses which give no lower National Institutes of Health Stroke Scale (NIHSS) limit for intravenous thrombolysis (IVT). Considering the accumulating evidence that the natural course in patients with mild symptoms is not as favorable as often assumed and taking the low risk of bleeding in those patients into account, patients with mild but disabling symptoms should be treated with IVT regardless of their baseline NIHSS score.

[Neuroradiological diagnosis and interventional therapy of carotid cavernous fistulas]

Carotid cavernous fistulas are pathologic connections between the internal and/or external carotid artery and the cavernous sinus. According to Barrow one can distinguish between direct (high flow) and indirect (low flow) fistulas, whereby direct fistulas are often traumatic while indirect fistulas more frequently occur spontaneously in postmenopausal women. Diagnosis can easily be established using MRI and angiography, which allow exact visualization of the anatomy of fistulas to plan the interventional neurological therapy that in recent years has replaced surgical therapy. This article provides an overview on imaging findings, diagnosis using MRI and angiography as well as interventional treatment strategies.

Long-term results with Matrix coils vs. GDC: an angiographic and histopathological comparison

INTRODUCTION

The aim of the study was to compare standard platinum Guglielmi detachable coils (GDC) with coated platinum coils (Matrix; both Boston Scientific, Fremont, CA) regarding handling, complications, occlusion and recanalization rate after 3 and 6A months.

METHODS

Aneurysms in the right common carotid artery were created in 25 rabbits. The animals were divided into five groups of five animals each. The animals of group 1 (the control group) received no treatment of the induced aneurysms, the animals of groups 2 and 3 (killed at 3 and 6A months) were treated with standard GDC, and the animals of groups 4 and 5 (killed at 3 and 6A months) were treated with Matrix coils.

RESULTS

Histopathological evaluation showed organized thrombus formation and connective tissue with neovascularization around the implanted coils in all the treated groups. The achieved occlusion rates in groups 2 and 3 were identical to those in groups 4 and 5. Thus the long-term results of aneurysm treatment with GDC and Matrix coils show no differences regarding occlusion and recanalization rates. The only noticeable difference was the difference in handling. More force was required to pushing the Matrix coils forward through the microcatheter and there was more friction in coil interaction in the aneurysm.

CONCLUSION

The bioactive coating of the Matrix coil produces no significant benefit in achieving higher occlusion and lower recanalization rates, and the coil is more difficult to handle. Future bioactive coils must be shown to produce significantly better long-term results than GDC and their ease of handling has to be improved.

Flat panel detector angiographic CT in the management of aneurysmal rupture during coil embolization

Angiographic CT (ACT) produces CT-like images within minutes in the angiography suite. We present the cases of 2 patients with intraprocedural aneurysmal rupture in which ACT enabled the neuroradiologist to rapidly assess the extent of bleeding during endovascular treatment. Additionally, ACT revealed pronounced rebleeding within the time between conventional CT and onset of treatment. In the management of aneurysmal rupture during coil embolization, ACT may be a valuable adjunct.

Flat panel detector angiographic CT for stent-assisted coil embolization of broad-based cerebral aneurysms

BACKGROUND AND PURPOSE

The purpose of this work was to evaluate angiographic CT (ACT) in the combined application of a self-expanding neurovascular stent and detachable platinum coils in the management of broad-based and fusiform intracranial aneurysms.

MATERIALS AND METHODS

Eleven patients harboring wide-necked intracranial aneurysms were treated with a flexible self-expanding neurovascular stent and subsequent aneurysm embolization with platinum microcoils. ACT was performed after the interventional procedure to analyze stent position and the relationship of coils to the stent. Postprocessing included multiplanar reconstructions (MPRs) and maximum intensity projections (MIPs). ACT volume datasets were postprocessed for soft tissue visualization.

RESULTS

Accurate stent placement with subsequent coil occlusion of the aneurysms was feasible in all of the patients. Similar to nonsubtracted digital subtraction angiography (DSA) images, radiopaque platinum stent markers showed excellent visibility in ACT as well. The stent struts themselves, hardly visible in nonsubtracted DSA, were visible in MPRs and MIPs of ACT in all of the patients. In aneurysms larger than 10 mm in diameter, accurate stent assessment at the level of the coils was limited due to beam hardening artifacts. Postprocedural ACT in all of the patients did not reveal any evidence of procedure-related intracranial hemorrhage.

CONCLUSION

ACT provides cross-sectional, 3D visualization of endovascular stents otherwise hardly visible with plain fluoroscopy. ACT enables us to accurately determine stent position, which may be helpful in complex stent-assisted aneurysm coiling procedures. However, in aneurysms larger than 10 mm in diameter, beam hardening artifacts caused by the endoaneurysmal coil package impair visibility of the stent. Further data are necessary to evaluate the usefulness of ACT in stent-assisted aneurysm coiling.

[Complex carotid cavernous sinus fistulas Barrow type D: endovascular treatment via the ophthalmic vein, imaging control with standardized MRI, long-term results]

PURPOSE

Since feeding arteries from both the internal and external carotid artery are common, cavernous fistulas of Barrow type D are difficult to treat. Embolization using the transarterial approach is considered to be the standard therapy. However, it is often impossible to embolize feeders from the internal carotid artery. The transorbital approach after anterior orbitotomy through the ophthalmic vein is an alternative in this complex situation. The following reports our experience with three female patients who underwent transvenous embolization. Procedural success was documented using standardized MRI and clinical reevaluation.

MATERIALS AND METHODS

Three female patients between 57 and 78 years of age were diagnosed with carotid cavernous fistulas by conventional angiogram. All patients were suffering from exophthalmus and visual impairment. Two patients showed secondary glaucoma and diplopia. In one patient we performed a technically successful transarterial embolization using particles, but no relevant improvement of the patient's condition was seen. Transfemoral transvenous access via the sinus petrosus was not possible in any patient. All patients were then embolized via the ophthalmic vein using GDC detachable coils. All patients were clinically reevaluated by an ophthalmologist. Also a standardized MRI was performed for documentation. Follow-up was performed for the first patient for 32 months, for the second patient for 34 months and for the third patient for 50 months.

RESULTS

Transvenous embolization was technically successful in all three cases. Clinical symptoms disappeared rapidly. Postprocedural MRI showed a symmetric diameter of the ophthalmic vein. Venous congestion of the orbit caused by fatty tissue edema regressed completely. Contrast-enhanced magnetic resonance angiography showed normal arterial vessels without evidence of fistula.

CONCLUSION

Complex carotid cavernous fistulas of Barrow type D seem to be successfully treatable by embolization using the transvenous approach. Clinical symptoms seem to regress rapidly after the procedure, with diplopia being the last to regress. MRI imaging criteria for procedural success include a diameter reduction of the ophthalmic vein, a reduction of the orbital fatty tissue edema and an inconspicuous CE-MRA.

An experimental aneurysm model: a training model for neurointerventionalists

SUMMARY

Reproducible animal models not only facilitate the pre-clinical assessment of aneurysm therapy but can also help in training for interventional procedures. The objective of this study was to find an animal model that can be used to test different endovascular occlusion techniques. Aneurysms in the right common carotid artery were created in 35 NZW rabbits by distal ligation and intraluminal elastase infusion. A total of 27 aneurysms were occluded by endovascular embolization with GDC-Coils. The time needed for placement of the microcatheter into the aneurysm by a professional interventionalist, a semi-professional interventionalist and a trainee was measured. The percentage of occlusion (occlusion rate) of the aneurysms was determined angiographically after embolization and again three months later, followed by a histological examination. Aneurysms of 2-6 mm size were reliably created in all 35 animals; mean size was 3.0 mm in height and 5.5 mm in diameter. Occlusion was achieved in 27 animals. Five animals from the group of 35 were initially planned as a control group with no embolization. We added to the control group one animal whose aneurysm could not be occluded endovascularly because of partial thrombosis and small size of the aneurysm. The angiographically determined mean occlusion rate was 89.5% +/- 11.3% standard deviation. Histological evaluation of the six aneurysms of the control group showed that they remained patent. Aneurysms that underwent embolization showed organized thrombus formation with no signs of recanalization. Two animals died from anaesthesia related or embolic complications. The time needed by the professional did not significantly decrease, after a little practice the trainee was nearly as quick as the professional. The beginner showed extensive progress, reducing the time for catheter placement by more than 50%. This paper describes the angiographic and histopathologic findings and also demonstrates possible methods for training in interventional procedures. Animal models will play a vital part in the training of future interventionalists. This model has the capability of testing different embolization devices (GDC, Onyx(R))and methods. Histologic long-term prognosis and the physical effect of the coils can be evaluated with this model.

Cognitive changes after carotid artery stenting

INTRODUCTION

We aimed to test changes in cognitive performance after carotid artery stenting (CAS).

METHOD

Ten patients were neuropsychologically tested at least 24 h before and 48 h after CAS. To diminish thromboembolic events, we used a proximal protection device. The following neuropsychological tests were selected: The Mini Mental State Examination (MMSE), symbol digit test and subtests of the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) battery (verbal fluency, constructional practice, word list memory and delayed recall). Affective state was determined by the Beck Depression Score (BDS).

RESULTS

No patient suffered from depression (BDS <1) or dementia (MMSE 29.9+/-1.5). Nine of the ten patients (P=0.12) showed increased speed in the Number Connection Test (NCT) (corresponding to trail making test). Most patients showed better or similar results concerning delayed recall (P=0.31). No change was observed in the symbol digit test, word list memory, verbal fluency or constructional practice. Better results concerning NCT and delayed recall after carotid stenting might be due to improved brain perfusion.

CONCLUSION

After CAS, cognitive and memory performance seem to improve. Further studies with different time intervals and more refined testing, as well as perfusion-weighted imaging, are needed.

[Imaging of the temporal bone. An overview]

Diseases of the temporal bone should be diagnosed by high resolution computed tomography (CT) and magnetic resonance imaging (MRI). Because of the excellent imaging of bony structures, CT is the method of choice for diagnosing pathologies of the external auditory channel, middle ear, and mastoid. Imaging of trauma is performed with CT. For examining the labyrinth system and interior auditory channel, MRI is the method of choice. This article gives an overview of the anatomy of the temporal bone and describes the most important pathologies.

[Imaging diagnostics of the pharynx and larynx]

The pharynx and larynx represent very sophisticated regions and may be involved in a diverse range of pathologic conditions. Evaluation of the head and neck has developed significantly with the establishment of CT and MRI as they provide true insights into the endoscopically blind areas as well as depth of tumor infiltration, its submucosal growth and contralateral involvement, cartilage invasion, bone marrow invasion, and nonpalpable adenopathy. Inflammations in the head and neck region are only exceptionally imaged with CT or MRI; indications are the diagnosis of retrotonsillar and parapharyngeal abscesses and ensuing complications. The different imaging modalities of malignant pharyngeal and laryngeal tumors and their differential diagnosis are presented in this paper.

Vaskuläre Erkrankungen des Kleinhirnbrückenwinkels

Vascular anomalies of the cerebellopontine angle are rare compared to tumors in this area. Irritation of the trigeminal, facial, or vestibulocochlear nerve may cause trigeminal neuralgia, hemifacial spasm and vertigo, or tinnitus accordingly. Vessel loops in the cerebellopontine cisterns may cause compression at the root entry or exit zone of the cranial nerves V, VII, and VIII, a phenomenon which is called "vascular loop syndrome." Megadolichobasilar artery and aneurysms of the vertebrobasilar system can also lead to dislocation and compression of the cranial nerves and brain stem. Three-dimensional CISS MR imaging and MR angiography are useful in the detection of neurovascular compression. Microvascular decompression is an effective surgical procedure in the management of compression syndromes of the cranial nerves V, VII, and VIII.

[Recent studies concerning treatment of acute, ischemic infarcts]

This article gives an overview over past and present studies concerning the acute management of stroke. Stroke trials involving intra-arterial thrombolytic agents, either alone or in combination with other therapies, are described.

[Congenital muscular dystrophies: muscle-eye-brain disease]

Three rare autosomal recessive disorders share the combination of congenital muscular dystrophy and brain malformations including a neuronal migration defect: muscle-eye-brain disease (MEB), Walker-Warburg syndrome (WWS), and Fukuyama congenital muscular dystrophy (FCMD). In addition, ocular abnormalities are a constant feature in MEB and WWS. We report on two brothers with MEB. The clinical and radiological characteristics are demonstrated.

Thrombolyse der A. basilaris: Ergebnisse im Saarland über einen Zeitraum von 5 Jahren

Acute thrombosis of the basilar artery has a fatal outcome if left untreated. The relatively good prognosis with intra-arterial thrombolysis makes it the therapy of choice for acute basilar thrombosis. In the Saarland stroke registry, we analyzed 47 patients with angiographically proven basilar artery thrombosis within the last 5 years. We observed a better outcome in patients with good income, with recanalization, and a short time between onset of symptoms and start of thrombolysis. The complications, such as intracerebral bleedings, occurred only in the group treated with rt-PA. Intra-arterial thrombolysis with urokinase or rt-PA is a relatively safe therapy, but should be performed in neuroradiological centers. With progressing symptoms the therapeutic window can be stretched up to 12 h, but coma lasting for more than 4 h is related to a bad outcome.

Intraarterielle Lyse der A. cerebri media: ein Überblick

Until 1996, treatment of strokes consisted exclusively of efforts to prevent recurrence. The development of intravenous and intra-arterial thrombolysis changed the approach to a causal therapy. This article provides an overview of state-of-the-art intravenous and intra-arterial therapeutic concepts and attempts to define the position of the local intra-arterial fibrinolysis approach.

[Spinal intradural tumors]

Spinal intradural tumors are uncommon lesions but may cause significant morbidity. In establishing the differential diagnosis for a spinal lesion, location, age, and the patient's clinical presentation are important. Magnetic resonance imaging plays a central role in the visualization of spinal tumors, easily allowing tumors to be classified as extradural, intradural extramedullary, or intramedullary which is very useful in tumor characterization. We describe intradural tumors; the majority is extramedullary, with nerve sheath tumors being the most frequent. Intramedullary tumors are uncommon spinal tumors. Ependymomas and astrocytomas comprise the majority of this group. Typical imaging features of both intradural extramedullary and intramedullary tumors are described.

Reliabilität der Quantifizierung von vaskulären Läsionen der weißen Hirnsubstanz - ein Beitrag zur replizierbaren quantitativen Diagnostik

PURPOSE

Microangiopathic lesions of the brain tissue correlate with the clinical diagnosis of vascular subcortical dementia. The "experience-based" evaluation is insufficient. Rating scales may contribute to reproducible quantification.

MATERIALS AND METHODS

In MRI studies of 10 patients, 9 neuroradiologists quantified vascular white matter lesions (WMLs) at two different points in time for 12 anatomically defined regions with respect to number, size and localization (score). For 9 observers and 10 studies, 90 intra-observer differences were obtained for each of the 12 WML scores. To calculate the inter-observer reliability, rating pairs were formed. Furthermore, 360 differences were computed for each score and rating for 12 anatomically defined WML scores, and the intraclass correlation (ICC) was calculated as a measure of agreement (reliability).

RESULTS

As to the intra-observer reliability, the median of the differences was 1.5 for the entire brain as opposed to 0 for defined brain regions. The corresponding values for the inter-observer reliability were 3 and 1, respectively. The mean intra-class correlation coefficient for the 10 studies was 0.88, whereas the mean interclass correlation concerning the inter-observer reliability was 0.70, with the first and second rating being averaged. The rating of each study took about 6 minutes.

CONCLUSION

The rating scale with high intra- and inter-observer reliability can dependably quantify WMLs and correlates with the clinical diagnosis of vascular dementia. Using a reliable rating scale, the diagnostic distinction of age-associated physiological vs. pathological size of the WML can make a contribution to the reproducible quantifiable diagnostic evaluation of vascular brain tissue lesions within the framework of dementia diagnostics.

Technik und Vorgehensweise beim Karotisstenting

Assuming that the ongoing large randomized controlled trials comparing CAS and endarterectomy support the efficacy and safety of CAS, this method will play a major role in patients with carotid stenosis in the near future. Patient selection, establishing standards of treatment, and systematic training of the interventionist are major issues. This article aims to give an overview of current techniques and devices available in CAS.

Behandlung der arteriosklerotischen Karotisstenose: ein �berblick

Endarterectomy for extracranial carotid stenosis has proven to be the method of choice for symptomatic patients suffering from ischemia (NASCET, ECST). The effectivity of the operation for asymptomatic stenosis seems to be likely since the publication of the first results of the ACST trial. The safety and efficiency of carotid stenting has not been proven so far and has to be evaluated in randomized trials comparing surgery and endovascular treatment. We provide an overview of the current trials and try to define the role of carotid stenting.

Proximale Protektionssysteme beim Karotisstent

Controversies as to whether or not a protection device should be used in carotid artery stenting exist. Currently three temporary cerebral protection devices are being used. These are devices with distal balloon occlusion or filtration baskets and proximal occlusion devices with flow reversal in the internal carotid artery. This article focuses on flow reversal systems and aims to give some advice as to which patients could benefit from their use.

[Craniocerebral trauma in childhood]

This article describes typical head injuries in infants and children. In comparison with adults there are distinct differences in the etiology of trauma and in the kind of reaction of the skull and brain. In infants and children there are three different types of trauma: birth trauma, accidental and non-accidental injury. The typical injuries in these three groups are described.

[Brain and head injury. Part 1: Clinical classification, imaging modalities, extra-axial injuries, and contusions]

This article describes the imaging tools for efficient diagnostic management of head trauma victims. The basic mechanisms of brain injuries are explained and the imaging features are described. Computed tomography remains the most important method for the initial screening and follow-up investigation. Though magnetic resonance imaging has a higher sensitivity to most traumatic lesions, it does not play an important role in the acute phase of head trauma patients. In the first part of this paper clinical classifications, imaging modalities, extra-axial injuries, and contusions are described. In the second part of this paper intra-axial and secondary injuries are discussed.