MR imaging- and MR spectroscopy-revealed changes in meningiomas for which embolization was performed without subsequent surgery

We describe our experience with follow-up MR imaging and MR spectroscopy in two patients after embolization of meningiomas without subsequent surgery. In both patients there was a marked reduction in tumor size and a decrease in contrast enhancement associated with spectroscopic signs of fatty degeneration. We did not observe regrowth; however, in one patient with incomplete angiographic devascularization, residual vital tumor tissue was seen at follow-up examinations.

[The role of diffuse axonal injury in psychiatric assessment of brain-head trauma]

The concept of diffuse axonal injury is presented and the relevance in medicolegal assessment of brain injured patients is discussed. The lesion pattern of diffuse axonal injury not only plays a significant role in the acute management and rehabilitation of brain injured patients but also in issues of litigation. Brain imaging techniques are most important in the evaluation of structural damage to the brain and play a pivotal role in the detection of diffuse axonal injury. While computer-tomography follow-up studies may be valuable for the detection of diffuse axonal injury, magnetic resonance imaging is superior due to better sensitivity and contrast-resolution. The article presents selected case studies and illustrates the different lesion patterns.

Efficacy of trisacryl gelatin microspheres versus polyvinyl alcohol particles in the preoperative embolization of meningiomas

BACKGROUND AND PURPOSE

Trisacryl gelatin microspheres are a new, commercially available nonabsorbable embolic agent. The purpose of this study was to evaluate their efficacy in the preoperative embolization of meningiomas as compared with polyvinyl alcohol (PVA) particles of various sizes.

METHODS

In 30 consecutive patients, trisacryl gelatin microspheres (150-300 microm) were used for the preoperative superselective embolization of meningiomas (group 1). Thirty other consecutive patients had embolization with PVA particles of 45 to 150 microm (n = 15, group 2) and of 150 to 250 microm (n = 15, group 3). Extent of devascularization, intraoperative blood loss, blood transfusion, and hemostasis at the time of surgery were recorded for every patient. The inflammatory reaction, the extent of necrotic areas, and the most distal intravascular location of the embolic agent (arterial, arteriolar, precapillary, capillary) were recorded.

RESULTS

There was no significant difference in the extent of angiographic devascularization among the groups. Intraoperative blood loss differed significantly between groups 1 and 2 and groups 1 and 3, but not between groups 2 and 3. The trisacryl gelatin microspheres were located more distally in tumor vessels than were the PVA particles of either size. The extent of intratumoral necrosis was not significantly different between the two embolic agents. In all groups there was a mild inflammatory tissue reaction in the vicinity of the embolic agent.

CONCLUSION

Trisacryl gelatin microspheres may be effective in the preoperative embolization of meningiomas, producing significantly less blood loss at surgery than seen with PVA particles of either size, possibly because of the significantly more distal vascular penetration of the microspheres.

Förster excitation energy transfer in peridinin-chlorophyll-a-protein

Time-resolved fluorescence anisotropy spectroscopy has been used to study the chlorophyll a (Chl a) to Chl a excitation energy transfer in the water-soluble peridinin-chlorophyll a-protein (PCP) of the dinoflagellate Amphidinium carterae. Monomeric PCP binds eight peridinins and two Chl a. The trimeric structure of PCP, resolved at 2 A (, Science. 272:1788-1791), allows accurate calculations of energy transfer times by use of the Förster equation. The anisotropy decay time constants of 6.8 +/- 0.8 ps (tau(1)) and 350 +/- 15 ps (tau(2)) are respectively assigned to intra- and intermonomeric excitation equilibration times. Using the ratio tau(1)/tau(2) and the amplitude of the anisotropy, the best fit of the experimental data is achieved when the Q(y) transition dipole moment is rotated by 2-7 degrees with respect to the y axis in the plane of the Chl a molecule. In contrast to the conclusion of, Biochemistry. 23:1564-1571) that the refractive index (n) in the Förster equation should be equal to that of the solvent, n can be estimated to be 1.6 +/- 0.1, which is larger than that of the solvent (water). Based on our observations we predict that the relatively slow intermonomeric energy transfer in vivo is overruled by faster energy transfer from a PCP monomer to, e.g., the light-harvesting a/c complex.

The basal ganglia in haemochromatosis

Haemochromatosis is characterised by deposition of iron-containing pigment in various organs, but little is known about possible deposition in the brain and its clinical impact. We therefore investigated 14 patients with hereditary haemochromatosis with MRI, CT and transcranial ultrasound (TCS) and examined them neurologically. In six of the patients dense lesions were found within the lentiform nucleus on CT, all of whom displayed hyperechogenic lesions in the same area on TCS, as did one other patient. In these patients the relative signal intensities of the lentiform nucleus measured by MRI relaxometry were higher. No patient had clinical signs of basal ganglia disorders.

Phase-contrast MR imaging of the cervical CSF and spinal cord: volumetric motion analysis in patients with Chiari I malformation

BACKGROUND AND PURPOSE

Most previous MR studies of the dynamics of Chiari I malformation have been confined to sagittal images and operator-dependent measurement points in the midline. To obtain a deeper insight into the pathophysiology of the Chiari I malformation, we performed a prospective study using axial slices at the level of C2 to analyze volumetric motion data of the spinal cord and CSF over the whole cross-sectional area.

METHODS

Eighteen patients with Chiari I malformation and 18 healthy control subjects underwent cardiac-gated phase-contrast imaging. Cross-sectional area measurements and volumetric flow/motion data calculations were made for the following compartments: the entire intradural space, the spinal cord, and the anterior and posterior subarachnoid space.

RESULTS

The most striking feature was an increased early systolic caudal and diastolic cranial motion of the spinal cord in the patients. CSF pulsations in the anterior subarachnoid space were unchanged at systole but showed an impaired diastolic upward flow. In the posterior compartment, the CSF systole was slightly shortened, with an impairment of diastolic upward flow. Fourteen of the 18 patients had associated syringeal cavities. This subgroup showed an increased systolic downward displacement of the cord as compared with patients without a syrinx.

CONCLUSION

Obstruction of the foramen magnum in patients with Chiari I malformation causes an abrupt systolic downward displacement of the spinal cord and impairs the recoil of CSF during diastole.

Depression in Parkinson's disease: brainstem midline alteration on transcranial sonography and magnetic resonance imaging

Recent studies using transcranial sonography (TCS) have provided evidence of alterations in the mesencephalic midline structures in patients with unipolar depression and depression in Parkinson's disease (PD), suggesting an involvement of the basal limbic system in primary and secondary mood disorders. This study tested the hypothesis of brainstem midline abnormality in depression and investigated 31 PD patients by magnetic resonance imaging (MRI) and TCS. Signal intensity of the pontine and mesencephalic brainstem midline was rated on T2-weighted images and measured by relaxometry. In addition, two blinded investigators assessed the echogenicity of the brainstem midline by TCS. The severity of motor symptoms and depression were graded independently using standard research scales. Rating of signal intensity and T2 relaxometry of the pontomesencephalic midline structures revealed significant difference between depressed and nondepressed PD patients (P < 0.05). This corresponded to a significant reduction in mesencephalic midline echogenicity of depressed PD patients on TCS images. No correlation was found between raphe signal intensity, T2 relaxation times, or TCS echogenicity and the severity of motor symptoms or depression. This study is the first to show changes in signal intensity and T2 relaxation time of the pontomesencephalic midline structures on MRI in depressed PD patients confirming previous TCS findings. As these midline structures comprise fiber tracts and nuclei of the basal limbic system, the findings may support the hypothesis of an alteration in the basal limbic system in mood disorders.

Silent embolism in diagnostic cerebral angiography and neurointerventional procedures: a prospective study

BACKGROUND

Cerebral angiography is associated with a small but definite risk of neurological complications with an unknown incidence of clinically silent embolism. We assessed the neurological complication rate compared with the frequency of silent embolism after angiography

METHODS

We used diffusion-weighted magnetic resonance imaging (MRI) before and after angiography to assess embolic events. 100 consecutive angiographies (66 diagnostic and 34 interventional procedures) were done on 91 patients. Patients underwent neurological assessment before, immediately after, and 1 day after angiography.

FINDINGS

Before angiography, no abnormalities were seen on diffusion-weighted MRI. Diffusion-weighted MRI showed 42 bright lesions in 23 patients after 23 procedures (17 diagnostic, six interventional) in a pattern consistent with embolic events. There was no new neurological deficit after any angiographic procedure. After diagnostic angiography in patients with a history of vasculopathy, the frequency of lesions was significantly higher than in patients without vascular risk factors (12 [44%] of 27 vs five [13%] of 39 patients, p=0.03). In diagnostic angiography, the appearance of lesions was significantly correlated with whether vessels were difficult to probe (p=0.01), amount of contrast medium needed (p<0.01), fluoroscopy time (p<0.01), and use of additional catheters (p=0.02).

INTERPRETATION

After diagnostic and interventional cerebral angiography, embolic events are more frequent than the apparent neurological complication rate. In diagnostic procedures, the incidence of embolism is closely related to a vascular risk profile.

Noninvasive direct stimulation of the cochlear nerve for functional MR imaging of the auditory cortex

We herein present our preliminary experience with functional MR imaging of the direct electrical stimulation of the cochlear nerve using an MR imaging-compatible electrode placed in the external auditory meatus of five patients with binaural sensorineural hearing loss. The stimulator was placed outside the imager's bore, and the electrode produced virtually no susceptibility artifacts. In three of five patients, it was possible to activate the superior temporal gyrus during functional MR imaging. No side effects were observed.

[Cerebral aneurysms in the posterior circulation. Treatment results in 44 consecutive cases]

PURPOSE

Evaluation of clinical and morphological results in 44 consecutive patients with 45 aneurysms of the posterior circulation.

METHODS

Retrospective analysis of patient charts and angiograms of all vertebrobasilar aneurysms diagnosed in our department between 10/95 and 08/99. All aneurysms were treated.

RESULTS

36/44 pts had a hemorrhage. Hunt/Hess (HH) gradings were as follows: HH1 in 10, HH2 in 6, HH3 in 9, HH4 in 10 cases, and HH5 in 1 case. 38 pts with 39 aneurysms were treated exclusively in the endovascular way, 3 pts with 3 aneurysms were operated on. 3 patients had to be operated upon following insufficient endovascular treatment. Endovascular treatment resulted in 63% total and 27% subtotal occlusions, results being stable in 85%. For our pts as a whole, the grading according to the Glasgow Outcome Scale (GOS) was GOS1 in 4, GOS3 in 8, GOS4 in 7, and GOS5 in 25 cases.

CONCLUSION

Despite a less favourable clinical status of pts pre-treatment, the results of our interdisciplinary concept compare favourably with those of other surgical or interventional groups.

Vulnerability of the nigrostriatal system as detected by transcranial ultrasound

OBJECTIVE

To assess the incidence of a hyperechogenic substantia nigra (SN) by transcranial sonography (TCS) in healthy people and to evaluate whether an enlarged hyperechogenic SN area is associated with functional impairment of the nigrostriatal system.

BACKGROUND AND METHODS

Until now, preclinical impairment of the nigrostriatal system could be identified only by functional neuroimaging techniques such as PET in selected groups of patients. TCS is a new, noninvasive ultrasound technique that has demonstrated an increased echogenicity of the SN in patients with PD, whereas in most healthy individuals, the SN is either barely detectable or undetectable by TCS.

RESULTS

Of 330 healthy volunteers, 8.6% exhibited an increased echogenicity of the SN. From these, 10 clinically healthy individuals with distinct unilateral or bilateral hyperechogenic signals in the SN region (SN area above 0.25 cm2) underwent comprehensive motor testing, neuropsychological assessment, MRI, and [18F]-dopa PET examination. With regard to motor functions, these individuals did not differ from 10 age- and sex-matched controls with a low echogenic SN and an area of echogenic signals below 0.2 cm2. Enlargement of hyperechogenic areas in the 10 healthy individuals was associated with a marked decrease in the accumulation of [15F]-dopa in the caudate nucleus and putamen.

CONCLUSIONS

Substantia nigra hyperechogenicity appears to indicate a functional impairment of the nigrostriatal system. Transcranial sonography may be a suitable method of identifying persons at risk of nigrostriatal alterations, making possible the introduction of early neuroprotective therapy.

"De novo" formation of intracranial aneurysms: who is at risk?

Although aneurysms are widely considered to be of congenital origin there is still debate as to whether some at least might be formed de novo during life. A review of all 49 reported cases plus one previously unpublished case reveals common clinical features and might aid in the management of this group of patients. Statistical analysis of all 50 cases of de novo aneurysms discloses a more frequent history of smoking (P = 0.0007) and arterial hypertension (P = 0.0026) than in a control cohort. Patients with de novo aneurysms are younger (P < 0.0001); the proportion with multiple aneurysms was 28 %. Of de novo aneurysms 44 % became symptomatic 3-6 years after the first subarachnoid haemorrhage (SAH), and the interval was significantly shorter in hypertensive patients. We suggest that young patients with a history of SAH and arterial hypertension and nicotine abuse should therefore be considered for conventional angiography after a 5-year interval. MRA might not be useful due to clip artefacts from even nonferromagnetic clips. Close control of blood pressure is essential in these patients.

Isolated absence of the septum pellucidum

Absence of the septum pellucidum in the human is a rare congenital anomaly. Previous reports suggest it is almost always associated with other brain anomalies. However, MRI in two patients with absence of the septum pellucidum presented here, indicates that this anomaly may occur without associated anomalies. It may be one manifestation of a spectrum of developmental anomalies. One patient presented with schizophrenic psychosis; developmental disturbances in limbic areas are believed to be associated with schizophrenia. Agenesis of the septum pellucidum may indicate abnormal development of limbic structures and it may be associated with anomalies, such as cytoarchitectural disturbances of cortical layers, as yet undetectable by MRI.

Uncommon morphologic characteristics in Leigh's disease

We describe a 4-month-old male patient with severe developmental delay and elevated lactate in blood and CSF. The MR images showed abnormalities differing from the typical pattern found in association with Leigh's disease. The examination of fibroblast cultures showed diminished activity of mitochondrial complexes I and III. The patient died at the age of 9 months.

Single-loop coil concepts for intravascular magnetic resonance imaging

Compared with other coil designs that have been investigated for intravascular use, the single-loop coil can be designed with a very small diameter for insertion into small vessels and with a longitudinal extent over several centimeters for multislice imaging. If it designed to be expandable inside the target vessel, then it combines these features with increased signal-to-noise ratio (SNR) and penetration depth. Expandable single-loop coils that are capable of meeting these requirements were developed and integrated into two different commercial catheter-based delivery systems: a self-expandable, single-loop made from NiTinol and a single-loop coil mounted on an inflatable balloon. The influence of a small-diameter coaxial cable for remote tuning and matching on the coil performance was investigated. Calculations showed the dependence of the signal on the separation between the conductors. The comparison of both catheter approaches in in vitro flow experiments and in an in vivo pig experiment revealed the influence of pulsatile flow on image quality during intravascular imaging with these designs.

Postoperative neuroimaging of high-grade gliomas: comparison of transcranial sonography, magnetic resonance imaging, and computed tomography

BACKGROUND

A precise and comprehensive knowledge of tumor burden and its extent and growth pattern in the pre- and postsurgical states is required to optimize tumor therapy and to determine treatment success and failure. This prospective study compares the diagnostic potential of computed tomography (CT), magnetic resonance imaging (MRI), and transcranial sonography (TCS) in the postoperative follow-up of brain tumors.

METHOD

Twenty-six patients with high-grade gliomas were included in the study. After tumor debulking, a total of 31 biopsy specimens were obtained from the resection margin in 21 patients and histological findings were compared with the findings of early postoperative TCS, CT, and MRI. Findings indicating residual tumor tissue were nonlinear contrast enhancement at the resection site revealed by CT or MRI or hyperechogenic lesions revealed by TCS. Follow-up examinations using all three imaging techniques were performed every 3 months. The end points of the follow-up were tumor recurrence as defined by CT and MRI, death, or severe clinical deterioration.

RESULTS

On the basis of the above criteria, TCS identified residual tumor more often than did CT or MRI. In the group of 19 patients with histologically proven tumor remnants, residual tumor tissue was identified by TCS in all patients, whereas MRI and CT failed to show contrast enhancement in three and eight patients, respectively. However, the results of the TCS were false positive for one patient because of hemorrhage into the resection site. The average time to identification of tumor regrowth was 27 weeks using TCS, 29 weeks using CT, and 33 weeks using MRI. Only the differences between TCS and MRI reached statistical significance. For one patient, multicentric tumor recurrence was not detected using TCS.

CONCLUSION

TCS may complement CT and MRI in the postoperative follow-up of patients with high-grade gliomas. Because none of these modalities alone is both sensitive and specific, an integrated analysis of imaging findings is recommended.

[Agenesis septum pellucidum in a schizophrenic patient]

Absence of the septum pellucidum is a rare developmental disorder of the human brain. Previous reports focused on the association with other cerebral anomalies. We present MRI scans showing an isolated absence of the septum pellucidum. The patient was suffering from a schizophrenic psychosis. Mental retardation or epileptic seizures, which are often found in more complex developmental brain disorders, were not observed. The septal area is part of the limbic system and aplasia of the septum pellucidum could indicate developmental anomalies of the limbic system. The concept of cerebral maldevelopment and the limbic system in schizophrenic psychosis is discussed.

Siderophore-mediated iron transport: crystal structure of FhuA with bound lipopolysaccharide

FhuA, the receptor for ferrichrome-iron in Escherichia coli, is a member of a family of integral outer membrane proteins, which, together with the energy-transducing protein TonB, mediate the active transport of ferric siderophores across the outer membrane of Gram-negative bacteria. The three-dimensional structure of FhuA is presented here in two conformations: with and without ferrichrome-iron at resolutions of 2.7 and 2.5 angstroms, respectively. FhuA is a beta barrel composed of 22 antiparallel beta strands. In contrast to the typical trimeric arrangement found in porins, FhuA is monomeric. Located within the beta barrel is a structurally distinct domain, the "cork," which mainly consists of a four-stranded beta sheet and four short alpha helices. A single lipopolysaccharide molecule is noncovalently associated with the membrane-embedded region of the protein. Upon binding of ferrichrome-iron, conformational changes are transduced to the periplasmic pocket of FhuA, signaling the ligand-loaded status of the receptor. Sequence homologies and mutagenesis data are used to propose a structural mechanism for TonB-dependent siderophore-mediated transport across the outer membrane.

Fusiform dilatations of the internal carotid artery following surgery for pediatric suprasellar tumors

Fusiform dilatations of the internal carotid artery (FDCA) represent a vascular complication following surgery for suprasellar tumors in children. In a long-term follow-up of 62 children we identified 7 children (11.3%) with a FDCA. In all children the FDCA was present within 15 months following surgery. It was not related to radiotherapy or a distinct histology. In 3 children the FDCA remained unchanged during the follow-up, in 3 children there was a progression and 1 child revealed a regression within 6 months. Clinically the FDCA was inapparent in all cases and not treated. In a follow-up study of an adult population who underwent surgery for suprasellar tumors no case of FDCA was encountered. Potential pathomechanisms and indications for treatment are discussed.

Differentiation between intracerebral hemorrhage and ischemic stroke by transcranial color-coded duplex-sonography

BACKGROUND AND PURPOSE

The differential diagnosis of intracerebral hemorrhage versus ischemic stroke has critical implications for stroke management. Transcranial color-coded duplex sonography (TCCS) has been shown to identify intracerebral hemorrhages and intracerebral vessel occlusions. We conducted this study to evaluate the sensitivity and specificity of TCCS in this differential diagnosis and in the detection of stroke complications.

METHODS

One hundred fifty-one patients (58 women, 93 men; mean age, 65.6 years [range, 32 to 89 years] ) with acute hemiparesis were enrolled in this prospective study. On admission all patients had a complete neurological examination. A cranial CT scan and a sonographic examination of the brain parenchyma and all extracranial and intracranial cerebral arteries were conducted. The sonographer was blinded for the radiological findings.

RESULTS

According to CT criteria, 60 patients had an intracerebral hemorrhage and 67 patients had an ischemic stroke, and in 24 patients CT findings were inconclusive, showing neither bleeding nor an ischemic stroke. On sonographic examination, 18 patients (12%) had no sufficient acoustic bone window. Of the remaining 133 patients, 126 (95%) were diagnosed correctly by sonography in agreement with CT. Sonography missed 3 atypical bleedings (2 with upper parietal location). In 4 patients without bleeding, an intracerebral hemorrhage was suspected by TCCS because of increased white matter echo density due to microangiopathy. Stroke complications depicted by CT (disturbance of cerebrospinal fluid circulation, hemorrhagic transformation, midline shift, ventricular bleeding) (n=54) were correctly shown by TCCS in 45 patients (83%). No complication was missed that would have required further treatment.

CONCLUSIONS

In comparison to the "gold standard" of CT, TCCS identified stroke complications and differentiated between intracerebral hemorrhage and ischemic stroke with reasonable sensitivity. Thus, if CT is not readily available, TCCS may complement clinical examination in patients with acute stroke. In addition, it may also be useful in detecting stroke complications in the follow-up of stroke patients.

MR-guided percutaneous angioplasty: assessment of tracking safety, catheter handling and functionality

PURPOSE

Magnetic resonance (MR)-guided percutaneous vascular interventions have evolved to a practical possibility with the advent of open-configuration MR systems and real-time tracking techniques. The purpose of this study was to assess an MR-tracking percutaneous transluminal angioplasty (PTA) catheter with regard to its safety profile and functionality.

METHODS

Real-time, biplanar tracking of the PTA catheter was made possible by incorporating a small radiofrequency (RF) coil in the catheter tip and connecting it to a coaxial cable embedded in the catheter wall. To evaluate potentially hazardous thermal effects due to the incorporation of the coil, temperature measurements were performed within and around the coil under various scanning and tracking conditions at 1.5 Tesla (T). Catheter force transmission and balloon-burst pressure of the MR-tracking PTA catheter were compared with those of a standard PTA catheter. The dilatative capability of the angioplasty balloon was assessed in vitro as well as in vivo, in an isolated femoral artery segment in a swine.

RESULTS

The degree of heating at the RF coil was directly proportional to the power of the RF pulses. Heating was negligible with MR tracking, conventional spin-echo and low-flip gradient-echo sequences. Sequences with higher duty cycles, such as fast spin echo, produced harmful heating effects. Force transmission of the MR-tracking PTA catheter was slightly inferior to that of the standard PTA catheter, while balloon-burst pressures were similar to those of conventional catheters. The MR-tracking PTA catheter functioned well both in vitro and in vivo.

CONCLUSION

The in vivo use of an MR-tracking PTA catheter is safe under most scanning conditions.

The ABC maltose transporter

Bacterial ATP-binding cassette (ABC) transporters and their homologues in eukaryotic cells form one of the largest superfamilies known today. They function as primary pumps that couple substrate translocation across the cytoplasmic membrane to ATP hydrolysis. Although ABC transporters have been studied for more than three decades, the structure of these multi-component systems is unknown, and the mechanism of transport is not understood. This article reviews one of the most widely studied ABC systems, the maltose transporter of Escherichia coli. A first structural model of the transport channel allows discussion of possible mechanisms of transport. In addition, recent experimental evidence suggests that regulation of gene expression and transport activity is far more complex than expected.