Tumor size, treatment patterns, and survival in neuro-oncology patients before and during the COVID-19 pandemic

The COVID-19 pandemic has disrupted healthcare delivery worldwide, leading to significant delays in cancer diagnosis and treatment. This study aimed to investigate the impact of the pandemic on the diagnosis and treatment of malignant brain tumors, specifically glioblastoma (GBM) and cerebral metastasis (CM), in a specialized neuro-oncology center. We analyzed data from 236 patients diagnosed with previously unknown malignant brain tumors between January 2018 and December 2021. Patients were classified into two groups: pre-COVID (January 2018 to December 2019) and COVID (January 2020 to December 2021). Tumor volumes were compared between the two groups and factors affecting tumor volumes were studied. Of 236 patients diagnosed with previously unknown malignant brain tumors, 114 were in the pre-COVID group and 122 were in the COVID group. Median tumor volumes at first diagnosis were significantly larger in the COVID group compared to the pre-COVID group (21.7 vs 15.7 cm3; p < 0.05). The survival times for the overall cohort and the GBM and CM subgroups did not differ significantly between the pre-COVID and COVID periods. Delays in diagnosis and treatment during the COVID-19 pandemic led to larger tumor volumes at diagnosis for patients with malignant brain tumors. However, these larger tumors did not result in worse survival outcomes. This counterintuitive finding highlights the crucial role of specialized neuro-oncological centers in mitigating the potential negative impact of delayed treatment and emphasizes the need for continued access to specialized care during times of crisis.

Emerging Microbes & Infections - Original Article: Human Borna disease virus 1 (BoDV-1) encephalitis cases in the north and east of Germany

In 2021, three encephalitis cases due to the Borna disease virus 1 (BoDV-1) were diagnosed in the north and east of Germany. The patients were from the states of Thuringia, Saxony-Anhalt, and Lower Saxony. All were residents of known endemic areas for animal Borna disease but without prior diagnosed human cases. Except for one recently detected case in the state of Brandenburg, all >30 notified cases had occurred in, or were linked to, the southern state of Bavaria. Of the three detected cases described here, two infections were acute, while one infection was diagnosed retrospectively from archived brain autopsy tissue samples. One of the acute cases survived, but is permanently disabled. The cases were diagnosed by various techniques (serology, molecular assays, and immunohistology) following a validated testing scheme and adhering to a proposed case definition. Two cases were classified as confirmed BoDV-1 encephalitis, while one case was a probable infection with positive serology and typical brain magnetic resonance imaging, but without molecular confirmation. Of the three cases, one full virus genome sequence could be recovered. Our report highlights the need for awareness of a BoDV-1 etiology in cryptic encephalitis cases in all areas with known animal Borna disease endemicity in Europe, including virus-endemic regions in Austria, Liechtenstein, and Switzerland. BoDV-1 should be actively tested for in acute encephalitis cases with residence or rural exposure history in known Borna disease-endemic areas.

Feasibility of the Big 5-Jena eCS Protocol : First Experience Implementing a New Extended CT Protocol in the Initial Diagnostics of Ischemic Stroke

PURPOSE

The most common protocols in the initial diagnostic of acute ischemic stroke do not assess cardiogenic or aortic causes of embolism. These are usually evaluated later by transthoracic (TTE) or transesophageal (TEE) echocardiography. This study aimed to evaluate the feasibility of a diagnostic tool for thoracic cardiovascular thrombi according to the first experience with a new extended cardio-stroke protocol (Big 5-Jena eCS protocol) in acute stroke patients.

METHODS

Retrospective analyses of the tomography scans database of the Jena University Hospital were performed. We included a total of 67 patients in the feasibility analyses, based on the evaluation of three outcomes.

RESULTS

Primary outcome: the Big 5-Jena eCS protocol was able to detect thoracic cardiovascular thrombi in a total of 20 patients in different locations including the arch of the aorta, the aortic valve, the left atrium, the left atrial appendage, the left ventricle, and the pulmonary arteries. Secondary outcome: implementating the protocol did not result in a significant elevation of the radiation exposure compared to traditional protocols. Tertiary outcome: the new protocol identified seven cases that were considered negative by echocardiography.

CONCLUSION

The implementation of an extended cardio-stroke protocol is feasible, no significantly time-consuming, acquiring assessable imaging, and maintaining radiation exposure acceptable. The Big 5-Jena eCS protocol was also able to detect some thrombi not reported by TTE or TEE; however, due to our data's explorative character, a conclusive comparison with cardiac ultrasound is not possible. A prospective pilot study and clinical trials should be conducted to assess the diagnostic accuracy of this protocol compared to echocardiography and determine the potential impact on diagnostic and treatment decisions.

Patterns of grey and white matter changes differ between bulbar and limb onset amyotrophic lateral sclerosis

Amyotrophic Lateral Sclerosis (ALS) is a progressive neurodegenerative disease that is characterized by a high heterogeneity in patients' disease course. Patients with bulbar onset of symptoms (b-ALS) have a poorer prognosis than patients with limb onset (l-ALS). However, neuroimaging correlates of the assumed biological difference between b-ALS and l-ALS may have been obfuscated by patients' diversity in the disease course. We conducted Voxel-Based-Morphometry (VBM) and Tract-Based-Spatial-Statistics (TBSS) in a group of 76 ALS patients without clinically relevant cognitive deficits. The subgroups of 26 b-ALS and 52 l-ALS patients did not differ in terms of disease Phase or disease aggressiveness according to the D50 progression model. VBM analyses showed widespread ALS-related changes in grey and white matter, that were more pronounced for b-ALS. TBSS analyses revealed that b-ALS was predominantly characterized by frontal fractional anisotropy decreases. This demonstrates a higher degree of neurodegenerative burden for the group of b-ALS patients in comparison to l-ALS. Correspondingly, higher bulbar symptom burden was associated with right-temporal and inferior-frontal grey matter density decreases as well as fractional anisotropy decreases in inter-hemispheric and long association tracts. Contrasts between patients in Phase I and Phase II further revealed that b-ALS was characterized by an early cortical pathology and showed a spread only outside primary motor regions to frontal and temporal areas. In contrast, l-ALS showed ongoing structural integrity loss within primary motor-regions until Phase II. We therefore provide a strong rationale to treat both onset types of disease separately in ALS studies.

Disease aggressiveness signatures of amyotrophic lateral sclerosis in white matter tracts revealed by the D50 disease progression model

Numerous neuroimaging studies in amyotrophic lateral sclerosis (ALS) have reported links between structural changes and clinical data; however phenotypic and disease course heterogeneity have occluded robust associations. The present study used the novel D50 model, which distinguishes between disease accumulation and aggressiveness, to probe correlations with measures of diffusion tensor imaging (DTI). DTI scans of 145 ALS patients and 69 controls were analyzed using tract‐based‐spatial‐statistics of fractional anisotropy (FA), mean‐ (MD), radial (RD), and axial diffusivity (AD) maps. Intergroup contrasts were calculated between patients and controls, and between ALS subgroups: based on (a) the individual disease covered (Phase I vs. II) or b) patients' disease aggressiveness (D50 value). Regression analyses were used to probe correlations with model‐derived parameters. Case–control comparisons revealed widespread ALS‐related white matter pathology with decreased FA and increased MD/RD. These affected pathways showed also correlations with the accumulated disease for increased MD/RD, driven by the subgroup of Phase I patients. No significant differences were noted between patients in Phase I and II for any of the contrasts. Patients with high disease aggressiveness (D50 < 30 months) displayed increased AD/MD in bifrontal and biparietal pathways, which was corroborated by significant voxel‐wise regressions with D50. Application of the D50 model revealed associations between DTI measures and ALS pathology in Phase I, representing individual disease accumulation early in disease. Patients' overall disease aggressiveness correlated robustly with the extent of DTI changes. We recommend the D50 model for studies developing/validating neuroimaging or other biomarkers for ALS.

Experiences from treating seven adult 5q spinal muscular atrophy patients with Nusinersen

Background:

The antisense oligonucleotide Nusinersen recently became the first approved drug against spinal muscular atrophy (SMA). It was approved for all ages, albeit the clinical trials were conducted exclusively on children. Hence, clinical data on adults being treated with Nusinersen is scarce. In this case series, we report on drug application, organizational demands, and preliminary effects during the first 10 months of treatment with Nusinersen in seven adult patients.

Methods:

All patients received intrathecal injections with Nusinersen. In cases with severe spinal deformities, we performed computed tomography (CT)-guided applications. We conducted a total of 40 administrations of Nusinersen. We evaluated the patients with motor, pulmonary, and laboratory assessments, and tracked patient-reported outcome.

Results:

Intrathecal administration of Nusinersen was successful in most patients, even though access to the lumbar intrathecal space in adults with SMA is often challenging. No severe adverse events occurred. Six of the seven patients reported stabilization of motor function or reduction in symptom severity. The changes in the assessed scores did not reach a significant level within this short time period.

Conclusions:

Treating adult SMA patients with Nusinersen is feasible and most patients consider it beneficial. It demands a complex organizational and interdisciplinary effort. Due to the slowly decreasing motor functions in adult SMA patients, long observation phases for this recently approved treatment are needed to allow conclusions about effectiveness of Nusinersen in adults.

Applying the D50 disease progression model to gray and white matter pathology in amyotrophic lateral sclerosis

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The D50 disease progression model well characterized a cross-sectional ALS cohort.

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VBM reveled ALS-related widespread gray and white matter density decreases.

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A spread of structural alterations occurs along with D50 model derived disease phases.

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White-matter alterations were associated with higher disease aggressiveness.

Therapeutic management and research in Amyotrophic Laterals Sclerosis (ALS) have been limited by the substantial heterogeneity in progression and anatomical spread that are endemic of the disease. Neuroimaging biomarkers represent powerful additions to the current monitoring repertoire but have yielded inconsistent associations with clinical scores like the ALS functional rating scale. The D50 disease progression model was developed to address limitations with clinical indices and the difficulty obtaining longitudinal data in ALS. It yields overall disease aggressiveness as time taken to reach halved functionality (D50); individual disease covered in distinct phases; and calculated functional state and calculated functional loss as acute descriptors of local disease activity. It greatly reduces the noise of the ALS functional rating scale and allows the comparison of highly heterogeneous disease and progression subtypes. In this study, we performed Voxel-Based Morphometry for 85 patients with ALS (60.1 ± 11.5 years, 36 female) and 62 healthy controls. Group-wise comparisons were performed separately for gray matter and white matter using ANCOVA testing with threshold-free cluster enhancement. ALS-related widespread gray and white matter density decreases were observed in the bilateral frontal and temporal lobes (p < 0.001, family-wise error corrected). We observed a progressive spread of structural alterations along the D50-derived phases, that were primarily located in frontal, temporal and occipital gray matter areas, as well as in supratentorial neuronal projections (p < 0.001 family-wise error corrected). ALS patients with higher overall disease aggressiveness (D50 < 30 months) showed a distinct pattern of supratentorial white matter density decreases relative to patients with lower aggressiveness; no significant differences were observed for gray matter density (p < 0.001 family-wise error corrected).

The application of the D50 disease progression model separates measures of disease aggressiveness from disease accumulation. It revealed a strong correlation between disease phases and in-vivo measures of cerebral structural integrity. This study underscores the proposed corticofugal spread of cerebral pathology in ALS. We recommend application of the D50 model in studies linking clinical data with neuroimaging correlates.

Acute Stroke Treatment by Surgical Recanalization of Extracranial Internal Carotid Artery Occlusion: A Single Center Experience

Ischemic stroke due to an acute occlusion of the extracranial internal carotid artery (eICA) is associated with high morbidity and mortality. The best treatment option remains unclear. This study aims to increase the available therapeutic experience documented for surgical recanalization of acute eICA occlusions. We retrospectively reviewed all hospital records of the University Hospital Jena between 2006 and 2018 to identified patients with acute ischemic stroke due to an occlusion of the eICA who underwent emergent surgical recanalization. We analyzed clinical data, surgical reports, imaging data, and outpatient records. The primary outcome parameter was the modified Rankin Scale (mRS) at 3 months. During the survey, 12 patients (mean age: 62.3 ± 10.8 years; range: 35-87) underwent emergent surgical recanalization for an acutely symptomatic eICA occlusion. All patients presented with neurological deficits with a mean National Institutes of Health Stroke Scale score at admission of 15.0 ± 5.1 (range 2-23). Patients were selected for surgery mainly due to the extent of the perfusion mismatch, while stroke severity and age were also considered. The median time from symptom onset to surgery was 309 ± 122 minutes (range 112-650 minutes). Complete recanalization was obtained in all 12 patients. No patient deteriorated postoperatively, no intracranial hemorrhage was observed, and no patient died in the following 3 months. Favorable outcomes (mRS: 0-2) after 3 months were achieved in 7 of 12 patients. The current study adds support to previous findings that the surgical recanalization of acute eICA occlusions is a possible and safe treatment option. However, a critical patient selection based on mismatch size in perfusion imaging is crucially important for successful treatment.

International survey on neuroradiological interventional and therapeutic devices and materials

A web-based survey was performed among the members of the World Federation of Interventional and Therapeutic Neuroradiology to determine the differences in availability, pricing, and performance of endovascular devices with special focus on coils, intra-arterial stroke devices, detachable balloons, and liquid embolic materials. The results of this survey show that the quality of the majority of interventional neuroradiology devices is good and compatibility issues are limited. Individual action towards suppliers is recommended to discuss the availability and pricing of devices and embolization materials.

Cryptogenic left main thrombosis: successful mechanical clot retrieval with a self-expanding trapping device

We present the case of a 52-year-old male with ST-segment elevation myocardial infarction due to a spontaneous large left main thrombosis, without any angiographic evidence for coronary artery disease. After multiple unsuccessful attempts of thrombaspiration the large clot was mechanically retrieved by a flow restoration device that was primarily made for intracranial interventions. Intravascular ultrasound revealed marginal lumen narrowing after the intervention, but the final coronary angiogram showed a patent left main and there was no relevant stenosis remaining.

Sex differences in oxytocin receptor binding in forebrain regions: correlations with social interest in brain region- and sex- specific ways

Social interest reflects the motivation to approach a conspecific for the assessment of social cues and is measured in rats by the amount of time spent investigating conspecifics. Virgin female rats show lower social interest towards unfamiliar juvenile conspecifics than virgin male rats. We hypothesized that the neuropeptide oxytocin (OT) may modulate sex differences in social interest because of the involvement of OT in pro-social behaviors. We determined whether there are sex differences in OT system parameters in the brain and whether these parameters would correlate with social interest. We also determined whether estrus phase or maternal experience would alter low social interest and whether this would correlate with changes in OT system parameters. Our results show that regardless of estrus phase, females have significantly lower OT receptor (OTR) binding densities than males in the majority of forebrain regions analyzed, including the nucleus accumbens, caudate putamen, lateral septum, bed nucleus of the stria terminalis, medial amygdala, and ventromedial hypothalamus. Interestingly, male social interest correlated positively with OTR binding densities in the medial amygdala, while female social interest correlated negatively with OTR binding densities in the central amygdala. Proestrus/estrus females showed similar social interest to non-estrus females despite increased OTR binding densities in several forebrain areas. Maternal experience had no immediate or long-lasting effects on social interest or OT brain parameters except for higher OTR binding in the medial amygdala in primiparous females. Together, these findings demonstrate that there are robust sex differences in OTR binding densities in multiple forebrain regions of rats and that OTR binding densities correlate with social interest in brain region- and sex-specific ways.

Delineation of alar ligament morphology: comparison of magnetic resonance imaging at 1.5 and 3 Tesla

Rupture of the alar and transverse ligaments due to whiplash injury can lead to upper cervical spine instability and subsequent neurological deterioration. The purpose of this study was to evaluate the normal anatomical variability of the alar ligaments in asymptomatic individuals with 3-T magnetic resonance imaging (MRI) and to compare the findings with standard 1.5-T examinations. Thirty-six participants underwent 3-T and 1.5-T MRIs. Magnetic resonance imaging findings were analyzed by classifying the alar ligaments with regard to the features detectability, signal intensity compared with muscle tissue, homogeneity, shape, spatial orientation, and symmetry. Delineation of the alar ligaments was significantly better on 3-T images, which were subjectively preferred for evaluation. The alar ligaments showed great variability. In the majority of participants, the alar ligaments were hypointense to muscle tissue, inhomogeneous, and different in shape and orientation. A statistically significantly higher number of ligaments appeared symmetric on 3-T imaging, indicating that 1.5-T imaging may underestimate the proportion of patients with normal, symmetric ligaments. This study demonstrates that high-field 3-T MRI provides better visualization of the alar ligaments compared with 1.5-T MRI. The higher signal-to-noise ratio allows detection of small signal changes. A great interindividual variety of the MRI morphology of the alar ligaments was found in participants with no history of neck trauma. Further studies with more participants are necessary to evaluate alar ligament pathologies in patients with a history of whiplash injury.

Renal ablation in patients with end-stage renal disease

BACKGROUND

Transarterial catheter embolization of the kidneys (TAE) is a minimally invasive, image-guided procedure. In this study outcome and TAE-related complications of the patients who underwent TAE of the kidneys were evaluated retrospectively.

PATIENTS AND METHODS

Between August 2003 and August 2009, 11 patients underwent selective percutaneous transarterial renal embolization for end stage renal disease associated with uncontrolled hypertension, nephrotic syndrome, bleeding or malignancy. TAE of renal arteries was performed using different embolization agents.

RESULTS

Successful renal embolization was possible in all 21 kidneys. All patients became anuric. Non-target embolization was not detectable. Nevertheless, all patients developed some degree of postembolization symptoms including nausea, vomiting, fever or pain. A typical finding after embolization was an increase in the C-reactive protein.

CONCLUSIONS

Renal embolization is rarely done but should be considered as an alternative to surgical nephrectomy in patients with end stage renal disease due to the lesser invasiveness. Our study confirms the safety and effectivity of percutaneous renal embolization in patients with ESRD. We were able to control the hypertension, nephrotic syndrome, and bleeding caused by ESRD.

Diffusion-weighted imaging of hyperacute cerebral hypoglycemia

BACKGROUND AND PURPOSE

Cerebral hypoglycemia can result in reversible metabolic brain insults and can be associated with impaired diffusion disturbances. Our aim was to evaluate possible changes in DWI of the human brain during hyperacute short-term severe hypoglycemia.

MATERIALS AND METHODS

Ten individuals scheduled for a clinical IST were examined with DWI while the test was performed. Venous blood glucose was continuously measured, and sequential DWI sequences were performed without interruption. Hypoglycemia was terminated with intravenous glucose administration when glucose levels were at ≤2.0 mmol/L.

RESULTS

Blood glucose levels were lowered to a mean nadir of 1.75 ± 0.38 mmol/L. No alterations of cerebral diffusion could be observed in any individuals on DWI.

CONCLUSIONS

Hyperacute short-term severe hypoglycemia does not induce visible changes in DWI of the human brain.

The Penumbra System: a mechanical device for the treatment of acute stroke due to thromboembolism

BACKGROUND AND PURPOSE

Data from recent reports have indicated that mechanical thrombectomy may have potential as a treatment for acute ischemic stroke. The purpose of this study was to assess the safety and performance of the Penumbra System (PS): a novel mechanical device designed to reduce clot burden in acute stroke due to large-vessel occlusive disease.

MATERIALS AND METHODS

A prospective, single arm, independently monitored and core laboratory adjudicated trial enrolled subjects with an acute neurologic deficit consistent with acute stroke, presenting within 8 hours of symptom onset and an angiographically verified occlusion (Thrombolysis in Myocardial Infarction [TIMI] grade 0 or 1) of a treatable intracranial vessel. The primary end point was revascularization of the target vessel to TIMI grade 2 or 3. Secondary end points were the proportion of subjects who achieved a modified Rankin Scale (mRS) score of 2 or less or a 4-point improvement on the National Institutes of Health Stroke Scale (NIHSS) score at 30-day follow-up, as well as all-cause mortality.

RESULTS

Twenty-three subjects were enrolled, and 21 target vessels were treated in 20 subjects by the PS. At baseline, mean age was 60 years, mean mRS score was 4.6, and mean NIHSS score was 21. Postprocedure, all 21 of the treated vessels (100%) were successfully revascularized by the PS to TIMI 2 or 3. At 30-day follow-up, 9 subjects (45%) had a 4-point or more NIHSS improvement or an mRS of 2 or less. The all-cause mortality rate was 45% (9 of 20), which is lower than expected in this severe stroke cohort, where 70% of the subjects at baseline had either an NIHSS score of more than 20 or a basilar occlusion.

CONCLUSION

Thus, early clinical experience suggests that the PS allows revascularization in certain subjects experiencing acute ischemic stroke.

Monitoring of clopidogrel-related platelet inhibition: correlation of nonresponse with clinical outcome in supra-aortic stenting

BACKGROUND AND PURPOSE

Clopidogrel and aspirin are antiplatelet medications used in patients intended for endovascular stent placement. Although various studies have investigated individual responsiveness to clopidogrel in patients undergoing coronary interventions, there are no studies regarding patients undergoing stent placement of supra-aortic arteries supplying the brain. We analyzed platelet function in a near-patient setting to determine the effects of antiplatelet treatment in neurologic patients and correlated the results with clinical outcome after stent placement.

MATERIALS AND METHODS

The platelet function of 50 consecutive patients scheduled for neuro-interventional stent placement procedures was assessed by using point-of-care testing. All of the patients had symptomatic arteriosclerotic lesions. Clopidogrel effects were tested by impedance aggregometry. Fifty healthy blood donors without clopidogrel medication served as the control group.

RESULTS

Reference values for responders and nonresponders were established from the results of the healthy control group. Fourteen (28%) of 50 neurologic patients were stratified as clopidogrel nonresponders. Adverse events were registered in 5 (10%) of 50 patients, 1 of them with a permanent neurologic deficit (1 of 50 [2%]). All 5 of the patients with adverse events were nonresponders. There was a statistically significant correlation between adverse events and clopidogrel nonresponse (Fisher exact test, P = .001).

CONCLUSION

A significant rate of clopidogrel nonresponders could be identified in the treated patients. Our data strongly suggest a correlation of insufficient clopidogrel-related platelet inhibition with an increased risk of thromboembolic events in supra-aortic stent placement.

[Management of acute basilar artery occlusion]

Basilar artery thrombosis is a life-threatening condition whose unfavorable spontaneous prognosis can only be improved by early detection and subsequent aggressive recanalization therapy. The therapeutic approach has not yet been standardized and ranges from intravenous thrombolytic therapy with pharmacological agents to experimental procedures of mechanical endovascular recanalization, but the availability of the treatment approach and location of the occlusion determine the procedure in individual cases. Multicenter studies will have to clarify which bridging therapy (single administration of i.v. rt-PA or in combination with GPIIbIIIb inhibitors) before endovascular treatment is superior in terms of effectivity and complication rate.

Admission Facility Is Associated With Outcome of Basilar Artery Occlusion

Background and Purpose— Basilar artery occlusion (BAO) is a stroke subtype with poor prognosis, but recanalizing therapies have been reported to be effective. We investigated whether initial admission to telemedically linked general hospitals with subsequent stroke-center transfer is related to poorer outcome than direct admission to stroke centers.

Methods— All BAO cases of 3 stroke centers in Munich and 1 center in Regensburg between March 1, 2003 and December 31, 2004 were included, either if patients were directly admitted to stroke centers (n=23) or had initial admission to general hospitals of the telemedical network for integrative stroke care (TEMPiS) and secondary transfer to stroke centers (n=16). BAO was defined as angiographically (CTA, MRI or conventional angiography) confirmed occlusion of the basilar artery. Baseline parameters and therapeutic procedures were recorded. One-year follow-up was conducted prospectively.

Results— Differences in baseline parameters were not statistically significant. Time from onset to first angiography was significantly longer in patients with secondary transfer (mean: 355±93 minutes versus 222±198 minutes; P <0.01), mainly attributable to transfer duration (mean:156±73 minutes). In-hospital mortality (22% versus 75%; P <0.01) and 1-year-mortality (30% versus 81%; P <0.01) were lower for patients with direct admission to stroke centers. Fifty-two percent of directly admitted patients versus 13% of patients with secondary transfer ( P =0.02) were living at home after 1 year.

Conclusions— BAO patients who were admitted primarily to community hospitals had a worse prognosis. Patients with typical symptoms should have direct access to stroke centers, or may need bridging therapies.

Functional outcome after severe cerebral venous thrombosis

Severe cerebral venous thrombosis (CVT) is a rare cerebrovascular condition which in the more severe cases warrants intensive care treatment. While the outcome in the majority of uncomplicated CVT cases is good, it may be fatal in more affected patients. We provide long-term functional and quality of life (QOL) outcome data in the form of a retrospective analysis of 10 patients admitted to a neurological ICU with severe CVT. Outcome measures used were the modified Rankin Scale, the 36-item Short Form Health Survey, and the Psychological General Well-Being index. The mortality rate was 50% but 4 out 5 survivors had a good functional outcome with normal QOL despite a very severe clinical course. This finding justifies extensive life-sustaining therapy as the prognosis even of severe cases may be good if the acute phase is survived.

Ischemic and hemorrhagic complications after intra-arterial fibrinolysis in vertebrobasilar occlusion

BACKGROUND AND PURPOSE

To evaluate the incidence and location of hemorrhagic and ischemic lesions after local intra-arterial (IA) fibrinolysis in patients with acute vertebrobasilar occlusion (VBO).

METHODS

One hundred forty-three patients with VBO treated with local IA fibrinolysis were retrospectively evaluated. Two different thrombolytic substances, namely urokinase (UK, n = 57 patients) and recombinant tissue plasminogen activator (rtPA, n = 86 patients), were used. Incidence and location of intracranial hemorrhage and ischemic infarction were assessed by means of 403 peri-interventional CT and MR imaging scans. Recanalization success and bleeding rate were correlated with the type and dosage of fibrinolytic agent. Multiple logistic regression was used for statistical analysis.

RESULTS

Intracranial hemorrhage was detected in 46 (32%) patients. Bleeding rate was significantly higher for high-dose rtPA than for UK (36% versus 21%, P < .01). Neurologic outcome was worse in patients with postinterventional bleeding (P < .001). Ischemic infarctions were present in 136 (95%) patients. Ischemic lesions of the occipital lobe and thalamus were more frequently seen in the case of successful recanalization than after absent recanalization (P < .005). Occlusion of the postcommunicating segment of the posterior cerebral artery after successful recanalization was seen in 39% of patients.

CONCLUSIONS

In acute VBO, bleeding rate after IA rtPA seems to be higher than that using IA UK, especially after high-dose rtPA. Ischemic lesion patterns after successful local IA fibrinolysis are common and correspond to the frequent distal migration of the thrombus. Novel recanalization techniques allowing for endovascular thrombectomy are needed to reduce ischemic and hemorrhagic complications in the treatment of acute VBO.

Outcome of acute vertebrobasilar occlusions treated with intra-arterial fibrinolysis in 180 patients

BACKGROUND AND PURPOSE

To evaluate predictors of recanalization and a favorable neurologic outcome in patients with acute vertebrobasilar occlusion (VBO) treated with local intra-arterial fibrinolysis (LIF).

METHODS

The multicentric data of 180 patients with acute VBO treated with LIF were retrospectively evaluated. The modified Rankin scale (mRS) was used to evaluate the neurologic status before LIF and at the time of discharge. Patient's sex, age, etiology of VBO, recanalization, symptom duration before LIF, and pretreatment mRS were correlated with posttreatment mRS. Multiple logistic regression analysis was used to identify independent variables for recanalization and neurologic outcome.

RESULTS

The overall mortality was 43%. Complete recanalization was achieved in 99 (55%) patients and a partial recanalization in 35 (19%) patients, respectively. Recanalization was significantly associated with a favorable outcome (P < .001). The success of recanalization was negatively correlated with the volume of the thrombus (P < .001). No correlation was found between site and etiology of VBO and recanalization. Neurologic outcome correlated strongly with the pretreatment mRS (P < .001) and also with age (P < .02). Coma lasting less than 4.5 hours led to a positive trend toward a better outcome after univariate testing (P < .001).

CONCLUSIONS

Success of recanalization and neurologic status before treatment predict neurologic outcome in patients with VBO. Thrombus volume has an adverse effect on the recanalization success.

Intraprocedural thrombus formation during coil placement in ruptured intracranial aneurysms: treatment with systemic application of the glycoprotein IIb/IIIa antagonist tirofiban

BACKGROUND AND PURPOSE

When using detachable coils to treat intracranial aneurysms, thromboembolism is the most feared and frequently reported complication during or after endovascular therapy. The purpose of this study was to document the therapeutic effect of tirofiban on patency of the parent vessel, rate of rebleedings, and outcome of the patients in the setting of acute subarachnoidal hemorrhage.

METHODS

A patient data base was retrospectively reviewed to identify patients in whom thrombus occurred during endovascular treatment of ruptured cerebral aneurysms within a 34-month period and who were treated with tirofiban. All patients underwent anticoagulation with heparin during endovascular treatment procedures. Sixteen patients (age range, 52.9 +/- 10.7 years; 10 women, 6 men) were identified with intraprocedural thrombus formation. The patency of the parent vessel was assessed in a retrospective analysis blinded to outcome. Eight patients received ventriculostomy and had a follow-up CT.

RESULTS

Local nonocclusive thrombus at the coil surface was detected in 5 patients, in all of whom the thrombus was dissolved. In 10 patients, partial or total occlusion of the parent vessel occurred during the intervention; in 8 of these, the vessel was recanalized completely and in 2 drug administration was assisted by mechanical means. In 1 patient, however, the occlusion persisted. No periprocedural rebleedings of the ruptured aneurysm occurred; 3 of 8 ventriculostomies had clinically silent small local bleedings.

CONCLUSION

The use of tirofiban in the setting of endovascular treatment of ruptured intracranial aneurysms to dissolve platelet aggregation seems relatively safe and effective.

[Diagnosis and therapy of basilar artery occlusion]

In view of the poor prognosis for untreated patients with basilar artery occlusion, rapid delivery of effective treatment has the highest priority. Early recanalization by intra-arterial thrombolysis can improve the outcome in some patients. Apart from this method, specialized centers are increasingly using mechanical devices and glycoprotein IIb/IIIa inhibitors to achieve recanalization. This review focuses on current developments in the diagnosis and treatment of acute basilar artery occlusion.

Stent-angioplasty of intracranial vertebral and basilar artery stenoses in symptomatic patients

BACKGROUND

To present our two-center treatment results with stent angioplasty of intracranial vertebrobasilar stenoses in symptomatic patients.

MATERIAL AND METHODS

Between 2001 and 2003, 21 patients with 22 stenoses, refractory to medical therapy, who underwent elective stenting of intracranial vertebrobasilar stenoses were retrospectively analyzed. All patients had ischemic events clinically referable to the stenoses. Only high-grade stenoses of at least 80% were treated. Clinical evaluation was done based on the modified ranking scale (MRS).

RESULTS

In all cases, the stent deployment turned out to be technically successful and control angiography demonstrated the elimination of the high-grade stenoses. A minor residual stenoses was still detectable in six cases. According to the MRS, clinical outcome improved in the case of four patients, seemed unchanged in 14 and worsened in three. The clinical morbidity rate amounted to 14%. Clinical follow-up was available for 13 patients after 9 months with no recurrent symptoms and angiographic follow-up was available after 10 months. Re-stenoses occurred in two cases without clinical symptoms. Retreatment was not done.

CONCLUSION

According to our data, stent angioplasty for symptomatic intracranial vertebrobasilar stenoses can be a treatment alternative in case of recurrent symptoms despite medical therapy; particularly, for stenoses of type Mori A or B.

Efficacy of stent angioplasty for symptomatic stenoses of the proximal vertebral artery

BACKGROUND

To evaluate the safety and efficacy of stent angioplasty in the treatment of symptomatic arteriosclerotic stenoses of the proximal vertebral artery (VA).

METHODS

Thirty-eight symptomatic stenoses of the vertebral origin were treated with flexible balloon-expandable coronary stents. Angiographic and clinical follow-up examinations were obtained in 26 patients at a mean of 11 months.

RESULTS

The immediate post-procedural angiographic results showed no residual stenosis in 33 vessels and mild residual stenoses in five vessels. Periprocedurally, there were two asymptomatic technical complications and one TIA. During follow-up re-stenosis could be detected in 10 cases (36%), and vessel occlusions in two patients. Two stents were broken. One of the restenosis caused a TIA within the follow-up period.

CONCLUSIONS

Flexible balloon-expandable coronary stents proved to be save and effective in preventing vertebrobasilar stroke but were incapable to preserve the proximal vertebral artery lumen. For the VA origine an adequate stent, self-expanding, bioresorbable, or drug-eluting has to be found.

Treatment of vertebrobasilar occlusion by using a coronary waterjet thrombectomy device: a pilot study

BACKGROUND AND PURPOSE

Despite improved patient outcomes because of intraarterial fibrinolysis, vertebrobasilar thromboembolism remains a fatal disease with a death rate of more than 50%. The outcome depends on the success of recanalization. Fibrinolysis achieves recanalization in only 50%-70% of the cases. Therefore, we investigated the feasibility of using a coronary mechanical device to increase the recanalization rate.

METHODS

Twelve patients with acute vertebrobasilar occlusion were included in the pilot study. The older 5F and the new 4F versions of the Possis Angiojet catheter, which use a waterjet to attract, fragment, and extract the thrombus, were used. Inclusion depended on the presence of acute multisegmental intracranial or any extracranial vertebrobasilar occlusion. Exclusion criteria included coma lasting >8 hours and age >80. The Angiojet treatment did not exclude other therapeutic options.

RESULTS

The Angiojet catheter accessed the thrombosed site in 10 of 12 patients. Combined treatment with the Angiojet and additional fibrinolysis or angioplasty resulted in a recanalization rate of 100%. Of 37 occluded vertebrobasilar segments, 30 were primarily recanalized with the Angiojet. Three symptomatic and two asymptomatic hemorrhages were detected by CT. Five of the 12 patients died. Fifty percent of all patients obtained a moderate to excellent outcome (Modified Rankin Scale 0-3).

CONCLUSIONS

Use of the coronary Angiojet in the vertebrobasilar system is feasible. The device has the potential to increase the recanalization rate, especially in cases of extensive thrombosis, and, thus, improve patient outcomes.

Neurological and neuropsychological examination and outcome after use of an intra-aortic filter device during cardiac surgery

Cerebral embolization of particles after cardiac surgery is frequently associated with neurological deficits. Aortic crossclamp manipulation seems to be the most significant cause of emboli release during cardiac surgery. The goal of this study was to demonstrate whether the use of an intra-aortic filter device has an effect on the magnet resonance imaging (MRI) and functional neurological outcome. Twenty-four patients undergoing cardiosurgical procedures using cardiopulmonary bypass (CPB) were selected: coronary artery bypass graft (CABG) surgery (n = 17), aortic valve replacement (AVR) surgery (n = 4) or combined procedures (n = 3). Patients were evaluated by diffusion weighted MRI of the brain, neurological examination and neuropsychological assessment regarding alertness as well as divided and selective attention before and five to seven days after surgery. The patients were divided into two groups. In group I, 12 patients received a filter through a modified 24 F arterial cannula immediately before the aortic crossclamp was released. Filters remained in the aorta until CPB was discontinued. Intraoperatively, bilateral middle cerebral artery transcranial Doppler (TCD) was monitored at baseline, at the beginning of CPB, at a timepoint when the aorta was crossclamped, when the filter was inserted and while the crossclamp was switched to partial clamping until the CPB was discontinued. TCD was used for detection of microembolic signals (MES). The captured material in the filter was examined histologically. Twelve patients served as controls without aortic filtration (group II). The MRI of the brain did not show any diffusion alterations in either group before or after surgery. No patient developed a focal neurological deficit or stroke. Intraoperative quantitative MES detection revealed a four to tenfold increase in patients of group I compared with group II (5-6 versus 0.5-1 MES/min) during the filter dwell time. There was no consistent pattern regarding the neurobehavioural sequelae. Filters showed arteriosclerotic debris in 75% of the patients. The use of the intra-aortic filter device did not show a positive effect on neurological, neuroradiographical and neuropsychological outcomes. The increase of the MES rate in group I patients may be due to microbubbles generated as microcavitations by the filter or the aortic filter cannula. The intra-aortic filter was able to capture atheromatous material in 75% of the patients.

Treatment of basilar artery embolism with a mechanical extraction device: necessity of flow reversal

BACKGROUND AND PURPOSE

The success of local fibrinolysis in vertebrobasilar thromboembolism depends on the volume and composition of the clot. Since thrombolysis can also be time consuming and cause bleeding, we investigated the feasibility of a mechanical clot retraction device based on a nitinol basket advanced through a microcatheter.

METHODS

Five patients with acute embolism of the basilar artery who presented with progressive stroke and impaired consciousness were included in a multicenter study (Neuronet Evaluation in Embolic Stroke Disease [NEED]). In 3 patients flow reversal was induced with the use of silicone balloons or coaxial catheters. Three patients required additional fibrinolysis.

RESULTS

The device failed to retrieve the clots in our first 2 patients with distal basilar artery embolism. After successful recanalization by local fibrinolysis, both patients survived, 1 disabled and 1 with little residual impairment. In the next 3 patients the anterograde flow in the basilar artery was reversed during the short retraction period by temporarily blocking the vertebral or subclavian arteries. Two of these patients were completely recanalized by solely mechanical means; the third patient needed additional fibrinolysis before also being recanalized. All 3 patients survived: 1 remained disabled, 1 had almost a full recovery, and 1 became asymptomatic the day after the procedure.

CONCLUSIONS

Mechanical thrombus extraction seems to be a feasible method for preventing infarction by rapid, complete, and safe recanalization of the basilar artery. We recommend the use of flow control to support retrieval of the thrombus (which the proximal flow would otherwise keep in place like a cork) and to protect the distal vessels from embolization by fragments.

Detection of hyperacute subarachnoid hemorrhage of the brain by using magnetic resonance imaging

OBJECT

The purpose of this study was to determine the diagnostic accuracy of high-field (1.5-tesla) magnetic resonance (MR) imaging in the assessment of hyperacute (< 12 hours after onset of symptoms) subarachnoid hemorrhage (SAH).

METHODS

This investigation included 13 patients who were examined 2 to 12 hours posthemorrhage by using an MR imaging protocol consisting of T2-weighted and proton-density (PD)-weighted images, T1-weighted images, fast echoplanar-diffusion-weighted (EP-DW) images, and fluid-attenuated inversion-recovery (FLAIR) images. Subarachnoid hemorrhage had been diagnosed using computerized tomography (CT) scanning in all cases. In all 13 cases, SAH was reliably detected on both PD-weighted and FLAIR images. In contrast with FLAIR studies, the PD-weighted images were free of cerebrospinal fluid flow artifacts. The SAH was detected on T1-weighted images in only two cases and could not be detected on any T2-weighted or EP-DW images.

CONCLUSIONS

Even hyperacute SAH can be diagnosed reliably from high-field MR images obtained using PD-weighted or FLAIR sequences. Use of these sequences in an emergency MR protocol may preclude the need for additional CT studies to rule out SAH.

Detection of hyperacute parenchymal hemorrhage of the brain using echo-planar T2*-weighted and diffusion-weighted MRI

We investigated the usefulness of echo-planar imaging (EPI) as well as T2*-weighted and diffusion-weighted MRI (DWI) to identify hyperacute hemorrhage (within 24 h after ictus) in the brain. Seven patients were examined 3.5 to 24 h after onset of symptoms using a whole-body 1.5-T MR system. Two diffusion-weighted sequences were run to obtain isotropic and anisotropic diffusion images. Apparent diffusion coefficients (ADC) were calculated from the isotropic diffusion images. All DWI images as well as the T2*-weighted EPI images showed the hematomas as either discrete, deeply hypointense homogeneous lesions, or as lesions of mixed signal intensity containing hypointense areas. We conclude that even in the early phase after hemorrhage, sufficient amounts of paramagnetic deoxyhemoglobin are present in intracerebral hemorrhages to cause hypointensity on EPI T2*-weighted and DWI images; thus, use of ultrafast EPI allows identification of intracerebral hemorrhage.

Intracranial bleeding rates associated with two methods of external ventricular drainage

We investigated the risk of intracranial haemorrhage with two frequently performed methods of external ventricular drainage (EVD). Haemorrhage is believed to be a rare complication of such procedures, although in most studies reported in the literature standardised evaluation of computed tomography (CT) scans was not performed in all cases. Data were analysed retrospectively for 82 patients who had undergone percutaneous needle trephination and 92 who had undergone classic ventriculostomy. We found an overall bleeding risk with EVD of 9.4%. Most haematomas were small, and only one caused neurological symptoms. Therefore, the risk of symptomatic haemorrhage in this study was low (0.5%). Percutaneous needle trephination was associated with a higher risk of haemorrhage (12.2%) than classic ventriculostomy (6.5%), although differences were not statistically significant. We conclude from our results that small asymptomatic haemorrhages occur far more often after EVD than has generally been suspected. To compare the true risk of bleeding associated with different drainage methods requires controlled studies in which CT scans are evaluated in a standardised way.

Dynamic CT perfusion imaging of acute stroke

BACKGROUND AND PURPOSE

Because cerebral perfusion imaging for acute stroke is unavailable in most hospitals, we investigated the feasibility of a method of perfusion scanning that can be performed rapidly during standard cranial CT. Our aim was to identify the scanning parameters best suited to indicate tissue at risk and to measure a perfusion limit to predict infarction.

METHODS

Seventy patients who had suffered stroke and had undergone cranial CT 0.5 to 12 hours (median, 3.75 hr) after the onset of symptoms participated in the study. While undergoing conventional CT, each patient received a bolus of iodinated contrast medium. Maps of time to peak (TTP), cerebral blood volume (CBV), and CBF were calculated from the resulting dynamically enhanced scans. These perfusion images were compared with follow-up CT scans or MR images showing the final infarctions.

RESULTS

CBF maps predicted the extent of cerebral infarction with a sensitivity of 93% and a specificity of 98%. In contrast, CBV maps were less sensitive and TTP maps were less specific and also showed areas of collateral flow. Infarction occurred in all of the patients with CBF reduction of more than 70% and in half of the patients with CBF reduction of 40% to 70%.

CONCLUSION

Dynamic CT perfusion imaging safely detects tissue at risk in cases of acute stroke and is a feasible method for any clinic with a third-generation CT scanner.

Serial CT and MRI of ischaemic cerebral infarcts: frequency and clinical impact of haemorrhagic transformation

The frequency, predisposing factors and clinical consequences of haemorrhagic infarcts and damaged blood-brain barrier as shown by contrast enhancement (CE) in ischaemic cerebral infarcts are controversial. We prospectively compared the sensitivity of CT and MRI to haemorrhagic transformation (HT) and CE. We also wished to investigate the clinical significance of HT and factors possibly associated with it. We studied 36 patients with acute ischaemic infarcts in the middle cerebral artery territory during the first 2 weeks after the ictus. After CT and rating of the neurological deficit on admission, serial examinations with clinical neuromonitoring, contrast-enhanced CT and MRI were done on the same day. The occurrence and severity of HT were correlated with CE, stroke mechanism, infarct size, development of neurological deficits and antithrombotic treatment. The frequency of HT detected by MRI was 80%. CE usually preceded HT or was seen simultaneously. MRI had a higher sensitivity than CT to HT and CE. Severity of HT was positively correlated with infarct size (P < 0.01). HT had no influence on patient's neurological status. Neither the type of antithrombotic treatment nor the stroke mechanism was associated with the severity of HT. No parenchymal haemorrhage occurred.