Modern preoperative imaging and functional mapping in patients with intracranial glioma

Magnetic resonance imaging (MRI) in therapy-naïve intracranial glioma is paramount for neuro-oncological diagnostics, and it provides images that are helpful for surgery planning and intraoperative guidance during tumor resection, including assessment of the involvement of functionally eloquent brain structures. This study reviews emerging MRI techniques to depict structural information, diffusion characteristics, perfusion alterations, and metabolism changes for advanced neuro-oncological imaging. In addition, it reflects current methods to map brain function close to a tumor, including functional MRI and navigated transcranial magnetic stimulation with derived function-based tractography of subcortical white matter pathways. We conclude that modern preoperative MRI in neuro-oncology offers a multitude of possibilities tailored to clinical needs, and advancements in scanner technology (e. g., parallel imaging for acceleration of acquisitions) make multi-sequence protocols increasingly feasible. Specifically, advanced MRI using a multi-sequence protocol enables noninvasive, image-based tumor grading and phenotyping in patients with glioma. Furthermore, the add-on use of preoperatively acquired MRI data in combination with functional mapping and tractography facilitates risk stratification and helps to avoid perioperative functional decline by providing individual information about the spatial location of functionally eloquent tissue in relation to the tumor mass. KEY POINTS::   · Advanced preoperative MRI allows for image-based tumor grading and phenotyping in glioma.. · Multi-sequence MRI protocols nowadays make it possible to assess various tumor characteristics (incl. perfusion, diffusion, and metabolism).. · Presurgical MRI in glioma is increasingly combined with functional mapping to identify and enclose individual functional areas.. · Advancements in scanner technology (e. g., parallel imaging) facilitate increasing application of dedicated multi-sequence imaging protocols.. CITATION FORMAT: · Sollmann N, Zhang H, Kloth C et al. Modern preoperative imaging and functional mapping in patients with intracranial glioma. Fortschr Röntgenstr 2023; 195: 989 - 1000.

Combined stent retriever angioplasty and continuous intra-arterial nimodipine infusion as salvage therapy for cerebral vasospasm and delayed cerebral ischemia after subarachnoid hemorrhage: illustrative case

BACKGROUND

Delayed cerebral ischemia (DCI) and cerebral vasospasm (CV) are severe complications of spontaneous subarachnoid hemorrhage (SAH) contributing to an inferior outcome. Rescue therapies include intra-arterial balloon angioplasty and repetitive and finally continuous intra-arterial nimodipine infusion.

OBSERVATIONS

In the presented case, a young female patient with fulminant refractory DCI and CV, despite induced hypertension and nimodipine application, was treated with three-vessel continuous intra-arterial infusion and additional repetitive angioplasty of the basilar and middle cerebral arteries using a stent retriever, leading to a good clinical outcome. Additional stent retriever dilatation to continuous intra-arterial nimodipine application in three vessel territories may represent a further escalation step in the rescue therapy for severe CV and DCI after SAH. Montreal Cognitive Assessment and SF-36 testing showed satisfactory results 3 months after initial treatment with intra-arterial nimodipine catheters in three vessel territory circulations and additional stent retriever vasodilation of severe CV.

LESSONS

We report a unique rescue strategy involving implantation of an additional intra-arterial catheter into the vertebral artery and repetitive stent retriever dilatations of the middle cerebral and basilar arteries as an extra therapy for continuous intra-arterial nimodipine vaspospasmolytic therapy in three vessel territories, resulting in a very good clinical outcome.

Pituitary Stalk Morphology as a Predictor of New-Onset Adrenocortical Insufficiency and Arginine Vasopressin Deficiency after Transsphenoidal Resections of Pituitary Macroadenomas: A Retrospective Single-Center Study with a Focus on iMRI

BACKGROUND

A new-onset adrenocortical insufficiency (NAI) is the most critical postoperative endocrinological complication after transsphenoidal surgery for macroadenomas. Because of increased mortality risk, arginine vasopressin deficiency (AVP-D) is also a relevant postoperative complication. This study aimed to identify easy-to-acquire magnet resonance imaging (MRI) aspects of the pituitary stalk to predict these insufficiencies after transsphenoidal surgery.

METHODS

Pituitary stalk morphology was reviewed intraoperatively and three months postoperatively in the MRIs of 48 transsphenoidal surgeries for macroadenomas. NAI was validated in endocrinological follow-up controls 10-14 months post-surgery.

RESULTS

Intraoperative pituitary stalk diameters were 0.5 mm larger in patients who developed NAI and AVP-D. The odds ratio was 29 for NAI and 6 for AVP-D in binary regression analysis. A value of 2.9 mm was identified as the optimal cut-off for the minimal pituitary stalk diameter regarding NAI, with a high specificity of 89%. There was no difference in pituitary stalk diameter regarding these insufficiencies three months post-surgery.

CONCLUSIONS

We identified an increased pituitary stalk diameter in intraoperative MRIs as a predictive factor of NAI and AVP-D after transsphenoidal surgery. These findings might improve the early detection of NAI and, thus, optimal management. However, validating these retrospective findings in prospective studies is obligatory.

Pictorial Review on Imaging Findings in Cerebral CTP in Patients with Acute Stroke and Its Mimics: A Primer for General Radiologists

The imaging evaluation of computed tomography (CT), CT angiography (CTA), and CT perfusion (CTP) is of crucial importance in the setting of each emergency department for suspected cerebrovascular impairment. A fast and clear assignment of characteristic imaging findings of acute stroke and its differential diagnoses is essential for every radiologist. Different entities can mimic clinical signs of an acute stroke, thus the knowledge and fast identification of stroke mimics is important. A fast and clear assignment is necessary for a correct diagnosis and a rapid initiation of appropriate therapy. This pictorial review describes the most common imaging findings in CTP with clinical signs for acute stroke or other acute neurological disorders. The knowledge of these pictograms is therefore essential and should also be addressed in training and further education of radiologists.

Defining patients needs and expectations for eHealth-based cardiac rehabilitation in Germany and Spain: living lab data from the TIMELY study

Background

eHealth innovations have set the stage to optimize personalized care and provide assistance for disease control to patients with CAD. TIMELY is the first artificial intelligence (AI)-driven eHealth approach that employs internet of things devices and is based on cardiac rehabilitation (CR) components. To guarantee acceptance and usability of eHealth solutions, patients are actively participating in development through a Living Lab approach.

Purpose

To define patients' needs for an eHealth-based lifestyle intervention and self-care support.

Methods

The Living Lab approach included a guided survey conducted among CAD patients at CR centers in Germany and Spain during inpatient or outpatient CR, respectively. Questions referred to current use of technology and patients' opinion on the usefulness of suggested features of a future eHealth application. Ratings for usefulness/importance were recorded on a 5-point Likert scale reported as median score.

Results

79 patients (20% female) were interviewed (DE, n=49; ES, n=30). Patients' mean age was 57 years (range 37–79), educational level was 87% ≤ high school and 13% > high school. All patients owned a smartphone that they also used for information (76%) and documentation (43%). Patients rated the importance of all CR components (regular exercise, healthy diet, stress management, smoking cessation, risk factor reduction) along the continuum of care as “very high” (5/5). Individual need for regular exercise support after structured CR was rated “high” (4/5). Exercise reminders, suggestions on activities, update of recommended training heart rate, evaluation of training progress, and achieved goals were rated “useful” (4/5) to “very useful” (5/5). The importance of support for diet, stress management, overall risk factor management, and medication was rated 3/5. Usefulness of a learning/education tool was rated 4/5, while motivational messages scored 3/5 and individual feedback of a person or virtual agent scored 4/5 and 3/5, respectively. The availability of electronic health records was evaluated as “very useful” (5/5) remote ECG monitoring and blood pressure management were rated as “useful” (4/5). The range of all items accessed was 1–5, indicating large interindividual differences. No significant differences existed between female and male patients or German and Spanish patients, though the importance of sharing training progress with family/ friends was rated higher by men (3/5) compared to women (1/5) and higher by Spanish (4/5) compared to German patients (2/5).

Conclusions

CR patients expressed a strong need for individual support of regular physical exercise and updated training recommendations. The observed inter-individual differences regarding usefulness and acceptance indicate the need for a highly adaptive system to prevent exclusion from eHealth access. CR patients from Germany and Spain showed equally high acceptance of eHealth components for the management of CAD.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Commission Horizon 2020

Deep learning-based classification of DSA image sequences of patients with acute ischemic stroke

PURPOSE

Recently, a large number of patients with acute ischemic stroke benefited from the use of thrombectomy, a minimally invasive intervention technique for mechanically removing thrombi from the cerebrovasculature. During thrombectomy, 2D digital subtraction angiography (DSA) image sequences are acquired simultaneously from the posterior-anterior and the lateral view to control whether thrombus removal was successful, and to possibly detect newly occluded areas caused by thrombus fragments split from the main thrombus. However, such new occlusions, which would be treatable by thrombectomy, may be overlooked during the intervention. To prevent this, we developed a deep learning-based approach to automatic classification of DSA sequences into thrombus-free and non-thrombus-free sequences.

METHODS

We performed a retrospective study based on the single-center DSA data of thrombectomy patients. For classifying the DSA sequences, we applied Long Short-Term Memory or Gated Recurrent Unit networks and combined them with different Convolutional Neural Networks used as feature extractor. These network variants were trained on the DSA data by using five-fold cross-validation. The classification performance was determined on a test data set with respect to the Matthews correlation coefficient (MCC) and the area under the curve (AUC). Finally, we evaluated our models on patient cases, in which overlooking thrombi during thrombectomy had happened.

RESULTS

Depending on the specific model configuration used, we obtained a performance of up to 0.77[Formula: see text]0.94 for the MCC[Formula: see text]AUC, respectively. Additionally, overlooking thrombi could have been prevented in the reported patient cases, as our models would have classified the corresponding DSA sequences correctly.

CONCLUSION

Our deep learning-based approach to thrombus identification in DSA sequences yielded high accuracy on our single-center test data set. External validation is now required to investigate the generalizability of our method. As demonstrated, using this new approach may help reduce the incident risk of overlooking thrombi during thrombectomy in the future.

Adverse Events and Complications in Continuous Intra-arterial Nimodipine Infusion Therapy After Aneurysmal Subarachnoid Hemorrhage

Objective

To determine the frequency and severity of complications associated with the continuous intra-arterial infusion of nimodipine (CIANI) as a new treatment of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (SAH).

Methods

Patients from two centers (n = 718) treated for SAH between 2008 and 2016 were included. Demographic and SAH-related parameters were evaluated, and also the frequency of adverse events (AEs) and complications including their severity (mild, moderate, and severe). Clinical outcome was analyzed using Glasgow Outcome Scale (GOS). The unfavorable outcome was defined as GOS 1 to 3, and favorable outcome as GOS 4 to 5. The Short-Form 36 (SF-36) health-related quality-of-life (QoL) questionnaire served as a QoL measurement.

Results

Of 718 patients, 65 (9%) were treated by CIANI and had a higher clinical or imaging grade of bleeding severity. Clinical deterioration while on treatment happened more often in patients who were treated with CIANI than in others. In patients with CIANI, 67% had AEs and/or complications during the treatment. Nimodipine-associated hypotension was seen in 8% (mild). Catheter-associated thrombus occurred in 9% (moderate). New intracerebral hemorrhage was found in 14% (moderate). A total of 6% treated by CIANI died during the treatment period (severe). More than one-third (39%) of patients of CIANI reached at least moderate disability, and 23% showed good recovery. Patients who received CIANI showed reduced QoL, but differences in mental and general health, and also pain were minimal.

Conclusion

Patients who received CIANI had higher rates of AEs and complications. However, this does not exclude the possibility that the use of CIANI might be helpful in patients with severe and therapy-refractory CV and DCI. Controlled and randomized studies would be helpful to clarify this question but they are methodologically and ethically challenging.

Evidence for the Vascular Origin of Benign Enhancing Foramen Magnum Lesions via Intraoperative Photographs: Case Report and Review of the Literature

A small, benign enhancing lesion posterior to the intracranial vertebral artery at the foramen magnum is a recently described image-based entity and believed to represent varix or ganglion. We report on an individual who underwent surgery due to a hybrid neurofibroma/schwannoma of the trigeminal nerve and additionally presented a small gadolinium-enhancing lesion in the right spinal canal at the level of the craniocervical junction (CCJ). The intraoperative finding of this enhancing lesion most likely represents the lateral internal vertebral venous plexus which does not require follow up or surgical excision.

CTNI-04. RECURRENT GLIOBLASTOMA LONG-TERM SURVIVORS TREATED WITH CUSP9v3

CUSP9v3 is a new treatment regimen for glioblastoma. It consists of continuous daily use of 9 drugs repurposed from general medicine. Their primary non-oncology uses are given in parentheses: aprepitant (nausea), auranofin (rheumatoid arthritis), celecoxib (pain), captopril (hypertension), disulfiram (alcohol abuse), itraconazole (fungal infection), minocycline (bacterial infection), ritonavir (viral infection) and sertraline (depression). All drugs have preclinical or clinical data indicating that they can retard glioblastoma growth, as reviewed in the published background papers. In CUSP9v3 all 9 medicines are given daily with added metronomic, low-dose (20 mg/m2 BSA twice daily) temozolomide. After 3 years of daily, uninterrupted use of CUSP9v3, of an initial cohort of 10 recurrent glioblastoma patients, as of May 2021, 3 are alive, functioning well, progression-free at 44, 44, and 57 months after recurrence and CUSP9v3 started. We report now that there were no unexpected toxicities from this combination of 10 daily drugs, although all patients required dose reduction of one or more of the drugs. CUSP9v3 was reasonably well-tolerated. Ritonavir, temozolomide, captopril and itraconazole were the drugs most frequently requiring dose reduction or pausing. The most common adverse events were nausea, headache, fatigue, diarrhea and ataxia. There were no treatment-related deaths. In the 3 long-term survivors, the median neutrophil-to-lymphocyte ratio decreased from 2.5 to 1.5 during CUSP9v3 treatment. In the group of the 3 shortest-term survivors that ratio increased from 4.7 to 14.3. CUSP9v3 follows the injunction of Palmer et al. that cancer therapy can be constructed using drug combinations that are independently effective, with non-overlapping mechanisms of action, and non-overlapping resistance pathways. We interpret the data accrued over the last few decades on the ever-shifting spatial and temporal growth drives active at any given moment in glioblastoma as requiring a complex pharmacological approach like CUSP9v3.

Analysis of laser-proton acceleration experiments for development of empirical scaling laws

Numerous experiments on laser-driven proton acceleration in the MeV range have been performed with a large variety of laser parameters since its discovery around the year 2000. Both experiments and simulations have revealed that protons are accelerated up to a maximum cut-off energy during this process. Several attempts have been made to find a universal model for laser proton acceleration in the target normal sheath acceleration regime. While these models can qualitatively explain most experimental findings, they can hardly be used as predictive models, for example, for the energy cut-off of accelerated protons, as many of the underlying parameters are often unknown. Here we analyze experiments on laser proton acceleration in which scans of laser and target parameters were performed. We derive empirical scaling laws from these parameter scans and combine them in a scaling law for the proton energy cut-off that incorporates the laser pulse energy, the laser pulse duration, the focal spot radius, and the target thickness. Using these scaling laws, we give examples for predicting the proton energy cut-off and conversion efficiency for state-of-the-art laser systems.

A phase Ib/IIa trial of 9 repurposed drugs combined with temozolomide for the treatment of recurrent glioblastoma: CUSP9v3

Background

The dismal prognosis of glioblastoma (GBM) may be related to the ability of GBM cells to develop mechanisms of treatment resistance. We designed a protocol called Coordinated Undermining of Survival Paths combining 9 repurposed non-oncological drugs with metronomic temozolomide—version 3—(CUSP9v3) to address this issue. The aim of this phase Ib/IIa trial was to assess the safety of CUSP9v3.

Methods

Ten adults with histologically confirmed GBM and recurrent or progressive disease were included. Treatment consisted of aprepitant, auranofin, celecoxib, captopril, disulfiram, itraconazole, minocycline, ritonavir, and sertraline added to metronomic low-dose temozolomide. Treatment was continued until toxicity or progression. Primary endpoint was dose-limiting toxicity defined as either any unmanageable grade 3–4 toxicity or inability to receive at least 7 of the 10 drugs at ≥ 50% of the per-protocol doses at the end of the second treatment cycle.

Results

One patient was not evaluable for the primary endpoint (safety). All 9 evaluable patients met the primary endpoint. Ritonavir, temozolomide, captopril, and itraconazole were the drugs most frequently requiring dose modification or pausing. The most common adverse events were nausea, headache, fatigue, diarrhea, and ataxia. Progression-free survival at 12 months was 50%.

Conclusions

CUSP9v3 can be safely administered in patients with recurrent GBM under careful monitoring. A randomized phase II trial is in preparation to assess the efficacy of the CUSP9v3 regimen in GBM.

The Impact of an Ultra-Early Postoperative MRI on Treatment of Lower Grade Glioma

The timing of MRI imaging after surgical resection may have an important role in assessing the extent of resection (EoR) and in determining further treatment. The aim of our study was to evaluate the time dependency of T2 and FLAIR changes after surgery for LGG. The Log-Glio database of patients treated at our hospital from 2016 to 2021 was searched for patients >18a and non-enhancing intra-axial lesion with complete MR-imaging protocol. A total of 16 patients matched the inclusion criteria and were thus selected for volumetric analysis. All patients received an intraoperative scan (iMRI) after complete tumor removal, an ultra-early postoperative scan after skin closure, an early MRI within 48 h and a late follow up MRI after 3-4 mo. Detailed volumetric analysis of FLAIR and T2 abnormalities was conducted. Demographic data and basic characteristics were also analyzed. An ultra-early postoperative MRI was performed within a median time of 30 min after skin closure and showed significantly lower FLAIR (p = 0.003) and T2 (p = 0.003) abnormalities when compared to early postoperative MRI (median 23.5 h), though no significant difference was found between ultra-early and late postoperative FLAIR (p = 0.422) and T2 (p = 0.575) images. A significant difference was calculated between early and late postoperative FLAIR (p = 0.005) and T2 (p = 0.019) MRI scans. Additionally, we found no significant difference between intraoperative and ultra-early FLAIR/T2 (p = 0.919 and 0.499), but we found a significant difference between iMRI and early MRI FLAIR/T2 (p = 0.027 and p = 0.035). Therefore, a postoperative MRI performed 24 h or 48 h might lead to false positive findings. An MRI scan in the first hour after surgery (ultra-early) correlated best with residual tumor at 3 months follow up. An iMRI with open skull, at the end of resection, was similar to an ultra-early MRI with regard to residual tumor.

Feasibility, Safety, and Outcome of Endovascular Recanalization in Childhood Stroke: The Save ChildS Study

Importance

Randomized clinical trials have shown the efficacy of thrombectomy of large intracranial vessel occlusions in adults; however, any association of therapy with clinical outcomes in children is unknown.

Objective

To evaluate the use of endovascular recanalization in pediatric patients with arterial ischemic stroke.

Design, Setting, and Participants

This retrospective, multicenter cohort study, conducted from January 1, 2000, to December 31, 2018, analyzed the databases from 27 stroke centers in Europe and the United States. Included were all pediatric patients (<18 years) with ischemic stroke who underwent endovascular recanalization. Median follow-up time was 16 months.

Exposures

Endovascular recanalization.

Main Outcomes and Measures

The decrease of the Pediatric National Institutes of Health Stroke Scale (PedNIHSS) score from admission to day 7 was the primary outcome (score range: 0 [no deficit] to 34 [maximum deficit]). Secondary clinical outcomes included the modified Rankin scale (mRS) (score range: 0 [no deficit] to 6 [death]) at 6 and 24 months and rate of complications.

Results

Seventy-three children from 27 participating stroke centers were included. Median age was 11.3 years (interquartile range [IQR], 7.0-15.0); 37 patients (51%) were boys, and 36 patients (49%) were girls. Sixty-three children (86%) received treatment for anterior circulation occlusion and 10 patients (14%) received treatment for posterior circulation occlusion; 16 patients (22%) received concomitant intravenous thrombolysis. Neurologic outcome improved from a median PedNIHSS score of 14.0 (IQR, 9.2-20.0) at admission to 4.0 (IQR, 2.0-7.3) at day 7. Median mRS score was 1.0 (IQR, 0-1.6) at 6 months and 1.0 (IQR, 0-1.0) at 24 months. One patient (1%) developed a postinterventional bleeding complication and 4 patients (5%) developed transient peri-interventional vasospasm. The proportion of symptomatic intracerebral hemorrhage events in the HERMES meta-analysis of trials with adults was 2.79 (95% CI, 0.42-6.66) and in Save ChildS was 1.37 (95% CI, 0.03-7.40).

Conclusions and Relevance

The results of this study suggest that the safety profile of thrombectomy in childhood stroke does not differ from the safety profile in randomized clinical trials for adults; most of the treated children had favorable neurologic outcomes. This study may support clinicians' practice of off-label thrombectomy in childhood stroke in the absence of high-level evidence.

Does Device Selection Impact Recanalization Rate and Neurological Outcome?

Background and Purpose—

The recent Save ChildS study provides multicenter evidence for the use of mechanical thrombectomy in children with large vessel occlusion arterial ischemic stroke. However, device selection for thrombectomy may influence rates of recanalization, complications, and neurological outcomes, especially in pediatric patients of different ages. We, therefore, performed additional analyses of the Save ChildS data to investigate a possible association of different thrombectomy techniques and devices with angiographic and clinical outcome parameters.

Methods—

The Save ChildS cohort study (January 2000–December 2018) analyzed data from 27 European and United States stroke centers and included all pediatric patients (<18 years), diagnosed with arterial ischemic stroke who underwent endovascular recanalization. Patients were grouped into first-line contact aspiration (A Direct Aspiration First Pass Technique [ADAPT]) and non-ADAPT groups as well as different stent retriever size groups. Associations with baseline characteristics, recanalization rates (modified Treatment in Cerebral Infarction), complication rates, and neurological outcome parameters (Pediatric National Institutes of Health Stroke Scale after 24 hours and 7 days; modified Rankin Scale and Pediatric Stroke Outcome Measure at discharge, after 6 and 24 months) were investigated.

Results—

Seventy-three patients with a median age of 11.3 years were included. Currently available stent retrievers were used in 59 patients (80.8%), of which 4×20 mm (width×length) was the most frequently chosen size (36 patients =61%). A first-line ADAPT approach was used in 7 patients (9.6%), and 7 patients (9.6%) were treated with first-generation thrombectomy devices. In this study, a first-line ADAPT approach was neither associated with the rate of successful recanalization (ADAPT 85.7% versus 87.5% No ADAPT) nor with the complication rate or the neurological outcome. Moreover, there were no associations of stent retriever sizes with rates of recanalization, complication rates, or outcome parameters.

Conclusions—

Our study suggests that neurological outcomes are generally good regardless of any specific device selection and suggests that it is important to offer thrombectomy in eligible children regardless of technique or device selection.

Registration—

URL: https://www.drks.de/ ; Unique identifier: DRKS00016528.

Value of whole-body low-dose computed tomography in patients with ventriculoperitoneal shunts: a retrospective study

OBJECTIVEThe gold standard for evaluation of ventriculoperitoneal (VP) shunt position, dislocation, or disconnection is conventional radiography. Yet, assessment with this modality can be challenging because of low image quality and can result in repetitive radiation exposure with high fluctuation in the radiation dose. Recently, CT-based radiation doses have been significantly reduced by using low-dose protocols. Thus, whole-body low-dose CT (LDCT) has become applicable for routine use in VP shunt evaluation. The authors here compared image quality and approximate radiation dose between radiography and LDCT in patients with implanted VP shunt systems.METHODSVentriculoperitoneal shunt systems have been investigated with LDCT scanning at the authors' department since 2015. A consecutive series of 57 patients (70 investigations) treated between 2015 and 2016 was retrospectively assessed. A historical patient cohort that had been evaluated with radiography was compared with the LDCT patients in terms of radiation dose and image quality. Three independent observers evaluated projection of the valve pressure level and correct intraperitoneal position, as well as complete shunt projection, using a Likert-type scale of 1-5, where 1 indicated "not assessable" and 5 meant "assessable with high accuracy." Descriptive statistics and the Mann-Whitney U-test were used for analysis.RESULTSTwenty-seven radiographs (38.6%) and 43 LDCT scans (61.4%) were analyzed. The median dose-length product (DLP) of the LDCT scans was 100 mGy·cm (range 59.9-183 mGy·cm). The median total dose-area product (DAP) of the radiographic images was 3177 mGy·cm2 (range 641-13,833 mGy·cm2). The estimated effective dose (EED) was significantly lower with the LDCT scan (p < 0.001). The median EED was 4.93 and 1.90 mSv for radiographs and LDCT, respectively. Significantly better identification of the abdominal position of the distal shunt catheter was achieved with LDCT (p < 0.001). Simultaneously, significantly improved visualization of the entire shunt system was realized with this technique (p < 0.001). On the contrary, identification of the valve settings was significantly worse with LDCT (p < 0.001).CONCLUSIONSWhole-body LDCT scanning allows good visualization of the distal catheter after VP shunt placement. Despite the fact that only a rough estimation of effective doses is possible in a direct comparison of LDCT and radiography, the data showed that shunt assessment via LDCT does not lead to greater radiation exposure. Thus, especially in difficult anatomical conditions, as in patients who have undergone multiple intraabdominal surgeries, have a high BMI, or are immobile, the use of LDCT shunt evaluation has high clinical value. Further data are needed to determine the value of LDCT for the evaluation of complications or radiation dose in pediatric patients.

Multicentric Registry Study on Epidemiological and Biological Disease Profile as Well as Clinical Outcome in Patients with Low-Grade Gliomas: The LoG-Glio Project

BACKGROUND

 World Health Organization (WHO) grade II low-grade gliomas (LGGs) in adults are rare, and patients' mean overall survival (OS) is relatively long. Epidemiological data on factors influencing tumor genesis and progression are scarce, and prospective data on surgical management are still lacking. Because of the molecular heterogeneity of LGG, a comprehensive molecular characterization is required for any clinical and epidemiological research. Further, a detailed radiologic assessment is needed as the only established objective criterion for progressive disease. Both radiologic and molecular assessments have to be standardized to produce comparable data. The aim of the registry is to improve the evidence for surgical management of LGG patients by establishing a multicenter registry with a strong surgical and clinical focus including mandatory biobanking.

METHODS

 The LoG-Glio project is a prospective national observational multicenter registry that began on November 1, 2015. Inclusion criteria encompass all patients > 18 years of age with a radiologic suspicion of LGG. Patients with severe neurologic or psychiatric disorders that may interfere with their informed consent or if there is no possibility for further follow-up are excluded. Diagnosis of glioblastoma WHO grade IV isocitrate dehydrogenase (IDH) wild type leads to a secondary exclusion of patients. In addition to demographic data, results of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, add-on for patients with brain tumors, and National Health Institute Stroke Scale before and after surgery and during regular follow-ups are collected. At each time point a detailed recording of surgical and adjuvant treatment is performed. Radiologic assessment involves three-dimensional (3D) acquisition of T1, fluid-attenuated inversion recovery, and T2 sequences. For the final evaluation, a central detailed neuropathologic and molecular assessment of tumor samples and a radiologic evaluation of imaging sets are part of the study protocol.

RESULTS

 We report the first 100 consecutively registered patients for LoG-Glio. Three patients dropped out due to loss of follow-up. Of the remaining recruited patients, 8 were classified as wait and scan; 89 had surgery. Using the inclusion criteria described previously, 70 patients had an IDH-mutated glioma, 10 had miscellaneous rare LGGs, and 8 patients had an IDH wild-type WHO grade II or III glioma.

CONCLUSION

 The LoG-Glio registry has been successfully implemented. Applied selection criteria result in an appropriately balanced patient cohort. Short-term outcome data on epidemiology as well as the influence of current surgical techniques and adjuvant treatment on patient outcomes are expected. In the long run, the aim of the registry is to validate the new molecular-based WHO classification and the influence of the extent of resection on progression-free survival and OS. The registry provides an open platform for future research projects benefiting patients with LGG.

TRIAL REGISTRATION

 NCT02686229 Clinical trials.

WEB-only treatment of ruptured and unruptured intracranial aneurysms: a retrospective analysis of 47 aneurysms

BACKGROUND

WEB (Woven EndoBridge) device is an intrasaccular flow diverter designed for endovascular treatment of intracranial aneurysms. Recent clinical trials showed good feasibility, safety, and efficacy profiles. In most of the published studies however, aneurysms treated with adjunctive devices other than WEB such as coils or stents were included which might make it difficult to reflect the real potential of this device. The purpose of this single-center study was to present the results of ruptured and unruptured aneurysms treated only with WEB device.

METHOD

Between April 2013 and July 2018, 47 (ruptured, 12; 25.5%) intracranial aneurysms treated only with WEB and a follow-up of at least 3 months were included in the study. Angiographic outcome at follow-up, peri-procedural complication rate, and rate of retreatment were recorded.

RESULTS

Of the 47 aneurysms, 12 (25.5%) were ruptured. The mean size of the aneurysms was 6.3 mm (ruptured, 5.4 mm; unruptured, 6.6 mm). Median follow-up period was 9 months. Complete occlusion was observed in 26/47 aneurysms (55.3%; ruptured, 66.6%; unruptured, 51.4%). Thirteen aneurysms (27.6%; ruptured, 16.6%; unruptured, 31.4%) showed a neck remnant. In 4/47 aneurysms (8.5%; ruptured, 8%; unruptured, 8.5%), persistent contrast enhancement inside the WEB was recorded. In 4/47 patients (8.5%; ruptured, 8%; unruptured, 8.5%), an aneurysm remnant was noted. Adequate occlusion (complete occlusion and neck remnant) was observed in 43/47 aneurysms (91.4%; ruptured, 91.6%; unruptured, 91.4%). Retreatment rate was 6.3% (ruptured, 8%; unruptured, 5.7%). Six (12.7%; ruptured, 25%; unruptured, 8.5%) thromboembolic events were recorded. Hemorrhagic complications occurred in two patients (4.2%; ruptured, 16.6%; unruptured, 0%).

CONCLUSIONS

WEB enables adequate occlusion of ruptured and unruptured intracranial aneurysms mostly without requirement of long-term antiplatelet therapy. The benefit is seen especially by the wide-necked aneurysms, but indications should be extended to include narrow-necked, smaller, and side-wall aneurysms.

To treat or not to treat? A retrospective multicenter assessment of survival in patients with IDH-mutant low-grade glioma based on adjuvant treatment

OBJECTIVE

The level of evidence for adjuvant treatment of diffuse WHO grade II glioma (low-grade glioma, LGG) is low. In so-called "high-risk" patients most centers currently apply an early aggressive adjuvant treatment after surgery. The aim of this assessment was to compare progression-free survival (PFS) and overall survival (OS) in patients receiving radiation therapy (RT) alone, chemotherapy (CT) alone, or a combined/consecutive RT+CT, with patients receiving no primary adjuvant treatment after surgery.

METHODS

Based on a retrospective multicenter cohort of 288 patients (≥ 18 years old) with diffuse WHO grade II gliomas, a subgroup analysis of patients with a confirmed isocitrate dehydrogenase (IDH) mutation was performed. The influence of primary adjuvant treatment after surgery on PFS and OS was assessed using Kaplan-Meier estimates and multivariate Cox regression models, including age (≥ 40 years), complete tumor resection (CTR), recurrent surgery, and astrocytoma versus oligodendroglioma.

RESULTS

One hundred forty-four patients matched the inclusion criteria. Forty patients (27.8%) received adjuvant treatment. The median follow-up duration was 6 years (95% confidence interval 4.8-6.3 years). The median overall PFS was 3.9 years and OS 16.1 years. PFS and OS were significantly longer without adjuvant treatment (p = 0.003). A significant difference in favor of no adjuvant therapy was observed even in high-risk patients (age ≥ 40 years or residual tumor, 3.9 vs 3.1 years, p = 0.025). In the multivariate model (controlled for age, CTR, oligodendroglial diagnosis, and recurrent surgery), patients who received no adjuvant therapy showed a significantly positive influence on PFS (p = 0.030) and OS (p = 0.009) compared to any other adjuvant treatment regimen. This effect was most pronounced if RT+CT was applied (p = 0.004, hazard ratio [HR] 2.7 for PFS, and p = 0.001, HR 20.2 for OS). CTR was independently associated with longer PFS (p = 0.019). Age ≥ 40 years, histopathological diagnosis, and recurrence did not achieve statistical significance.

CONCLUSIONS

In this series of IDH-mutated LGGs, adjuvant treatment with RT, CT with temozolomide (TMZ), or the combination of both showed no significant advantage in terms of PFS and OS. Even in high-risk patients, the authors observed a similar significantly negative impact of adjuvant treatment on PFS and OS. These results underscore the importance of a CTR in LGG. Whether patients ≥ 40 years old should receive adjuvant treatment despite a CTR should be a matter of debate. A potential tumor dedifferentiation by administration of early TMZ, RT, or RT+CT in IDH-mutated LGG should be considered. However, these data are limited by the retrospective study design and the potentially heterogeneous indication for adjuvant treatment.

Extra-foraminal Intraneural L5-S1 Disc Herniation Mimicking a Retroperitoneal Peripheral Nerve Sheath Tumour: Case Report and Review of the Literature

Disc herniations can present with unusual findings at unusual locations, mimic different pathologies and create confusion in the daily practice. Extra-foraminal intraneural location of L5-S1 disc herniation is extremely rare and may not be noticed on initial imaging extending the time to reach the diagnosis. There is no specific imaging finding suggesting the intraneural location of the lesion. Here, we report a case of an extra-foraminal intraneural L5-S1 disc herniation mimicking a retroperitoneal peripheral nerve sheath tumour and review similar cases in the literature. 

The influence of nimodipine and vasopressors on outcome in patients with delayed cerebral ischemia after spontaneous subarachnoid hemorrhage

OBJECTIVE

Delayed cerebral ischemia (DCI) is a major factor contributing to the inferior outcome of patients with spontaneous subarachnoid hemorrhage (SAH). Nimodipine and induced hypertension using vasopressors are an integral part of standard therapy. Consequences of the opposite effect of nimodipine and vasopressors on blood pressure on patient outcome remain unclear. The authors report the detailed general characteristics and influence of nimodipine and vasopressors on outcome in patients with SAH.

METHODS

The authors performed a 2-center, retrospective, clinical database analysis of 732 SAH patients treated between 2008 and 2016. Demographic and clinical data such as age, sex, World Federation of Neurosurgical Societies (WFNS) grade, BMI, Fisher grade, history of arterial hypertension and smoking, aneurysm location, C-reactive protein (CRP) level, and detailed dosage of vasopressors and nimodipine during the treatment period were evaluated. Clinical outcome was analyzed using the modified Rankin Scale (mRS) 6 months after treatment. Univariate and multivariate regression analyses were performed. Additionally, mean arterial pressure (MAP), age, nimodipine, and vasopressor dose cutoff were evaluated with regard to outcome. The level of significance was set at ≤ 0.05.

RESULTS

Follow-up was assessed for 397 patients, 260 (65.5%) of whom achieved a good outcome (defined as an mRS score of 0-3). Univariate and multivariate analyses confirmed that nimodipine (p = 0.049), age (p = 0.049), and CRP level (p = 0.002) are independent predictors of good outcome. WFNS grade, Fisher score, hypertension, initial hydrocephalus, and total vasopressor dose showed significant influence on outcome in univariate analysis, and patient sex, smoking status, BMI, and MAP showed no significant association with outcome. A subgroup analysis of patients with milder initial SAH (WFNS grades I-III) revealed that initial hydrocephalus (p = 0.003) and CRP levels (p = 0.001) had significant influence on further outcome. When evaluating only patients with WFNS grade IV or V, age, CRP level (p = 0.011), vasopressor dose (p = 0.030), and nimodipine dose (p = 0.049) were independent predictors of patient outcome. Patients with an MAP < 93 mm Hg, a nimodipine cutoff dose of 241.8 mg, and cutoff total vasopressor dose of 523 mg had better outcomes.

CONCLUSIONS

According to the authors' results, higher doses of vasopressors can safely provide a situation in which the maximum dose of nimodipine could be administered. Cutoff values of the total vasopressor dose were more than 3 times higher in patients with severe SAH (WFNS grade IV or V), while the nimodipine cutoff remained similar in patients with mild and severe SAH. Hence, it seems encouraging that a maximum nimodipine dosage can be achieved despite the need for a higher vasopressor dose in patients with SAH.

A randomized, intraindividual, non-inferiority, Phase III study comparing daylight photodynamic therapy with BF-200 ALA gel and MAL cream for the treatment of actinic keratosis

Background

The most effective treatment modality for actinic keratosis (AK) is photodynamic therapy (PDT). Major obstacles of PDT are the need of a special illumination device and pain accompanying the illumination. These issues may be overcome by replacing an artificial high‐power light source with natural daylight for more extended illumination at lower light doses.

Objective

To determine whether BF‐200 ALA (a nanoemulsion gel containing 7.8% 5‐aminolaevulinic acid) is non‐inferior to MAL (a cream containing 16% methyl‐aminolaevulinate) in the treatment of mild‐to‐moderate AK with daylight PDT (dPDT). Non‐inferiority of the primary efficacy variable (total lesion clearance rate per patient's side 12 weeks after PDT) is established if the mean response for BF‐200 ALA is no worse than for MAL, within a statistical margin of Δ = −12.5%.

Methods

The study was performed as an intraindividual comparison with 52 patients in seven centres in Germany and Spain. Each patient received one dPDT. Results include clinical endpoints as well as 1‐year follow‐up results.

Results

Twelve weeks after a single dPDT, 79.8% of the AK lesions treated with BF‐200 ALA gel and 76.5% of the lesions treated with MAL cream were completely cleared. The median of differences was 0.0 with a one‐sided 97.5% CI of 0.0, establishing non‐inferiority (P < 0.0001). Results for secondary efficacy parameters were in line with the primary outcome. Recurrence rates 1 year after the treatment were 19.9% for lesions treated with BF‐200 ALA and 31.6% for lesions treated with MAL. Adverse reactions including pain were mostly mild and transient and identical to those previously described for dPDT.

Conclusion

Daylight PDT of AK with BF‐200 ALA is well‐tolerated and non‐inferior to MAL/dPDT. The study demonstrates a trend towards higher efficacies after 3 months and significantly lower recurrence rates after 1 year follow‐up.

Diagnostic accuracy of intraoperative perfusion-weighted MRI and 5-aminolevulinic acid in relation to contrast-enhanced intraoperative MRI and 11C-methionine positron emission tomography in resection of glioblastoma: a prospective study

The aim of our study was to compare depicted pre-, intra-, and postoperative tumor volume of met-PET, perfusion-weighed MRI (PWI), and Gd-DTPA MRI. Further, to assess their sensitivity and specificity in correlation with histopathological specimen. Inclusion criteria of the prospective study were histological confirmed glioblastoma (GB), age > 18, and eligible for gross total resection (GTR). Met-PET was performed before and after surgery. Gd-DTPA MRI and PWI were performed before, during, and after surgery. A combined 5-aminolevulinic acid (5-ALA) and iMRI-guided surgery was performed. Volumetric analysis was evaluated for all imaging modalities except for 5-ALA. A total of 59 navigated biopsies were taken. Sensitivity and specificity were calculated for Gd-DTPA MRI, PWI, met-PET, and 5-ALA according to the histology of specimen. Met-PET depicted significantly larger tumor volume before surgery (p = 0.01) compared to PWI and Gd-DTPI MRI. We found no significant difference in tumor volume between met-PET and PWI after surgery (p = 0.059). Both PWI and met-PET showed significantly larger tumor volume after surgery when compared to Gd-DTPA (p = 0.018 and p = 0.003, respectively). Intraoperative PWI reading was impaired in 33.3% due to artifacts. Met-PET showed the highest sensitivity for detection of GB with 95%. The lowest sensitivity was found with Gd-DTPA MRI (50%), while 5-ALA and intraoperative PWI showed similar results (69 and 67%). Met-Pet is the imaging modality with the highest sensitivity to detect a residual tumor in GB. Intraoperative PWI seems to have a synergistic effect to Gd-DTPA and 5-ALA. However, its value may be limited by artifacts. Both pre- and intraoperative PWI cannot substitute met-PET in tumor detection.

Magnetometric mapping of superconducting RF cavities

A scalable mapping system for superconducting RF (SRF) cavities is presented. Currently, it combines local temperature measurement with 3D magnetic field mapping along the outer surface of the resonator. This allows for the observation of dynamic effects that have an impact on the superconducting properties of a cavity, such as the normal to superconducting phase transition or a quench. The system was developed for a single cell 1.3 GHz TESLA-type cavity, but can be easily adopted to arbitrary other cavity types. A data acquisition rate of 500 Hz for all channels simultaneously (i.e., 2 ms acquisition time for a complete map) and a magnetic field resolution of currently up to 14 mA/m/μ₀ = 17 nT have been implemented. While temperature mapping is a well known technique in SRF research, the integration of magnetic field mapping opens the possibility of detailed studies of trapped magnetic flux and its impact on the surface resistance. It is shown that magnetic field sensors based on the anisotropic magnetoresistance effect can be used in the cryogenic environment with improved sensitivity compared to room temperature. Furthermore, examples of first successful combined temperature and magnetic-field maps are presented.

Clipping as re-treatment strategy after treatment of a cerebral aneurysm with the Woven EndoBridge embolization device: case report

Recently, treatment of cerebral aneurysms with the Woven EndoBridge (WEB) device has become an established endovascular strategy. However, over time, neurosurgeons and neuroradiologists will be confronted with the challenge of how to treat aneurysm recanalization. The authors report the case of a 49-year-old woman who underwent re-treatment with clipping after the recanalization of a 4 × 3-mm anterior communicating artery aneurysm that had previously been treated using a 4 × 3 WEB device. In contrast to the authors' prior experiences with clipping of previously coiled aneurysms, the WEB device was found to have a responsive softness during clip placement, and the aneurysm was more maneuverable. Moreover, evaluation with indocyanine green angiography was easy to perform because of the transparent mesh of the WEB device. No profound scarring or WEB protrusion was noted during surgery, making the procedure easier and less dangerous with regard to additional complications. The authors suggest that re-treatment via clipping should be considered in select cases of aneurysm recurrence after treatment with an intraaneurysmal flow diverter.

Bevacizumab in temozolomide refractory high-grade gliomas: single-centre experience and review of the literature

Background

Despite multidisciplinary treatment approaches, the prognosis for patients with high-grade glioma (HGG) is poor, with a median overall survival (OS) of 14.6 months for glioblastoma multiforme (GB). As high levels of vascular endothelial growth factor A (VEGF) are found in HGG, targeted anti-antiangiogenic therapy using the humanized monoclonal antibody bevacizumab (BEV) was studied in a series of clinical trials. Still, the discrepancy of BEV's efficacy with regard to initial clinical and radiological response and its reported failure to prolong survival remains to be explained. Here, we illustrate the effectiveness of BEV in recurrent HGG by summarizing our single-centre experience.

Methods

We have retrospectively investigated the effect of BEV in temozolomide refractory HGG in 39 patients treated at the University Hospital of Ulm, Germany.

Results

Median duration of BEV treatment was 12.5 weeks; 23% of patients received BEV for more than 6 months and 15% for more than 1 year, until clinical or radiological tumour progression led to discontinuation. Furthermore, Karnofsky performance status increased in 30.6% and steroid dose decreased in 39% of all patients.

Conclusions

The review of literature reveals that phase II and III studies support BEV as an effective therapy in recurrent HGG, at least with regard to progression-free survival (PFS), but landmark phase III trials failed to prove benefit concerning OS. Here, we discuss reasons that may account for this observation. We conclude that prolonging PFS with maintenance of neurological function and personal and economic independency justifies the off-label use of BEV.

Role of Three-Dimensional Rotational Angiography in the Treatment of Spinal Dural Arteriovenous Fistulas

Spinal dural arteriovenous fistulas (AVFs), being the most commonly encountered spinal vascular malformations, result in considerable morbidity with progressive spinal cord symptoms. A selective spinal digital subtraction angiography (DSA) is needed to confirm the diagnosis, to better evaluate the fine vascular structures and to plan therapy. With the introduction of three-dimensional rotational angiography (3D-RA), the information available for the treating physician has vastly increased. In the following article, we present a case series of four patients, in which the advantages of 3D-RA over the conventional biplane projections could be observed clearly.

Impact of immunosuppressive therapy on therapy-neutralizing antibodies in transplanted patients with Fabry disease

BACKGROUND

Inhibitory antibodies towards enzyme replacement therapy (ERT) are associated with disease progression and poor outcome in affected male patients with lysosomal disorders such as Fabry disease (FD). However, little is known about the impact of immunosuppressive therapy on ERT inhibition in these patients with FD.

METHODS

In this retrospective study, we investigated the effect of long-term immunosuppression on ERT inhibition in male patients with FD (n = 26) receiving immunosuppressive therapy due to kidney (n = 24) or heart (n = 2) transplantation.

RESULTS

No ERT-naïve transplanted patient (n = 8) developed antibodies within follow-up (80 ±72 months) after ERT initiation. Seven (26.9%) patients were tested ERT inhibition positive prior to transplantation. No de novo ERT inhibition was observed after transplantation (n = 18). In patients treated with high dosages of immunosuppressive medication such as prednisolone, tacrolimus and mycophenolate-mofetil/mycophenolate acid, ERT inhibition decreased after transplantation (n = 12; P = 0.0160). Tapering of immunosuppression (especially prednisolone) seemed to re-increase ERT inhibition (n = 4, median [range]: 16.6 [6.9; 36.9] %; P = 0.0972) over time. One ERT inhibition-positive patient required interventions with steroid therapy and increased doses of tacrolimus, which also lowered ERT inhibition.

CONCLUSION

We conclude that the immunosuppressive maintenance therapy after transplantations seems to be sufficient to prevent de novo ERT inhibition in ERT-naïve patients. Intensified high dosages of immunosuppressive drugs are associated with decreased antibody titres and decreased ERT inhibition in affected patients, but did not result in long-term protection. Future studies are needed to establish ERT inhibition-specific immunosuppressive protocols with long-term modulating properties to warrant an improved disease course in ERT inhibition-positive males.

First use of flat-panel computed tomography during cochlear implant surgery : Perspectives for the use of advanced therapies in cochlear implantation

BACKGROUND

Cochlear implantation in routine cases with normal anatomy is commonly performed without intraoperative image guidance. Revision cochlear implantation as well as surgery in malformations require not only a precise understanding of the underlying complex anatomy, but surgeons need to transform two-dimensional computed tomography (2D CT) scans into the surgical field and use this information for intraoperative surgical navigation. So far, information about the exact position of the electrode during insertion cannot be provided to the surgeon. Here, we present our first operative experience with cochlear implant surgery supported by intraoperative Dyna-CT technology, providing the surgeon with detailed views of the electrode location.

METHODS

To prove the feasibility of the procedure, two cases of cochlear implantation were performed with intraoperative application of cone-beam CT acquired by a C-arm Dyna-CT system (Artis Zeego, Siemens Healthcare, Erlangen, Germany). Image reconstruction was performed intraoperatively in order to assess the correct positioning of the electrodes.

RESULTS

Intraoperative Dyna-CT enabled clear visualization of the surgical anatomy and intracochlear electrode position. Dyna-CT technology can be applied with acceptable additional time requirements without adding too much complexity to the surgical procedure.

CONCLUSION

Intraoperative data acquisition by Dyna-CT represents a suitable option for online surgical navigation during cochlear implant surgery. This imaging technology will push further advances in cochlear implant surgery and lateral skull base surgery, particularly if linked to intraoperative navigation.

Hyperfine and crystal field interactions in multiferroic HoCrO3

We report a comprehensive specific heat and inelastic neutron scattering study to explore the possible origin of multiferroicity in HoCrO3. We have performed specific heat measurements in the temperature range 100 mK-290 K and inelastic neutron scattering measurements were performed in the temperature range 1.5-200 K. From the specific heat data we determined hyperfine splitting at 22.5(2) μeV and crystal field transitions at 1.379(5) meV, 10.37(4) meV, 15.49(9) meV and 23.44(9) meV, indicating the existence of strong hyperfine and crystal field interactions in HoCrO3. Further, an effective hyperfine field is determined to be 600(3) T. The quasielastic scattering observed in the inelastic scattering data and a large linear term [Formula: see text] mJ mol(-1)  K(-2) in the specific heat is attributed to the presence of short range exchange interactions, which is understood to be contributing to the observed ferroelectricity. Further the nuclear and magnetic entropies were computed to be, ∼17.2 Jmol(-1) K(-1) and  ∼34 Jmol(-1) K(-1), respectively. The entropy values are in excellent agreement with the limiting theoretical values. An anomaly is observed in the peak position of the temperature dependent crystal field spectra around 60 K, at the same temperature an anomaly in the pyroelectric current is reported. From this we could elucidate a direct correlation between the crystal electric field excitations of Ho(3+) and ferroelectricity in HoCrO3. Our present study, along with recent reports, confirm that HoCrO3, and RCrO3 (R  =  rare earth) in general, possess more than one driving force for the ferroelectricity and multiferroicity.

[Percutaneous paraumbilical embolization of bleeding rectal varices due to portal hypertension]

Introduction Portal hypertension may lead to severe esophageal or rectal variceal bleeding. Case report We present a case of a 67-year-old patient presenting with recurrent rectal variceal bleeding who was non-responsive to endoscopic treatment. We are reporting on an interventional therapeutic approach found in interdisciplinary consensus. Discussion Endoscopy, surgery or TIPS (transjugular intrahepatic portosystemic shunt) can be performed in patients with gastrointestinal bleeding due to portal hypertension in liver cirrhosis. In cases not suitable for these treatment options, or in cases where these failed to stop the bleeding, radiological percutaneous paraumbilical coil embolization of the portal vein collateral feeding the bleeding could be performed. In our case, as well as in published cases with embolization of jejunal or esophageal hemorrhage, complete stopping of the bleeding could be achieved without further treatment or re-bleeding.

Physical Exercise in Patients with Fabry Disease - a Pilot Study

The aim of this study was to assess the extent of exercise intolerance in Fabry disease (FD) patients and to report individual effects of physical exercise. Exercise capacity and strength of 14 patients (mean age 46 years, 6 females) were determined using cycle ergometry and isokinetic measurements. Patients performed a strength/circuit exercise training protocol for 12 months. The mean relative maximum performance of the group was low at baseline and increased by 12.1% (baseline: 1.9 [0.9-3.4] W·kg^-1vs. re-test: 2.1 [1.1-3.8] W·kg^-1; p=0.035) during the study. Patients' mean baseline maximum performance blood lactate of 5.4 [1.3-9.9] mmol·L^-1 increased to a mean of 7.2 (2.4-10.2) mmol·L^-1 (p=0.038). Mean strength of the lower limbs (left/right extensors and flexors, total work of 5 sets) changed from 2269 (1017-2913) kg·m²·s^- 2 to 2325 (1359-3107) kg·m²·s^-2 (not significant). Patients reported increased well-being, daily activity and reduced fatigue during the study. Our results indicate that exercise intolerance in FD patients often results from physical inactivity. FD patients may perform exercise training to improve exercise capacity and muscle strength. Future studies will address the clinical benefits of exercise in FD.

A new type of solar-system material recovered from Ordovician marine limestone

From mid-Ordovician ∼470 Myr-old limestone >100 fossil L-chondritic meteorites have been recovered, representing the markedly enhanced flux of meteorites to Earth following the breakup of the L-chondrite parent body. Recently one anomalous meteorite, Österplana 065 (Öst 65), was found in the same beds that yield L chondrites. The cosmic-ray exposure age of Öst 65 shows that it may be a fragment of the impactor that broke up the L-chondrite parent body. Here we show that in a chromium versus oxygen-isotope plot Öst 65 falls outside all fields encompassing the known meteorite types. This may be the first documented example of an 'extinct' meteorite, that is, a meteorite type that does not fall on Earth today because its parent body has been consumed by collisions. The meteorites found on Earth today apparently do not give a full representation of the kind of bodies in the asteroid belt ∼500 Myr ago.

The Value of Intraoperative and Early Postoperative Magnetic Resonance Imaging in Low-Grade Glioma Surgery: A Retrospective Study

BACKGROUND

The presence of residual tumor is crucial in decision-making for low-grade gliomas (LGGs), because patients older than 40 years of age with residual tumor are considered for adjuvant treatment. There are hints that early postoperative fluid-attenuated inversion recovery (FLAIR) and T2 (within 48 hours) may overestimate residual tumor volume in LGG. Intraoperative magnetic resonance imaging (MRI) without subsequent resection or ultra-early postoperative MRI may assess the amount of residual tumor more adequately. To evaluate the utility of postoperative imaging in LGG, we volumetrically analyzed intraoperative, early, and late (3-4 months after surgery) postoperative MRIs of LGGs.

PATIENTS AND METHODS

A total of 33 patients with LGG were assessed retrospectively. Residual tumor was defined as signal-enhanced tissue in T2 and FLAIR. Volumetric assessment was performed with intraoperative, early, and late postoperative T2/FLAIR via Brainlab-iPlan 3.0. Wilcoxon and χ(2) tests were used for statistical analysis.

RESULTS

A significant difference of FLAIR/T2 abnormalities was found in intraoperative and early postoperative MRIs (FLAIR mean volume = 5.433 cm(3), T2 mean volume = 3.374 cm(3) vs. FLAIR mean volume = 14.090 cm(3), P = 0.002, T2 mean volume = 7.597 cm(3), P = 0.006). There was no significant difference between intraoperative and late postoperative FLAIR/T2 abnormalities (late postoperative FLAIR/T2 mean volume = 5.560 cm(3) and 2.370 cm(3), P = 0.520, P = 0.398), whereas a significant difference was detected between early and late postoperative images (FLAIR, P < 0.0001; T2, P < 0.00001).

CONCLUSION

Intraoperative MRI without further resection or ultra-early postoperative MRI seems to reflect the actual volume of residual tumor in LGG more precisely compared with early postoperative MRI and therefore seems to be more useful regarding decisions for adjuvant therapy.

Development of a Performance Improvement Program: A Workplace-Based Educational Intervention on Magnetic Resonance Imaging in Spinal Trauma

OBJECTIVE

Performance improvement (PI) programs are an educational tool used to analyze clinical performance of clinicians. The effect of this tool has not been fully explored in orthopedic and trauma surgery.

DESIGN AND SETTING

A needs assessment was conducted in connection with a worldwide webinar on magnetic resonance imaging in spinal injuries to identify the clinical need for an educational intervention. A 3-step PI process was defined and implemented over a 6-month period in 1 hospital department. Opportunities for improvement were identified by applying a 10-item quality checklist to 26 cases. A focused educational intervention was delivered to address the identified gaps, and a set of 22 posteducation cases was compared.

PARTICIPANTS

The department of radiology and the department of trauma surgery of a level I university hospital participated in this study.

RESULTS

A total of 26 cases collected before the educational intervention showed several areas for potential improvement. Important information was not provided by the surgeons in their communication with the radiologist. The educational intervention outlined the data and suggested actions. Comparing the information transfer of the preintervention and postintervention data, there was a significant improvement following the intervention (p = 0.0013).

CONCLUSION

Our PI program was able to demonstrate a significant influence on the behavior and the attitude of surgeons and radiologists.

Cerebrospinal fluid outflow along lumbar nerves and possible relevance for pain research: case report and review

CSF outflow through the cribriform plate near the olfactory nerves and the outflow along brain and spinal nerves are together known as peripheral CSF outflow pathway (PCOP). It is still not clear whether the PCOP has pathogenetic relevance. Our previous clinical observations have indicated that CSF may interact with nerves along the PCOP and in this article we present our finding of CSF outflow demonstrated by myelography in a single patient. We also discuss unexplained experimental pain pathomechanisms against the background of the PCOP hypothesis. We observed that CSF flowed along lumbar nerves in distal direction at a speed of about 10 cm per hour on its way through the tissues, mainly muscles. Total CSF outflow volume at the lumbar site was remarkable. CSF outflow at lumbar nerves was also documented by neuroradiology. It is plausible that CSF signaling serves for interaction with nerves along the PCOP, which could explain previously unknown pathomechanisms in pain generation. Experimental findings of tactile pain hypersensitivity within lumbosacral pain pathways could be explained by releasing of molecules, microparticles, or exosomes into the CSF by mast cells, which then move with CSF outflow along the PCOP and interact with nerves, initiating even retrograde synaptic stripping.

[Weightings and sequences in magnetic resonance imaging in orthopedic surgery]

Magnetic resonance imaging (MRI) plays a very important role in the diagnosis of musculoskeletal conditions; its importance in orthopedic trauma continues to grow. To ensure optimal imaging and to be able to answer all clinically relevant questions, some prerequisites must be taken into account. Of uttermost importance is a functioning communication between surgeons and radiologists. To adapt the best sequences, the radiologist needs to know all suspected injuries and the mechanism of trauma. Second, the surgeon must have basic knowledge regarding this technology to optimally use all its possibilities. The aim of this article is to familiarize the reader with basic MRI in traumatology focusing on weightings and sequences.

Epilepsy in the elderly: restrictions, fears, and quality of life

OBJECTIVES

Due to demographic change and high incidence of epilepsy in elderly, the number of elderly with epilepsies is increasing. However, only few studies investigated the impact of epilepsy on quality of life (QoL). We investigated how epilepsy affects different aspects of QoL dependent on the age of the patients and the age of onset of epilepsy.

MATERIALS AND METHODS

In a multicenter, cross-sectional study, three patient groups were recruited from five centers: Group A1: 45 elderly (≥65 years.) with late onset of epilepsy (≥65 years), group A2: 51 elderly (≥65 years.) with early-onset, long-lasting epilepsy (≤50 years), group B: 41 young adults (≤50 years) with epilepsy. Statistical analysis of differences between groups was performed using generalized linear models.

RESULTS

Elderly with late-onset epilepsy (group A1) had a significantly lower seizure frequency, were treated with less anti-epileptic drugs (AEDs), and reported a better tolerability of AED treatment, but had more comorbidities compared with groups A2 and B. After adjusting for seizure frequency, tolerability of AEDs and comorbidity, young adults (group B) reported the highest overall QoL, whereas patients of group A1 and A2 did not differ significantly. Epilepsy-related fears, especially fears of stigmatization, were significantly higher in elderly with long-lasting epilepsy compared with groups A1 and B.

CONCLUSION

Seizure-related variables, tolerability of AEDs and comorbidity have a stronger impact on QoL and on restrictions due to epilepsy than age, age at onset of epilepsy or duration of epilepsy. However, some results indicate group-specific patterns of impairment and epilepsy-related fears.