Acute Glaucoma Following Internal Carotid Artery Stenting: A Rare But Serious Complication of Ocular Ischemic Syndrome

Acute glaucoma following carotid artery recanalization is a rare but severe complication of underlying ocular ischemic syndrome. We present a case of a 71-year-old woman with ocular ischemic syndrome and severe stenosis of the right internal and external carotid artery undergoing carotid artery stenting. Immediate postprocedural angiography showed pronounced reperfusion of the ophthalmic artery. Subsequently, the patient developed vision-threatening acute glaucoma despite treatment with acetazolamide. Monitoring of intraocular pressure is important in patients who are at risk of developing ocular ischemic syndrome because of internal carotid artery stenosis. Interventionalists should also assess the degree of vascular collateralization from the external carotid artery.

Sonografisches Neuromonitoring auf der Stroke Unit und in der neurologischen Intensivmedizin

Hintergrund Der Artikel gibt einen Überblick über die aktuellen diagnostischen Einsatzmöglichkeiten sonographischer Anwendung in der neurologischen Intensivmedizin.

Methoden Selektive Literaturrecherche mit kritischer Beurteilung ab dem Jahr 1984 sowie nationaler und internationaler Leitlinien sowie Expertenmeinung.

Ergebnisse Neben der raschen validen Abklärung akuter Schlaganfälle bieten verschiedene neurosonografische Monitoring-verfahren gerade in der Intensivmedizin spezifische Vorteile wie die beliebig häufige Wiederholbarkeit am Patientenbett selbst und die Darstellung in Echtzeit. Innovative Entwicklungen machen die Neurosonografie auch wissenschaftlich zu einem interessanten Gebiet.

Schlussfolgerung Die neurosonografische Diagnostik nimmt seit Jahren einen wichtigen Stellenwert in der neurologischen Intensivmedizin ein. Weitere Anstrengungen sind notwendig, um die Verbreitung der Methode zu fördern und durch wissenschaftliche Evidenz zu stärken.

[Ultrasound diagnostics of extracranial cerebral arteries]

Color-coded duplex sonography (CCDS) remains the primary angiological method for most clinical cerebrovascular problems. The application of ultrasound is a non-invasive, cost-effective and arbitrarily repeatable examination technique. Simultaneous acquisition of morphologic B‑mode images and hemodynamic parameters with high temporal and spatial resolution is unequalled by any other neurovascular imaging modality. The correct and reproducible use of CCDS requires knowledge of technical details and adequate examination techniques. Its multiparametric approach uses main and additional criteria to detect and precisely quantify clinically highly relevant stenosis of the proximal internal carotid artery. Quantification of vertebral artery stenosis is performed semiquantitatively due to the generally less reliable sonographic approach. The use of CCDS plays an essential role in supporting endovascular and operative procedures as well as in monitoring hemodynamically relevant dissections.

Focal subarachnoid haemorrhage mimicking transient ischaemic attack--do we really need MRI in the acute stage?

Background

Acute non-traumatic focal subarachnoid haemorrhage (fSAH) is a rare transient ischaemic attack (TIA)-mimic. MRI is considered to be indispensable by some authors in order to avoid misdiagnosis, and subsequent improper therapy. We therefore evaluated the role of CT and MRI in the diagnosis of fSAH patients by comparing our cases to those from the literature.

Methods

From 01/2010 to 12/2012 we retrospectively identified seven patients with transient neurological episodes due to fSAH, who had received unenhanced thin-sliced multiplanar CT and subsequent MRI within 3 days on a 1.5 T scanner. MRI protocol included at least fast-field-echo (FFE), diffusion-weighted imaging (DWI), T2-weighted fluid-attenuated inversion recovery (FLAIR) and time-of-flight (TOF) MRA sequences. By using MRI as gold-standard, we re-evaluated images and data from recent publications regarding the sensitivity to detect fSAH in unenhanced CT.

Results

fSAH was detected by CT and by FFE and FLAIR on MRI in all of our own cases. However, DWI and T2w-spin-echo sequences revealed fSAH in 3 of 7 and 4 of 6 cases respectively. Vascular imaging was negative in all cases. FFE-MRI revealed additional multiple microbleeds and superficial siderosis in 4 of 7 patients and 5 of 7 patients respectively. Including data from recently published literature CT scans delivered positive results for fSAH in 95 of 100 cases (95%), whereas MRI was positive for fSAH in 69 of 69 cases (100%).

Conclusions

Thin-sliced unenhanced CT is a valuable emergency diagnostic tool to rule out intracranial haemorrhage including fSAH in patients with acute transient neurological episodes if immediate MRI is not available. However, MRI work-up is crucial and mandatorily has to be completed within the next 24–72 hours.

Hyperattenuated intracerebral lesions after mechanical recanalization in acute stroke

BACKGROUND AND PURPOSE

Following mechanical recanalization of an acute intracranial vessel occlusion, hyperattenuated lesions are frequently found on postinterventional cranial CT. They represent either blood or-more frequently-enhancement of contrast agent. Here, we aimed to evaluate the prognostic value of these hyperattenuated intracerebral lesions.

MATERIALS AND METHODS

One hundred one consecutive patients with acute stroke in the anterior circulation who underwent mechanical recanalization were included. Risk factors for hyperattenuated intracerebral lesions were assessed, and lesion volume was compared with the volume of final infarction. Clinical outcome and relative risk of secondary hemorrhage were determined in patients with and without any hyperattenuated lesions and compared.

RESULTS

The frequency of hyperattenuated lesions was 84.2%. Risk factors for hyperattenuated lesions were female sex, higher NIHSS score on admission, and higher amount of contrast agent applied. On follow-up, 3 patients showed no infarction; 53 patients, an ischemic infarction; and 45 patients, a hemorrhagic infarction. In all except 1 case, final volume of infarction (median = 92.4 mL) exceeded the volume of hyperattenuated intracerebral lesions (median = 5.6 mL). Patients with hyperattenuated lesions were at a 4 times higher relative risk for hemorrhagic transformation but had no significantly worse clinical outcome.

CONCLUSIONS

Our data show that the extent of postinterventional hyperattenuated intracerebral lesions underestimates the volume of final infarction. Although hyperattenuated lesions indicate a higher risk of secondary hemorrhagic transformation, their presence seems not to be of any prognostic value regarding clinical outcome.

Extent of spontaneous cross-flow via the anterior communicating artery in steno-occlusive carotid artery disease

PURPOSE

Our purpose was to evaluate the agreement of transcranial color-coded duplex sonography (TCCS) measurements and intra-arterial digital subtraction angiography (DSA) findings in determining the extent of spontaneous cross-flow via the anterior communicating artery (AcoA) in patients with internal carotid artery (ICA) stenosis.

METHODS

Thirty adult patients with suspected uni- or bilateral high-grade carotid artery stenosis were prospectively examined by DSA and angle-corrected TCCS. The extent of cross-flow was determined considering retrograde flow in the ipsilateral anterior cerebral artery (ACA) and sideto-side differences of the A1-segments of the ACA and middle cerebral arteries (MCAs) by both techniques. Cross-flow was angiographically categorized by means of a four-step scale. DSA findings were correlated with side-to-side differences in mean blood flow velocity as well as flow direction measured by TCCS.

RESULTS

Twenty-seven of 30 patients had a uni- or bilateral ICA stenosis of >49%. Excellent agreement between TCCS and DSA was evaluated for the detection of lack (grades 0 and 1) or presence (grades 2 and 3) of reversed flow in the ACA (sensitivity 100%, specificity 93%, positive predictive value 94%). Post hoc analysis of the mean velocities in the ACA and MCA revealed a side-to-side difference of 25 cm/s as a cutting point allowing for definition of a corresponding four-grade scale for ultrasound. However, full agreement, i.e.same grade of cross-flow detected by both techniques, was only found in 17(57%) of 30 cases.

CONCLUSIONS

Non-invasive TCCS is reliable for detecting reversed flow in the ACA in patients with ICA stenosis. However, there is only a moderate agreement between angiography and TCCS in quantifying the extent of spontaneous anterior cross-flow because different information on the intracranial hemodynamics may be obtained.

Intra-individual, randomised comparison of the MRI contrast agents gadobutrol versus gadoteridol in patients with primary and secondary brain tumours, evaluated in a blinded read

OBJECTIVE

To prove that 1.0 M gadobutrol provides superior contrast enhancement and MRI image characteristics of primary and secondary brain tumours compared with 0.5 M gadoteridol, thereby providing superior diagnostic information.

METHODS

Brain MRI was performed in two separate examinations in patients scheduled for neurosurgery. Independent injections of 1.0 M gadobutrol and 0.5 M gadoteridol at doses of 0.1 mmol Gd/kg body weight were administered per patient in randomised order. Evaluation was performed in an off-site blinded read.

RESULTS

Fifty-one patients in the full analysis set (FAS) were eligible for efficacy analysis and 44 for the per-protocol analysis. For the primary efficacy variable "preference in contrast enhancement for one contrast agent or the other", the rate of "gadobutrol preferred" was estimated at 0.73 (95 % confidence interval 0.61; 0.83), showing significant superiority of gadobutrol over gadoteridol. Calculated lesion-to-brain contrast and the results of all qualitative secondary efficacy variables were also in favour of gadobutrol. Keeping a sufficient time delay after contrast application proved to be essential to get optimal image quality.

CONCLUSION

Compared with 0.5 M gadoteridol, 1.0 M gadobutrol was proven to have significantly superior contrast enhancement characteristics in a routine MRI protocol of primary and secondary brain tumours.

The potential of neurosonography in neurological emergency and intensive care medicine: monitoring of increased intracranial pressure, brain death diagnostics, and cerebral autoregulation– part 2

Transcranial B-mode sonography is an easy to use bedside imaging modality to monitor significant changes of the brain parenchyma such as in malignant middle cerebral infarction or intracerebral hemorrhage. The elevation of intracranial pressure can be followed with various neurosonographical techniques: Measurements of the ventricular width, midline shift, arterial resistance, and optic nerve sheath diameter. They should be viewed as complementary to each other and to other imaging modalities. Repeated cCT and MRI may be avoided in unstable patients by bedside neurosonography in the hands of an experienced physician. Monitoring of evolving hydrocephalus using serial measurements of the third and lateral ventricles can be used to guide therapeutic decisions such as the removal of a ventricular drainage. The cessation of cerebral blood flow in the case of intracranial pressure exceeding systemic arterial pressure is an important part of brain death diagnostics. Early demonstration of a sufficient temporal bone window is needed in patients in whom brain death may be expected. Cerebrovascular autoregulation is an integer component of the brain's blood supply and is compromised in a variety of neurological diseases. In neurological/neurosurgical patients in the intensive care unit, its assessment allows for extended neuromonitoring and control of therapeutic procedures.

Current strategies in the diagnosis of diffuse large B-cell lymphoma of the central nervous system

Lymphomas can arise within the central nervous system (CNS) as primary CNS lymphoma (PCNSL) typically involving the brain and less often the leptomeninges, eyes, and spinal cord. In contrast to PCNSL, secondary CNS lymphoma (SCNSL) is considered to originate as quasi metastasis from systemic lymphoma spreading to the CNS. Both types of CNS lymphomas are predominantly tumours of the diffuse large B-cell type and represent aggressive diseases necessitating a rapid diagnosis. Following neuroimaging based on magnetic resonance imaging, stereotaxy and histopathological diagnosis of CNS lymphoma currently remain obligatory to plan treatment. However, progress in cytopathological, immunophenotypic, and molecular genetic analyses of the cerebrospinal fluid (CSF) has been achieved recently and potentially will facilitate lymphoma diagnosis in the future. This review describes the diagnostic procedures in patients with suspected CNS lymphomas, primarily PCNSL. In addition to a summary of the standard diagnostic work-up, an overview and discussion of current data on different techniques for evaluation of the CSF in CNS lymphoma are given.

Ultrasound computed tomography in breast imaging: first clinical results of a custom-made scanner

PURPOSE

To test a system using ultrasound computed tomography (USCT) that superimposes ultrasound data acquired in one cross-sectional plane from multiple angles around the breast (Full Angle Spatial Compounding, FASC) and to reconstruct the distribution of the speed of sound in the breast (SoS reconstruction).

MATERIALS AND METHODS

We developed a system combining a conventional ultrasound scanner with a PC-controlled mechanical setup integrated in a custom-made examination couch. In a feasibility study, 3 volunteers (age 26 - 74 years) and one patient with breast cancer were studied. Subjects were placed in the prone position on this couch, with the breast hanging in a water tank. The ultrasound probe was moved in several planes around the breast. A curved reflector that followed the movement of the probe behind the breast was used to calculate the SoS within the breast tissue. Echo-data was processed offline by custom-made software to calculate both FASC and SoS images.

RESULTS

In FASC images a reduction of artifacts (i. e. shadowing of Cooper's ligaments and irregular edges of inhomogeneous lesions) and speckles as well as clear visualization of the inner architecture of the breast was achieved. SoS images delivered further diagnostic information and helped to compensate for geometric distortions in the computed images. Difficulties in the visualization of lesions near the thoracic wall and/or the axillary are limitations of this technique.

CONCLUSION

The first clinical results of USCT imaging have proven its feasibility as an automated and standardized technique for breast imaging.

[Color duplex sonography of extracranial brain-supplying arteries]

Ultrasound examination of extracranial blood-supplying arteries allows the simultaneous acquisition of morphologic and hemodynamic information with high spatial and temporal resolution. For detection and quantification of stenoses in the carotid and vertebral arteries, an intrastenotic peak systolic velocity of more than 120 cm/s is the threshold value for a diameter reduction of >50%. In addition there are further direct and indirect stenosis parameters (intrastenotic and poststenotic circulation disturbance, increased pulsatility in the prestenotic common carotid artery, intracranial or extracranial collateral pathways) which together with diameter and area reduction in the B-scan, lead to a high reliability of color duplex sonography for stenoses of the internal carotid artery (ICA). Sonographic and patho-anatomic comparative studies have shown a high agreement (r >0.9) by using a battery of several ultrasound criteria. Following stenting of the ICA the blood flow velocity in the stent is generally increased so that a > or =70% in-stent restenosis is present in case of a peak systolic velocity of 300-450 cm/s. For the description of arteriosclerotic plaques in the B-scan, ultrasound terminology but not histological terms should be used to describe the internal, surface and motion structure of plaques as well as the sonic shadow formation.

Three-dimensional constructive interference in steady-state magnetic resonance imaging in obstructive hydrocephalus: relevance for endoscopic third ventriculostomy and clinical results

Object

Endoscopic third ventriculostomy is the treatment of choice in patients with obstructive hydrocephalus caused by aqueductal stenosis. The authors examined the clinical course and results of surgical treatment for obstructive hydrocephalus with pre- and postoperative refined constructive interference in steady-state (CISS) MR imaging.

Methods

Forty patients with obstructive hydrocephalus underwent pre- and postoperative 3D-CISS imaging and clinical evaluation. Radiological findings were correlated with intraoperative observations of the thickness and transparency of the floor of the third ventricle and the patient's postoperative clinical course.

Results

Three-dimensional CISS MR imaging provides precise visualization of the basilar/posterior cerebral artery, its distance to the clivus, the diameter of the foramen of Monro, and the extension of and thickness of the floor of the third ventricle. In 71% of patients a flow void was detectable postoperatively on the ventriculostomy. In this group 81.5% had strong and 14.8% moderate clinical benefit, and 3.7% required secondary shunt placement. In the remaining 29% of the patients without a visible flow void, strong improvement was seen in 54.5%, moderate improvement in 18.2%, and stoma failure occurred in 27.3% (p = 0.094). Radiological measurements of the thickness of the third ventricle floor correlated with intraoperative findings (r = 0.35, p = 0.029). Comparison of outcomes showed a statistically significant tendency for a better outcome in patients with thin and easily perforated third ventricle floors (p = 0.04).

Conclusions

Endoscopic ventriculostomy in patients with obstructive hydrocephalus is safe and mostly successful, and 3D-CISS MR imaging seems to be a valuable diagnostic method for precisely identifying the anatomy of relevant structures. Furthermore, 3D-CISS MR imaging allows judgment of the thickness of the third ventricle floor and display of the ventriculostomy/flow void, which are predictive for intraoperative course and clinical outcome.

[Value of vascular ultrasound in the evaluation of hemodialysis fistulas]

Vascular ultrasound has been proven to be effective in the assessment of hemodialysis fistulas providing noninvasive diagnostic work-up of vascular morphology and hemodynamics. The most common reason for hemodialysis fistula failure is thrombosis due to stenosis. Therefore, early identification of stenosis is essential to avoid complications. Ultrasound-based identification of hypoechoic plaques and intimal proliferation helps to reach therapeutic decisions. An estimation of the grade of stenosis is also feasible. An occlusion rate of up to 45% due to reduced blood flow justifies follow-up examinations. Due to frequent puncture of the fistula the risk of hemodynamically relevant stenoses is increased. Establishment of new ultrasound methods like B-flow and advanced dynamic flow (ADF) enable direct visualization of the flow in the area of the anastomosis. In addition, high-resolution ultrasound techniques allow improved flow detection without aliasing. Our report addresses the topics of examination strategy, possible complications, and treatment like percutaneous intervention techniques.

[Developmental venous anomaly (DVA)]

As congenital anatomic variants of venous drainage, developmental venous anomalies (DVA) represent up to 60% of all cerebral vascular malformations. The prior term "venous angioma" is a misnomer implicating an abnormal vascular structure with an increased bleeding risk. They are often found incidentally and are hardly ever symptomatic. Their morphologic characteristics are dilated vessels in the white matter, which converge on a greater collector vein, forming the typical caput medusae. They drain into the superficial or deep venous system. The frequent association with other, potentially bleeding-prone vascular malformations is clinically relevant, in particular cavernous angioma, which might require therapeutic action. Therefore, coincident vascular lesions need to be actively sought by appropriate additional imaging techniques.

[Cavernous malformations]

Cavernomas of the CNS may involve brain parenchyma as well as the spinal cord and belong to those cerebrovascular malformations that have no arteriovenous shunt and thus are generally angiographically occult. Contrary to computed tomography (CT), which is generally suited to reveal calcifications or acute bleeding, magnetic resonance imaging (MRI) enables detection of even small cavernomas. A frequently associated venous anomaly is helpful for correct diagnosis.

[Modern ultrasound diagnostics of deep vein thrombosis in lung embolism of unknown origin]

PURPOSE

We compared innovative ultrasound techniques such as tissue harmonic imaging (THI) and cross-beam technique with speckle reduction imaging (SRI) to conventional fundamental B scan in the diagnosis of deep vein thrombosis.

MATERIAL AND METHODS

We investigated a total number of 185 patients with clinical symptoms of acute vein thrombosis. We documented the thrombosis in the patients using multifrequency ultrasound probes (5-7 MHz, 6-9 MHz, 9-14 MHz, Logig 9, GE) and recorded ultrasound sequences in fundamental B scan, THI, and cross-beam technique with SRI (grade 2). Three blinded ultrasound investigators ranked the marking of the thrombosis in each of these image modalities and graded them with the numbers 5 = weak, 4 = moderate, 3 = satisfactory, 2 = good, and 1 = excellent. We calculated the median and a t-test for each of these image modalities.

RESULTS

We diagnosed 115 thromboses (62%) in 185 investigated patients. This group could be divided as follows: 11 patients (6%) with three-level thrombosis, 37 patients (20%) with two-level thrombosis, and 67 (36%) with one-level thrombosis. The one-level thrombosis group included five (3%) patients with muscle vein thromboses, seven (4%) cases of thrombophlebitis without involvement of the deep vein system, and three (2%) cases of thrombophlebitis with involvement of the deep vein system. The t-test for unconnected samples showed significant differences (p <0.05) in iliac veins and highly significant differences (p <0.001) in the veins of the lower extremity due to the superior capabilities for detection of thrombosis using the cross-beam technique with SRI compared to THI and the fundamental B scan.

CONCLUSION

The use of high-resolution linear ultrasound probes with the concomitant application of THI and cross-beam technique with SRI facilitates the diagnosis of deep vein thrombosis. The employment of these new ultrasound modalities is an advantage in distinguishing the veins from the surrounding tissue structures and helps in evaluating the compressibility of venous vessels.

Structural and functional MRIs disclose cerebellar pathologies in idiopathic downbeat nystagmus

BACKGROUND

Neurologic disorders in which the etiology and pathogenesis are not yet understood are termed idiopathic. Downbeat nystagmus (DBN) is a frequent eye movement disorder that clinically manifests with oscillopsia and postural instability. Forty percent of patients with DBN are classified as having idiopathic DBN, because no underlying pathology can be demonstrated by conventional MRI or laboratory tests.

METHODS

We evaluated gray matter brain volumes of 11 patients with idiopathic DBN and compared them to those of healthy controls using voxel-based morphometry. In a second, functional MRI experiment, patients and controls performed downward smooth pursuit eye movements (DOWN), which were then compared with straight-ahead fixation of a stationary target (MID).

RESULTS

Small areas of localized gray matter atrophy were detected in the lateral cerebellar hemispheres (lobule VI) and ocular motor vermis of patients with idiopathic DBN, but not in the flocculus and paraflocculus. The functional imaging data, however, revealed reduced activation in the parafloccular lobule and in the ponto-medullary brainstem of the patients when they performed smooth pursuit eye movements downwards.

CONCLUSIONS

The applied specialized imaging and data analysis techniques disclosed pathologies in an idiopathic eye movement disorder. The focal atrophy found in the vermal and lateral cerebellar regions in downbeat nystagmus (DBN) may lead to deficits in smooth pursuit eye movement initiation, which in turn causes hypofunction of the parafloccular lobe, associated with DBN. Our data are in line with experiments in primates showing that ablation of the floccular and parafloccular lobes disrupts smooth pursuit and causes DBN.

Treatment of wide-necked intracranial aneurysms with a novel self-expanding two-zonal endovascular stent device

INTRODUCTION

Endovascular treatment of intracerebral wide-necked aneurysms carries the risk of incomplete embolisation and recanalisation of the aneurysm as well as coil protrusion into the parent artery and embolic complications. We present preliminary results with the placement of a novel tightly braided stent across the aneurysm neck which might lead to thrombosis of these aneurysms.

METHODS

A bifurcation artery aneurysm was created in a male New Zealand White Rabbit. After 4 weeks, a novel highly flexible stent with a central tightly braided mesh was placed across the aneurysm neck. Diagnostic angiography was performed during the procedure and immediately after stent deployment as well as 2 and 4 weeks following stent placement. Histological analyses, including microscopic investigations for evaluating intra-aneurysmal thrombosis and proliferation of the intima, were performed after 1 month.

RESULTS

Intra-aneurysmal flow reduction due to stent placement was achieved as early as 45 min after deployment. Unchanged complete occlusion of the aneurysm could be observed by angiography 2 and 4 weeks post-stent deployment. Histological analysis confirmed angiographical findings of complete aneurysm occlusion and excluded significant neointimal coverage.

CONCLUSION

This newly designed flexible stent may offer the potential to expand endovascular treatment of wide-necked intracranial aneurysms.

[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.

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.

[Stroke]

Today stroke represents a major medical and political problem in Western industrial nations. High demands need to be placed on the initial diagnostic work-up and therapeutic treatment to ensure that the patients benefit from the recent advancements achieved in diagnostic and therapeutic fields. According to the motto "time is brain" the clinical examination and imaging have to be performed within 60 min ("door to needle time") so that potential patients can be quickly treated with systemic or intra-arterial lysis. However, it should be taken into consideration that the selection of diagnostic imaging facilities depends on several factors such as infrastructure, the time remaining in the diagnostic window, and the severity of the clinical symptoms.

A multicenter, site-independent, blinded study to compare the diagnostic accuracy of contrast-enhanced magnetic resonance angiography using 1.0M gadobutrol (Gadovist™) to intraarterial digital subtraction angiography in body arteries

PURPOSE

Prospective evaluation of diagnostic accuracy of single field-of-view contrast-enhanced MR Angiography (ceMRA) with 1.0M gadobutrol compared to intraarterial DSA in body arteries.

MATERIALS AND METHODS

In an European multicenter study 179 patients underwent ceMRA and DSA. For each indication five prospectively defined vessel segments were evaluated by local investigators onsite and by three site-independent blinded readers (BR) independently.

RESULTS

The agreement between ceMRA and DSA diagnosis was statistically significant in the onsite (96.6%) and blinded reader (86.6-90.2%) evaluation. Sensitivity, specificity, accuracy, positive (PPV) and negative predictive values (NPV) for detection of relevant stenosis (>50%) were calculated for the right and left internal carotid arteries, and common and external iliac arteries: Sensitivity was 95-98% (onsite) and 76-96% (BR), specificity 94-96% (onsite) and 86-94% (BR), accuracy 96% (onsite) and 87-93% (BR), NPV 98-99% (onsite) and 84-98% (BR), and PPV 79-93% (onsite) and 44-91% (BR), respectively.

CONCLUSION

CeMRA of body arteries using 1.0M gadobutrol provides diagnostic information comparable to intraarterial DSA.

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.

Differenzialdiagnostik der nichtneoplastischen spinalen Raumforderung

This overview addresses the topic of non-neoplastic intraspinal space-occupying lesions. Knowledge of these entities is essential to distinguish them from tumorous processes. A selection of clinically relevant differential diagnoses is presented which pertain to inflammatory, vascular, and degenerative diseases. In addition, special clinical findings, the radiological procedure, and therapeutic possibilities are outlined.

[Postoperative syndrome after spine surgery]

Postoperative syndrome after spine surgery, i.e., symptoms or syndromes caused by complications or procedure-related consequences, is gaining more and more importance. Due to great improvements concerning imaging and operative techniques (microsurgery, instrumentation) the total number of spinal surgeries as well as their related complications are increasing. Procedure-related postoperative complications including neurological deficit syndromes can occur acutely or at a later date. Concerning imaging techniques for postoperative evaluation after spinal surgery there are several modalities available. Their indications depend on complex factors including initial pathology the surgery was performed for, kind of surgical technique (surgical approach, instrumentation), anatomy of the patient as well as the time between onset of symptoms and surgery. In cases of ambiguous findings, the combination of different imaging techniques can be instrumental.

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.