Horst Urbach

Focal cortical dysplasia: Long-term seizure outcome after surgical treatment

Background: Studies of long term outcome after epilepsy surgery for cortical malformations are rare. In this study, we report our experience with surgical treatment and year to year long term outcome for a subgroup of patients with focal cortical dysplasia (FCD). Methods: We retrospectively analysed the records of 49 patients (females nu200a=u200a26; males nu200a=u200a23; mean age 25 (11) years) with a mean duration of epilepsy of 18 years (range 1–45). Preoperative MRI, histological results based on the Palmini classification and clinical year to year follow-up according to the International League Against Epilepsy (ILAE) classification were available in all patients. Results: 98% of patients had a lesion on preoperative MRI. In addition to lobectomy (nu200a=u200a9) or lesionectomy (nu200a=u200a40), 14 patients had multiple subpial transections of the eloquent cortex. The resected tissue was classified as FCD type II b in 41 cases with an extratemporal (88%) and FCD type II a in 8 cases with a temporal localisation (100%). After a mean follow-up of 8.1 (4.5) years, 37 patients (76%) were seizure free, a subgroup of 23 patients (47%) had been completely seizure free since surgery (ILAE class 1a) and 4 patients (8%) had only auras (ILAE class 2). Over a 10 year follow-up, the proportion of satisfactory outcomes decreased, mainly within the first 3 years. During long term follow-up, 48% stopped antiepileptic drug treatment, 34% received a driver’s license and 57% found a job or training. Conclusion: Surgical treatment of epilepsy with FCD is not only successful in the short term but also has a satisfying long term outcome which remains constant after 3 years of follow-up but is not associated with better employment status or improvement in daily living.

GREAT—a randomized controlled trial comparing HydroSoft/HydroFrame and bare platinum coils for endovascular aneurysm treatment: procedural safety and core-lab-assessedangiographic results

IntroductionHybrid hydrogel-platinum coils (HydroCoil) have proven effective for endovascular aneurysm treatment. To overcome technical limitations (coil stiffness, time restriction for placement), a second generation of softer hydrogel coils has been brought to clinical practice (HydroSoft, HydroFrame). We report on procedural safety and core-lab-assessed angiographic results from an open-label multicenter randomized controlled trial.MethodsWeb-based randomization occurred in 15 medical centers in France and seven in Germany between coil embolization with second-generation hydrogel coils and treatment with any bare platinum coil. Assist devices could be used as clinically required. Primary endpoint is a composite outcome including major aneurysm recurrence and poor clinical outcome at 18xa0months follow-up.ResultsFive hundred thirteen patients were randomized (hydrogel nu2009=u2009256, bare platinum nu2009=u2009257). Twenty patients were excluded for missing informed consent and nine patients for treatment related criteria. Four hundred eighty-four patients were analyzed as randomized (hydrogel nu2009=u2009243, bare platinum nu2009=u2009241). Two hundred eight had ruptured aneurysms (43xa0%). Prespecified procedural complications occurred in 58 subjects (hydrogel nu2009=u200928, bare platinum nu2009=u200930, pu2009=u20090.77). The 14-day mortality rate was 2.1xa0% in both arms of the study. The median calculated packing densities for aneurysms assigned to hydrogel and bare platinum were 39 and 31xa0% respectively (pu2009<u20090.001). No statistically significant differences were found between arms in the post procedural angiographic occlusion rate (pu2009=u20090.8).ConclusionSecond-generation hydrogel coils can be used in a wide spectrum of aneurysms with a risk profile equivalent to bare platinum. Packing density was significantly higher in aneurysms treated with hydrogel coils.Trial registrationhttp://www.germanctr.de, DRKS00003132

GREAT—a randomized aneurysm trial. Design of a randomized controlled multicenter study comparing HydroSoft/HydroFrame and bare platinum coils for endovascular aneurysm treatment

The effectiveness of a hybrid hydrogel platinum detachable coil (HydroCoil; MicroVention Inc., Tustin, CA) for endovascular aneurysm treatment has been proven in a recently published RCT. Due to technical restrictions (coil stiffness, time restriction for placement), the HydroSoft coil as well as a corresponding 3D framing coil, the HydroFrame coil (MicroVention Inc., Tustin, CA), a class of new softer coils containing less hydrogel and swelling more slowly than the HydroCoil, have been developed and brought to clinical practice. The present study aims to compare the effectiveness of endovascular aneurysm treatment with coil embolization between patients allocated HydroSoft/HydroFrame versus bare platinum coiling. GREAT is a randomized, controlled, multicentre trial in patients bearing cerebral aneurysms to be treated by coil embolization. Eligible patients were randomized to either coil embolization with HydroSoft/HydroFrame coils (>50xa0% of administered coil length), or bare platinum coils. Inclusion criteria were as follows: age 18–75, ruptured aneurysm (WFNS 1–3) and unruptured aneurysm with a diameter between 4 and 12xa0mm. Anatomy such that endovascular coil occlusion deemed possible and willingness of the neurointerventionalist to use either HydroSoft/HydroFrame or bare platinum coils. Exclusion criteria were as follows: aneurysms previously treated by coiling or clipping. Primary endpoint is a composite of major aneurysm recurrence on follow-up angiography and poor clinical outcome (modified Rankin scale 3 or higher), both assessed at 18xa0months post treatment. Risk differences for poor outcomes will be estimated in a modified intention-to-treat analysis stratified by rupture status (DRKS-ID: DRKS00003132).

Angiocentric neuroepithelial tumor mimicking Ammon's horn sclerosis : case report

CASE REPORTnWe report on a 46-year-old male patient with pharmacoresistant temporal lobe epilepsy (TLE). Based on ictal EEG patterns and MRI scans, Ammons horn sclerosis (AHS) or an epilepsy-associated tumor was included in the differential diagnosis.nnnRESULTSnHistopathological examination of the surgical specimen revealed the unusual finding of a monomorphous angiocentric neuroepithelial tumor composed of small round cells and bipolar processes with perivascular aggregation. Immunohistochemistry detected perivascular-oriented expression of GFAP and cytoplasmic immunoreactivity of EMA and vimentin. Mitotic or other signs of proliferative activity were lacking. During a 2-year follow-up, the patient was seizure-free.nnnCONCLUSIONSnAlbeit AHS is the most frequent finding in TLE specimens, uncommon neuroepithelial tumors with hippocampal growth pattern have to be considered in the differential diagnosis of mesial TLE. The present case meets the criteria of an angiocentric neuroepithelial tumor recently proposed as a new clinicopathological entity. These tumors may be compatible with a maldevelopmental origin during early brain development.

Magnetic resonance imaging of focal cortical dysplasia: Comparison of 3D and 2D fluid attenuated inversion recovery sequences at 3T.

PURPOSEnFocal cortical dysplasia (FCD) is a frequent finding in drug resistant epilepsy. The aim of our study was to evaluate an isotropic high-resolution 3-dimensional Fluid-attenuated inversion recovery sequence (3D FLAIR) at 3T in comparison to standard 2D FLAIR in the diagnosis of FCD.nnnMATERIALS AND METHODSnIn a prospective study, 19 epilepsy patients with the MR diagnosis of FCD were examined with a sagittal 3D FLAIR sequence with modulated refocusing flip angle (slice thickness 1.10mm) and a 2D FLAIR in the coronal (thk. 3mm) and axial planes (thk. 2mm). Manually placed regions of interest were used for quantitative analysis. Qualitative image analysis was performed by two neuroradiologists in consensus.nnnRESULTSnContrast between gray and white matter (p ≤ 0.02), the lesion (p ≤ 0.031) or hyperintense extension to the ventricle (p ≤ 0.021) and white matter was significantly higher in 2D than in 3D FLAIR sequences. In the visual analysis there was no difference between 2D and 3D sequences.nnnCONCLUSIONnConventional 2D FLAIR sequences yield a higher image contrast compared to the employed 3D FLAIR sequence in patients with FCDs. Potential advantages of 3D imaging using surface rendering or automated techniques for lesion detection have to be further elucidated.

Surgical Resection Can Be Successful in a Large Fraction of Patients With Drug-Resistant Epilepsy Associated With Multiple Cerebral Cavernous Malformations

BACKGROUNDnMultiple cerebral cavernous malformations (mCCMs) are known as potentially epileptogenic lesions. Treatment might be multimodal. Management of patients with mCCMs and epilepsy is challenging.nnnOBJECTIVEnTo evaluate (1) algorhythmic therapeutic sequences in patients with epilepsy associated to mCCMs, (2) whether there are predictive parameters to anticipate the development of drug-resistant epilepsy, and (3) seizure after epilepsy surgery compared to conservatively-treated drug-resistant patients.nnnMETHODSnAll inpatients and outpatients with epilepsy associated to mCCMs from 1990 to 2010 and follow-up >12 months available were retrospectively analyzed.nnnRESULTSnTwenty-three patients matched inclusion criteria. Epilepsy became drug-resistant in 18/23 (78%) patients. No predictors were found for development of drug-resistant epilepsy. Median follow-up for both groups was 7.8 years. Nine patients did not qualify for surgical therapy and were treated conservatively. One patient of this cohort (11%) was seizure-free (International League Against Epilepsy [ILAE] class 1). Surgical treatment was performed in 9 patients; 7/9 (78%) of these patients were seizure-free (ILAE class 1) after epilepsy surgery for at least 12 months compared with 1/9 patients in the non-operated group. In 7/9 cases (78%) the largest CCM was resected. In 8/9 (89%) not all CCMs were resected.nnnCONCLUSIONnAfter initial diagnosis of epilepsy associated to mCCMs, a primary conservative approach is reasonable. Surgical treatment can be successful in a large fraction of cases with drug-resistant epilepsy where an epileptogenic lesion is identified. Cases where surgery is not undertaken are likely to remain intractable.

Gated multidetector computed tomography. A technique to reduce intracranial aneurysm clip and coil artifacts.

Background and Purpose:Streak artifacts caused by aneurysm clips and coils impede image quality in multidetector computed tomography (MDCT). The authors propose a technique to minimize these artifacts by gated data reconstruction and shifting the reconstruction window.Patients and Methods:Intracranial CT angiograms were acquired in the follow-up of six patients with clipped and coiled intracranial aneurysms, respectively. Images were reconstructed from four consecutive 45° rotated segments with an acquisition time of 52.5xa0ms/segment. Data acquisition was gated via an external pacemaker cable-connected to the scanner.Results:Artifact orientation could be rotated by shifting the reconstruction window and interesting vessel segments visualized without disturbing streak artifacts. This allowed to assess the posterior communicating artery origin in two cases and a middle cerebral artery aneurysm remnant in another case, respectively. However, due to a higher noise interesting vessel segments were not adjustable in another three patients.Conclusion:Gated MDCT is a promising technique to reduce the amount and to change the position of artifacts induced by clips or coils.ZusammenfassungHintergrund und Ziel:Metallartefakte, verursacht durch Gefäßclips und -coils beeinträchtigen die Bildqualität im CT. Wir stellen eine neue Methode zur Artefaktreduktion vor durch Verwendung einer getriggerten Datenakquisition und durch Verschiebung des Rekonstruktionsintervalls.Material und Methodik:Sechs Patienten mit geclippten bzw. gecoilten intrakraniellen Aneurysmen haben im Rahmen der Nachsorge intrakraniale CT-Angiogramme erhalten. In den getriggerten Untersuchungen erfolgte die Bilddaten-Rekonstruktion aus vier 45° Rotationssegmenten mit einer Akquisitionsdauer von 52,5 ms jeweils. Die Triggerung der Datenakquisition erfolgte durch einen externen, am MDCT angeschlossenen Schrittmacher.Ergebnisse:Die getriggerte Datenakquisition und die Drehung der Artefakte in den verschiedenen Rekonstruktionsintervallen hat eine verbesserte Darstellbarkeit der Gefäßsegmente in der Umgebung der Clips/Coils ermöglicht. Auf diese Weise konnten bei drei Patienten das aneurysmatragende Gefäß bzw. ein Aneurysmarest dargestellt werden. In drei weiteren Fällen waren die interessierenden Gefäßsegmente aufgrund des höheren Bildrauschens nicht besser visualisierbar.Schlussfolgerung:Die getriggerte MDCT ist eine erfolgversprechende Technik um die Menge der Metallartefakte zu reduzieren und um die Position der Artefakte zu ändern.

Regional Differences in Thrombectomy Rates

Background and PurposeMechanical thrombectomy, in addition to intravenous (i.v.) thrombolysis is recommended for treatment of acute stroke in patients with large vessel occlusions (LVO) in the anterior circulation up to 6u202fh after symptom onset. We compared thrombectomy rates of eight university hospitals of the MIRACUM consortium to analyze the implementation of this guideline in clinical routine.MethodsAnonymized billing data in a standardized format were loaded into a local i2b2 data warehouse by applying already existing extract, transform and load (ETL) routines. A locally executed uniform SQL (structured query language) query delivered aggregated site data for all inpatients with a discharge diagnosis of ischemic stroke (ICD-10 I63) containing counts for type of acute treatment, type of admission and age groups, which were centrally analyzed with R.ResultsFrom 2014 to 2016, the thrombectomy rate almost doubled from a mean of 4.7% to 9.6%, although significant differences between centers exist (range in 2016: 5.8–17%). The number of drip-and-ship procedures increased in 3 out of 8 centers. There was no evidence for a decrease in thrombectomy rates during weekends/holiday or among patients older than 80 years, but this age group is more likely to receive i.v. recombinant tissue plasminogen activator (rtPA).ConclusionThe observed increase of thrombectomy rates and drip-and-ship procedures without a significant difference between weekdays and weekends or patients of different ages is substantiating a rapid implementation of stroke guidelines within the analyzed neurovascular centers. The prototype of the MIRACUM Data Integration Center already contributes to health services research in Germany.

Stereotactic Catheter Ventriculocisternostomy for Clearance of Subarachnoid Hemorrhage in Patients with Coiled Aneurysms

BACKGROUNDnCerebral vasospasm leading to delayed cerebral infarction (DCI) is a central source of poor outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). Current treatments of cerebral vasospasm are insufficient. Cisternal blood clearance is a promising treatment option. However, a generally applicable, safe, and effective method to access the cisterns of the brain is lacking.nnnOBJECTIVEnTo report on stereotactic catheter ventriculocisternostomy (STX-VCS) as a method to access the cisterns of the brain for clearance of subarachnoid hemorrhage in patients with aSAH and coiled aneurysms.nnnMETHODSnIn 9 aSAH patients at high risk for DCI (Hunt and Hess grade ≥3, modified Fisher grade ≥3), access to the basal cisterns of the brain was created by STX-VCS. Fibrinolytic and/or spasmolytic lavage therapy was administered.nnnRESULTSnSTX-VCS was feasible and safe in all patients. Subarachnoid blood was rapidly cleared by irrigation with urokinase. Vasospasm occurred in 2 patients and was interrupted by irrigation with nimodipine. There was 1 fatality due to pneumogenic sepsis. Minor DCI occurred in 1 patient. Eight survived without DCI and are independent (modified Rankin score [mRS] ≤ 3) at 6 mo after aSAH.nnnCONCLUSIONnSTX-VCS allows for rapid clearance of subarachnoid hemorrhage in patients with coiled aneurysms.

Bildgebung beim akuten ischämischen Schlaganfall unter Verwendung automatisierter Analysealgorithmen

ZusammenfassungEs existieren mehrere automatische Analyseverfahren mit der Zielsetzung, mittels einer multimodalen CT- oder MRT-Bildgebung den thromboembolischen Gefäßverschluss, den Infarktkern und das potenziell infarktgefährdete Gewebe („tissue at risk“) darzustellen. Der Infarktkern wird mit DWI-MRT oder CT-Perfusion zuverlässiger als mit der nativen CT dargestellt. Die „Tissue-at-risk“-Ausdehnung und -Gefährdung kann nur abgeschätzt werden. Wesentlich erscheint aber, ob überhaupt „tissue at risk“ vorliegt. Um eine einheitliche Patientenversorgung zu gewährleisten, sollten einheitliche Bildgebungsprotokolle im zuweisenden und Thrombektomie-Krankenhaus akquiriert und die erhobenen Daten standardisiert und automatisiert ausgewertet und dargestellt werden. Ob Patienten mit großem Infarktkern und mit oder ohne „tissue at risk“ oder Patienten mit großen Gefäßverschlüssen, aber niedrigem NIHSS von der Thrombektomie profitieren, muss mithilfe standardisierter Bildgebung in kontrollierten klinischen Studien überprüft werden. Ein vielversprechender Ansatz ist auch, ein natives CT und CT-Angiogramm mit der Beurteilung des Gefäßverschlusses und der leptomeningealen Kollateralen mit einer Flachdetektor-Angiographie-Anlage zu erstellen.AbstractThere are several automated analytical methods to detect thromboembolic vascular occlusions, the infarct core and the potential infarct-endangered tissue (tissue at risk) by means of multimodal computed tomography (CT) and magnetic resonance imaging (MRI). The infarct core is more reliably visualized by diffusion-weighted imaging (DWI) MRI or CT perfusion than by native CT. The extent of tissue at risk and endangerment can only be estimated; however, it seems essential whether “tissue at risk” actually exists. To ensure consistent patient care, uniform imaging protocols should be acquired in the referring hospital and thrombectomy center and the collected data should be standardized and automatically evaluated and presented. Whether patients with axa0large infarct core and with or without tissue at risk or patients with large vessel occlusion (LVO) but low NIHSS benefit from thrombectomy has to be evaluated in controlled clinical trials using standardized imaging protocols. Axa0promising, potentially time-saving approach is also native CT and CT angiography using axa0flat-panel detector angiography system for assessment of vessel occlusion and leptomeningeal collaterals.There are several automated analytical methods to detect thromboembolic vascular occlusions, the infarct core and the potential infarct-endangered tissue (tissue at risk) by means of multimodal computed tomography (CT) and magnetic resonance imaging (MRI). The infarct core is more reliably visualized by diffusion-weighted imaging (DWI) MRI or CT perfusion than by native CT. The extent of tissue at risk and endangerment can only be estimated; however, it seems essential whether tissue at risk actually exists. To ensure consistent patient care, uniform imaging protocols should be acquired in the referring hospital and thrombectomy center and the collected data should be standardized and automatically evaluated and presented. Whether patients with axa0large infarct core and with or without tissue at risk or patients with large vessel occlusion (LVO) but low NIHSS benefit from thrombectomy has to be evaluated in controlled clinical trials using standardized imaging protocols. Axa0promising, potentially time-saving approach is also native CT and CT angiography using axa0flat-panel detector angiography system for assessment of vessel occlusion and leptomeningeal collaterals.