Johannes Weber

Complex Plaques in the Proximal Descending Aorta. An Underestimated Embolic Source of Stroke

Background and Purpose— To investigate the incidence of retrograde flow from complex plaques (≥4-mm-thick, ulcerated, or superimposed thrombi) of the descending aorta (DAo) and its potential role in embolic stroke. Methods— Ninety-four consecutive acute stroke patients with aortic plaques ≥3-mm-thick in transesophageal echocardiography were prospectively included. MRI was performed to localize complex plaques and to measure time-resolved 3-dimensional blood flow within the aorta. Three-dimensional visualization was used to evaluate if diastolic retrograde flow connected plaque location with the outlet of the left subclavian artery, left common carotid artery, or brachiocephalic trunk. Complex DAo plaques were considered an embolic source if retrograde flow reached a supra-aortic vessel that supplied the territory of visible acute and embolic retinal or cerebral infarction. Results— Only decreasing heart rate was correlated (P<0.02) with increasing flow reversal to the aortic arch. Retrograde flow from complex DAo plaques reached the left subclavian artery in 55 (58.5%), the left common carotid artery in 23 (24.5%), and the brachiocephalic trunk in 13 patients (13.8%). Based on routine diagnostics and MRI of the ascending aorta/aortic arch, stroke etiology was determined in 57 and cryptogenic in 37 patients. Potential embolization from DAo plaques was then identified in 19 of 57 patients (33.3%) with determined and in 9 of 37 patients (24.3%) with cryptogenic stroke. Conclusions— Retrograde flow from complex DAo plaques was frequent in both determined and cryptogenic stroke and could explain embolism to all brain territories. These findings suggest that complex DAo plaques should be considered a new source of stroke.

Head and Neck Paragangliomas in Von Hippel-Lindau Disease and Multiple Endocrine Neoplasia Type 2

BACKGROUNDnHead and neck paragangliomas (HNPs) occur as sporadic or familial entities, the latter mostly in association with germline mutations of the SDHB, SDHC, or SDHD (SDHx) genes. Heritable non-SDHx HNP might occur in von Hippel-Lindau disease (VHL, VHL gene), multiple endocrine neoplasia type 2 (MEN2, RET gene), and neurofibromatosis type 1 (NF1, NF1 gene). Reports of non-SDHx HNP presentations are scarce and guidance for genetic testing nonexistent.nnnPATIENTS AND METHODSnAn international consortium registered patients with HNPs and performed mutation analyses of the SDHx, VHL, and RET genes. Those with SDHx germline mutations were excluded for purposes of this study. Personal and family histories were evaluated for paraganglial tumors, for the major tumor manifestations, and for family history of VHL, MEN2, or NF1.nnnRESULTSnTwelve patients were found to have hereditary non-SDHx HNPs of a total of 809 HNP and 2084 VHL registrants, 11 in the setting of germline VHL mutations and one of a RET mutation. The prevalence of hereditary HNP is five in 1000 VHL patients and nine in 1000 non-SDHx HNP patients. Comprehensive literature review revealed previous reports of HNPs in five VHL, two MEN2, and one NF1 patient. Overall, 11 here presented HNP cases, and four previously reported VHL-HNPs had lesions characteristic for VHL and/or a positive family history for VHL.nnnCONCLUSIONSnOur observations provide evidence that molecular genetic testing for VHL or RET germline mutations in patients with HNP should be done only if personal and/or family history shows evidence for one of these syndromes.

STENT-ASSISTED COIL EMBOLIZATION OF POSTERIOR CIRCULATION ANEURYSMS USING SOLITAIRE AB: PRELIMINARY EXPERIENCE

OBJECTIVETo evaluate patients with wide-necked aneurysms of the posterior circulation who underwent Solitaire AB (ev3, Inc., Irvine, CA) stent-assisted coil embolization. METHODSRetrospective analysis of 10 patients (age range, 32–76 years; mean age, 59.1 years) with aneurysms of the basilar artery (basilar tip, n = 5; basilar trunk, n = 4; posterior cerebral artery, n = 1). Seven of the patients presented with an acute subarachnoid hemorrhage. Five aneurysms were small, 2 were large, and 3 were giant. All patients were treated by different applications (n = 14) of the Solitaire AB neurovascular remodeling device followed by a standard coiling procedure using bioactive coils. RESULTSPositioning of all Solitaire AB stents was easy and successful. No stent required retrieving and repositioning after full deployment. There were no thromboembolic complications, and no dissection/rupture or vasospasm occurred during stent placement. In all cases except 3, 100% lesion occlusion was observed after the initial treatment. CONCLUSIONThe initial technical and clinical results of Solitaire AB stent-assisted coiling of different types of wide-necked aneurysms in the posterior circulation are highly encouraging, and this technique may improve the endovascular treatment of these aneurysms.

Treatment of venous malformations: First experience with a new sclerosing agent – A multicenter study

PURPOSEnTo study the efficacy and safety of a new sclerosing gel of absolute ethanol in the percutaneous treatment of venous malformations (VM).nnnMATERIALS AND METHODSnIn this prospective, non-randomized multicenter study patients with clinically and by magnetic resonance imaging diagnosed VM were treated. Efficacy and safety of the gel was evaluated. Therapeutic outcome was judged at day 56 after the last sclerosing therapy. Blood ethanol levels of ethanol were measured after each infusion. Local and systemic adverse events were recorded.nnnRESULTSnSeventy-five (75) patients (age 4-46 y, mean 26 y) were treated in 172 sessions. Compared to no treatment, ethanol gel showed a complete cure rate of about 15% per session (p<0.00001). At the end of the last session, therapeutic outcome was complete (score 2) and partial (score 1) in 28 (37%) and 42 patients (56%), respectively, whereas treatment failure (score 0) was observed in 5 patients (7%). The plasmatic ethanol levels were very low (mean±SEM 0.03±0.06 g L(-1)), with only one patient above the legal 0.5 g L(-1) intoxication limit (0.6 g L(-1)). Forty-six (46) product-related adverse events (all local, none systemic) were reported. They included temporary mild isolated pain (N=21), inflammatory reactions (N=4), and local complications (7 skin necroses, 7 compressive neuropathies, 4 product leakage/fistula, 2 intralesional fibrous or granulomatous tissue, 1 dense node; 12.2% of the infusions). All local complications resolved spontaneously, except for 2 skin necroses requesting surgical paring.nnnCONCLUSIONnEthanol gel is an embosclerosing substance that provides high efficiency and improves safety of ethanol in the treatment of VM lesions.

Predictors of Severity of Cerebral Vasospasm caused by Aneurysmal Subarachnoid Hemorrhage

BACKGROUNDnCerebral vasospasm is one of the leading causes of poor outcome after aneurysmal subarachnoid hemorrhage. The risk factors for the development of vasospasm have been evaluated in many clinical studies. However, it remains unclear if vasospasm severity can be predicted. The purpose of this study was to determine if different demographic and clinical factors that appear to be predictors of vasospasm can also prognosticate the severity of cerebral vasospasm.nnnMETHODSnWe retrospectively analyzed consecutive patients with subarachnoid hemorrhage who underwent endovascular vasospasm treatment in a single center. In order to define predictors of vasospasm severity, we studied the demographic and clinical characteristics of these patients. Vasospasm severity was defined by cerebral angiography, transcranial Doppler ultrasound, and therapeutic response on endovascular treatment. Statistical analyses were performed to determine significant predictors.nnnRESULTSnA total of 70 patients with vasospasm were included. Early onset of mean flow velocities>160 cm/second on transcranial Doppler ultrasound correlated with severity of angiographic vasospasm (P=.0469) and resistance against intra-arterial papaverine (P=.0277). Younger age (<51 years of age) was significantly associated with severity of vasospasm regarding extension on angiography (P=.0422), the need for repetitive endovascular treatment (P=.0084), persistence of transcranial Doppler ultrasound vasospasm after endovascular treatment (P=.0004), and resistance against intra-arterial papaverine (P=.0341).nnnCONCLUSIONSnYounger age and early onset of vasospasm on transcranial Doppler ultrasound are important predictors for vasospasm severity. We recommend early and aggressive therapy in this subgroup.

Contrast-enhanced magnetic resonance angiography in stroke diagnostics: additional information compared with time-of-flight magnetic resonance angiography?

PurposeThe aim of this study was a comparison of the diagnostic value of time-of-flight magnetic resonance angiography (TOF-MRA) and contrast-enhanced (CE) MRA in the setting of acute stroke MRI. The hypothesis was that CE-MRA has at least the same diagnostic value as the commonly used TOF-MRA.Materials and MethodsA total of 66 stroke patients underwent MRI up to 24xa0h after symptom onset and again after 3–6xa0days. Primary slices and maximum intensity projections (MIP) of both techniques were evaluated separately and in combination by two readers in consensus. The quality of imaging and degree of vascular pathologies were evaluated.ResultsOut of 109 examinations 105 could be evaluated. There were no significant differences in imaging quality in normal vascular segments. For arterial segments distal to an occlusion CE-MRA allowed better visualization of vessels than TOF-MRA. A combined evaluation of both techniques allowed a significantly better assessment than evaluation of images by one technique alone. In contrast to TOF-MRA, CE-MRA included extracranial segments.ConclusionCE-MRA and TOF-MRA do not differ regarding the evaluation of normal intracranial vessels. CE-MRA provides the advantage of good visualization of vessels distal to occluded segments. Furthermore CE-MRA allows visualization of extracranial vessels and faster image acquisition. TOF-MRA can be equivalently used if the administration of contrast agents is not possible.ZusammenfassungZielDie Standardmethode zur Darstellung der hirnversorgenden Arterien in der Schlaganfallmagnetresonanztomographie ist die „Time-of-flight“-MR-Angiographie (TOF-MRA). Sie hat eine relativ lange Untersuchungszeit bei eingeschränktem Untersuchungsfeld, das nur die intrakraniellen Hirnarterien einschließt. Diese Studie vergleicht die kontrastmittelverstärkte MRA (CE-MRA) und die TOF-MRA bei Patienten, die mit einem Schlaganfall-MRT untersucht worden sind.Material und MethodenInnerhalb von 24xa0h nach Schlaganfall und wiederholt nach 3 bis 6xa0Tagen wurden 66xa0Patienten im MRT untersucht. Die Bilder der beiden MRA-Techniken wurden zunächst getrennt, dann in Kombination ausgewertet. Analysiert wurden die Primärschichten und die Maximum-Intensitäts-Projektionen (MIP). Die Qualität der Darstellung und der Zustand einzelner Arteriensegmente wurden von 2xa0Betrachtern im Konsensus bewertet.ErgebnisseEs waren 105 von 109xa0Untersuchungen auswertbar. Für nichtpathologisch veränderte intrakranielle Arterien bestand für die Qualität der Darstellung kein signifikanter Unterschied. Gefäßsegmente distal eines Verschlusses waren aber in der CE-MRA deutlich besser beurteilbar. Eine kombinierte Auswertung beider Verfahren ergab für alle Segmente eine signifikant bessere Darstellung und Beurteilbarkeit als das jeweilige Einzelverfahren. In der CE-MRA waren bei technisch guten Untersuchungen die extrakraniellen Gefäßsegmente beurteilbar. In der TOF-MRA wurden diese Segmente nicht erfasst.SchlussfolgerungenHinsichtlich der Beurteilbarkeit von nichtpathologisch veränderten intrakraniellen Gefäßen unterscheiden sich CE-MRA und TOF-MRA nicht. Die CE-MRA bietet allerdings den Vorteil, auch Gefäßabschnitte distal von Verschlüssen sowie extrakranielle Gefäße beurteilen zu können. Die Akquisition ist schneller. Wenn eine Applikation von Kontrastmittel nicht möglich ist, stellt die TOF-MRA für die Untersuchung der intrakraniellen Arterien eine gleichwertige Alternative dar.

Contrast-enhanced Magnetic Resonance Angiography in Stroke Diagnostics

PurposeThe aim of this study was a comparison of the diagnostic value of time-of-flight magnetic resonance angiography (TOF-MRA) and contrast-enhanced (CE) MRA in the setting of acute stroke MRI. The hypothesis was that CE-MRA has at least the same diagnostic value as the commonly used TOF-MRA.Materials and MethodsA total of 66 stroke patients underwent MRI up to 24xa0h after symptom onset and again after 3–6xa0days. Primary slices and maximum intensity projections (MIP) of both techniques were evaluated separately and in combination by two readers in consensus. The quality of imaging and degree of vascular pathologies were evaluated.ResultsOut of 109 examinations 105 could be evaluated. There were no significant differences in imaging quality in normal vascular segments. For arterial segments distal to an occlusion CE-MRA allowed better visualization of vessels than TOF-MRA. A combined evaluation of both techniques allowed a significantly better assessment than evaluation of images by one technique alone. In contrast to TOF-MRA, CE-MRA included extracranial segments.ConclusionCE-MRA and TOF-MRA do not differ regarding the evaluation of normal intracranial vessels. CE-MRA provides the advantage of good visualization of vessels distal to occluded segments. Furthermore CE-MRA allows visualization of extracranial vessels and faster image acquisition. TOF-MRA can be equivalently used if the administration of contrast agents is not possible.ZusammenfassungZielDie Standardmethode zur Darstellung der hirnversorgenden Arterien in der Schlaganfallmagnetresonanztomographie ist die „Time-of-flight“-MR-Angiographie (TOF-MRA). Sie hat eine relativ lange Untersuchungszeit bei eingeschränktem Untersuchungsfeld, das nur die intrakraniellen Hirnarterien einschließt. Diese Studie vergleicht die kontrastmittelverstärkte MRA (CE-MRA) und die TOF-MRA bei Patienten, die mit einem Schlaganfall-MRT untersucht worden sind.Material und MethodenInnerhalb von 24xa0h nach Schlaganfall und wiederholt nach 3 bis 6xa0Tagen wurden 66xa0Patienten im MRT untersucht. Die Bilder der beiden MRA-Techniken wurden zunächst getrennt, dann in Kombination ausgewertet. Analysiert wurden die Primärschichten und die Maximum-Intensitäts-Projektionen (MIP). Die Qualität der Darstellung und der Zustand einzelner Arteriensegmente wurden von 2xa0Betrachtern im Konsensus bewertet.ErgebnisseEs waren 105 von 109xa0Untersuchungen auswertbar. Für nichtpathologisch veränderte intrakranielle Arterien bestand für die Qualität der Darstellung kein signifikanter Unterschied. Gefäßsegmente distal eines Verschlusses waren aber in der CE-MRA deutlich besser beurteilbar. Eine kombinierte Auswertung beider Verfahren ergab für alle Segmente eine signifikant bessere Darstellung und Beurteilbarkeit als das jeweilige Einzelverfahren. In der CE-MRA waren bei technisch guten Untersuchungen die extrakraniellen Gefäßsegmente beurteilbar. In der TOF-MRA wurden diese Segmente nicht erfasst.SchlussfolgerungenHinsichtlich der Beurteilbarkeit von nichtpathologisch veränderten intrakraniellen Gefäßen unterscheiden sich CE-MRA und TOF-MRA nicht. Die CE-MRA bietet allerdings den Vorteil, auch Gefäßabschnitte distal von Verschlüssen sowie extrakranielle Gefäße beurteilen zu können. Die Akquisition ist schneller. Wenn eine Applikation von Kontrastmittel nicht möglich ist, stellt die TOF-MRA für die Untersuchung der intrakraniellen Arterien eine gleichwertige Alternative dar.

Freiburg Neuropathology Case Conference: a Suprasellar Mass

Clinical Case A 46-year-old man presented with sudden, temporary loss of tonus in the upper extremities without loss of consciousness. The patient had a past history of chronic schizophrenic psychosis and chronic active hepatitis C. A brain computed tomogram revealed a midline interpeduncular mass. Upon admission, the patient had mild hyperprolactinemia (916 mIU/ml), the neurologic exam and the vital signs were all normal. An ophthalmologic exam failed to reveal any visual disturbances. Partial tumor removal was achieved through a small left frontolateral craniotomy and a transsylvian approach. The postoperative course was uneventful. Clinical Case Neuroradiology Clinical

Complex Plaques in the Proximal Descending Aorta: An Underestimated Embolic Source of Stroke * Supplemental Data - Video:

Background and Purpose— To investigate the incidence of retrograde flow from complex plaques (≥4-mm-thick, ulcerated, or superimposed thrombi) of the descending aorta (DAo) and its potential role in embolic stroke. Methods— Ninety-four consecutive acute stroke patients with aortic plaques ≥3-mm-thick in transesophageal echocardiography were prospectively included. MRI was performed to localize complex plaques and to measure time-resolved 3-dimensional blood flow within the aorta. Three-dimensional visualization was used to evaluate if diastolic retrograde flow connected plaque location with the outlet of the left subclavian artery, left common carotid artery, or brachiocephalic trunk. Complex DAo plaques were considered an embolic source if retrograde flow reached a supra-aortic vessel that supplied the territory of visible acute and embolic retinal or cerebral infarction. Results— Only decreasing heart rate was correlated (P<0.02) with increasing flow reversal to the aortic arch. Retrograde flow from complex DAo plaques reached the left subclavian artery in 55 (58.5%), the left common carotid artery in 23 (24.5%), and the brachiocephalic trunk in 13 patients (13.8%). Based on routine diagnostics and MRI of the ascending aorta/aortic arch, stroke etiology was determined in 57 and cryptogenic in 37 patients. Potential embolization from DAo plaques was then identified in 19 of 57 patients (33.3%) with determined and in 9 of 37 patients (24.3%) with cryptogenic stroke. Conclusions— Retrograde flow from complex DAo plaques was frequent in both determined and cryptogenic stroke and could explain embolism to all brain territories. These findings suggest that complex DAo plaques should be considered a new source of stroke.

Aneurysm Treatment – a Neuroradiologic Success Story

This short review portrays the treatment of cerebral aneurysms from the very early surgical beginning to current endovascular multimodal therapy. The evolution to today’s mainly nonoperative treatment of aneurysms illustrates the enormous progress of interventional neuroradiology, which has attained its outstanding success through the concurrence of deeper understanding and knowledge of diseases, technical development, and endovascular manual skills.ZusammenfassungDie Behandlung zerebraler Aneurysmen wird in einer kurzen Übersicht von den chirurgischen Anfängen bis zur endovaskulären multimodalen Therapie dargestellt. Die Entwicklung zur inzwischen überwiegend nichtoperativen Therapie von Aneurysmen steht stellvertretend für die enormen Fortschritte der interventionellen Neuroradiologie, die ihre Erfolge aus dem Zusammenwirken von Krankheitsverständnis, technischer Entwicklung und endovaskulären manuellen Fähigkeiten bezieht.