Klaus Sartor

Role of CT Angiography in Patient Selection for Thrombolytic Therapy in Acute Hemispheric Stroke

BACKGROUND AND PURPOSE It has been shown that thrombolytic therapy can improve clinical outcome in a subgroup of patients with acute cerebral ischemia. This subgroup was characterized by certain clinical and imaging findings (eg, moderate to severe neurological deficit for less than 3 to 6 hours, occlusion of the middle cerebral artery, lack of extended infarct signs on CT, and efficient leptomeningeal collaterals). Although not part of published prospective randomized rtPA trials, information about the status of the brain vessels would be helpful in the selection of patients who may benefit the most. Our purpose was to determine the feasibility of CT angiography (CTA) in patients with acute hemispheric ischemia and to evaluate its relevance for thrombolytic therapy. METHODS CTA was performed in 40 consecutive patients (11 women and 29 men; age range, 19 to 80 years) with moderate or severe symptoms (National Institutes of Health Stroke Scale score of > or =8) of acute hemispheric ischemia. CTA findings were compared with Doppler ultrasonography (US; n=22) and intra-arterial digital subtraction angiography (DSA; n=7). Twenty patients received thrombolytic therapy, the remaining patients received intravenous heparin. RESULTS Images and 3-dimensional reconstructions of diagnostic quality could be obtained in all patients. Thirty-four patients had a vessel occlusion. The extent of leptomeningeal collaterals correlated significantly with the outcome after thrombolytic therapy (rs=0.46, P<0.05). The evaluation of diagnostic accuracy showed a high agreement with US (22 of 22) and DSA (6 of 7). CONCLUSIONS CTA can provide important information for the initiation of therapy in patients with acute hemispheric ischemia. Identification of patients with autolyzed thrombi, occlusion of the internal carotid artery bifurcation, and poor leptomeningeal collaterals is feasible with the use of CTA. These patients may have little potential for benefit from thrombolytic therapy.

Simultaneous assessment of cerebral hemodynamics and contrast agent uptake in lesions with disrupted blood– brain–barrier ☆

The purpose of this study was to develop a method that eliminates the influence of the T1 relaxation time upon the signal-time course in perfusion-weighted imaging of cerebral lesions with blood-brain-barrier (BBB) disruption. On a 1.5 T whole body clinical magnetic resonance (MR) imager, we implemented a dual-echo RF-spoiled FLASH sequence (TE=6/23.6 ms). We developed a postprocessing routine that allowed to calculate a signal-time course representing only the change in T2* and another one representing only the change in T1. Using this method, we examined 7 patients with various brain lesions showing evidence of BBB disruption. In the signal-time-curves obtained from the early echo we found a distinct signal drop due to the T2* effect. These effects could be eliminated by the correction algorithm yielding a 67% higher signal increase. Correction of the signal-time curve of the late echo yielded a more pronounced maximum signal drop and a decrease in postcontrast signal intensity. We found that without this correction the relative regional cerebral blood volume and the first moment of the concentration-time curve were underestimated by 72% and 22%, respectively. The dual echo-sequence combined with the postprocessing algorithm separates T1 and T2* effects and thus allows to assess cerebral hemodynamics and contrast agent kinetics simultaneously. This method may be a useful tool for characterizing, staging, and therapy monitoring of brain tumors.

Einfluß des Hirnödems auf das Rezidivwachstum maligner Gliome

ZusammenfassungFragestellung: Beeinflussen Form und Größe des präoperativen peritumoralen Hirnödems die Rezidiventwicklung bei malignen supratentoriellen Gliomen? Methodik: Prospektiv wurden 79 Patienten mit einem malignen supratentoriellen Gliom mit einem standardisierten MRT-Protokoll untersucht. MRT-Untersuchungen erfolgten vor der neurochirurgischen Operation, möglichst innerhalb der ersten 3 Tage nach Operation und während der Nachbeobachtungszeit in Abständen von 2–3 Monaten. Die mediane Nachbeobachtungszeit betrug 11 Monate. Die initiale präoperative Ödemkonfiguration auf den T2-gewichteten MRT-Aufnahmen wurde mit der Rezidivtumorkonfiguration auf den Kontrastmittel verstärkten T1-gewichteten Aufnahmen verglichen. Ergebnisse: 47 Patienten entwickelten während der Nachbeobachtungszeit ein Rezidiv. Die Konfiguration des Rezidivtumors imitierte in 35/47 Patienten (75%) die initiale präoperative Ödemkonfiguration. Bei 11/47 Patienten entwickelte sich ein lokales und bei einem Patienten ein multilokales Rezidiv. Schlußfolgerungen: Die präoperative Tumorödemkonfiguration im T2-gewichteten MRT-Bild korreliert mit der Rezidivtumorausdehnung. Zukünftige Therapiestudien sollten daher die Ausdehnung des initalen präoperativen Ödems als zusätzlichen prognostischen Faktor mitberücksichigen.SummaryPurpose: To assess the influence of initial preoperative brain edema in malignant gliomas on regrowth patterns. Subjects and methods: 79 patients with histologically verified supratentorial malignant glioma were prospectively studied by magnetic resonance imaging (MRI) before and every 2–3 months after surgery. The median follow-up time was 11 months. We correlated the configuration of the initial vasogenic edema on T2-weighted images with tumor regrowth patterns on contrast-enhanced T1-weighted images. Results: 35/47 tumor regrowths (75%) imitated the initial edema configuration, while 11/47 occurred within the initial tumor bed; in one case tumor recurrence was multilocal. Conclusion: In glioblastoma, tumor regrowth patterns correlate positively with the configuration of the initial vasogenic brain edema. The initial, „presurgical” peritumoral edema should thus be considered when planning further treatment.

Local fibrinolysis and aspiration of intracerebral hematomas in rats. An experimental study using MR monitoring

Serial magnetic resonance (MR) imaging has not yet been validated in the therapy of experimental intracerebral hematomas in a rat model. It is possible to test the effect of local fibrinolysis and aspiration on the clot volume using serial magnetic resonance imaging and different MR-sequences. Experiments were carried out in 22 male Sprague-Dawley rats. Intracerebral hematoma was produced by injection of fresh autologous blood into the caudate nucleus using a double injection technique. Thirty minutes later 10 rats were treated by injecting 12 microliters of recombinant tissue plasminogen activator. MR-imaging was performed immediately after generation of the hematoma and after clot lysis. The clot volume measured in the magnetic resonance images was compared with that obtained in stained histological serial sections at the end of the experiment. Serial MR scanning demonstrated a significant reduction (p < 0.01) of hematoma volume after fibrinolysis followed by aspiration of the blood clot. The best correlation between MR- and histological volumetry was found on RF-spoiled FLASH 2D-images. This study documents the efficacy of MRI in detecting and delineating the size of acute intracerebral hematomas and its time course. Local fibrinolysis and aspiration can be simulated in an experimental rat model.

Utilization of magnetic resonance imaging in autopsy planning with specimen preservation for thoraco-omphalopagus symmetricus conjoined twins†

Conjoined twinning is a rare obstetric event that has fascinated physicians and laypersons alike for centuries. When this event occurs, early diagnosis, close prenatal management, and the proper route of delivery will assure the best possible outcome for mother and affected infants. Magnetic resonance imaging (MRI) is used both as an ancillary technique to the sonography for the antepartum diagnosis and in the preoperative planning for the surgical separation of conjoined twins. This report describes the MRI findings in conjoined twins of the thoraco-omphalopagus symmetricus type, a condition incompatible with extrauterine life. The twins were delivered at 21 weeks gestation. The MRI was used to evaluate the anatomic nature of the internal anomalies. These findings were then used to develop an autopsy approach plan that preserved the external phenotype. After dissection, the specimen was preserved by using polyethylene glycol and ultimately prepared for use as a teaching specimen.