Michael Kirsch

Incidence of blunt craniocervical artery injuries: use of whole-body computed tomography trauma imaging with adapted computed tomography angiography.

BACKGROUND:The incidence of traumatic craniocervical artery dissection varies in published trauma series. OBJECTIVE:To determine the frequency of traumatic craniocervical artery injury in polytrauma patients by using standardized whole-body trauma computed tomography with adapted computed tomography angiography of the craniocervical vessels. METHODS:A total of 718 consecutive patients requiring whole-body trauma computed tomography (16-row multislice) because of the mechanism of their injury patterns and an Injury Severity Scale score greater than 16 were analyzed prospectively. After a cranial scan, computed tomography angiography of the craniocervical vessels with 40 mL of iodinated contrast agent was performed using bolus tracking. RESULTS:The overall incidence of blunt carotid and vertebral injuries (BCVIs) in the screened population was 1.7%. BCVIs were observed in 27.3% of patients with detected isolated cervical spine injuries and in 3.9% of patients with isolated cranial fractures with or without intracranial hemorrhage, whereas 5.3% of patients with combined cervical and cranial lesions were associated with BCVIs. In addition, 0.4% of BCVIs occurred in patients without evidence of head or neck trauma. CONCLUSION:Whole-body trauma computed tomography with an adapted scanning protocol for the craniocervical vessels is a fast, safe, and feasible method for detecting vascular injuries. It allows prompt further treatment if necessary. Computed tomography angiography could be a part of a broad screening protocol for craniocervical vessels in documented injuries of the head and neck and in trauma mechanisms influencing the craniocervical region as well.

Endovaskuläre Therapie des akut ischämischen Schlaganfalls unter Analgosedierung im Vergleich zur Intubationsnarkose – Durchführbarkeit, periprozedurale Sicherheit, klinisches und radiologisches Outcome

PURPOSE Vessel recanalization is an important predictor of clinical outcome in the treatment of acute ischemic stroke. Endovascular therapies are used with increasing frequency. There is no general agreement on the policy of anesthesia during endovascular therapy, ranging from general anesthesia (GA) to local anesthesia at the puncture site with conscious sedation (CS) as needed. The aim of the study was to evaluate the safety and feasibility and radiological and clinical outcome of endovascular stroke therapy under CS. MATERIALS AND METHODS We retrospectively included all patients with acute ischemic stroke who were treated with endovascular therapy over a five-year period. Data was evaluated with respect to type of sedation, conversion from CS to GA, recanalization rate, infarct volume and peri- and post-procedural complications. RESULTS There was a technical failure in 7 patients. Of the remaining 124 patients (mean age 68.8 ± 14.6 years), 65 were female (52 %). The site of occlusion was located in the anterior circulation in 94 patients (76 %) and in the posterior circulation in 30 cases (24 %). 105 patients (85 %) were treated under CS and 16 cases (13 %) primarily under GA. In 3 cases (2 %) peri-procedural conversion to GA was necessary. Primary intra-arterial thrombolysis, mechanical recanalization only, and combination therapy were performed in 60 (48 %), 27 (22 %) and 37 (30 %) patients, respectively. There were no significant differences for recanalization rate and complications between GA and CS. The mean procedure time was significantly shorter in patients treated under CS (p < 0.01). CONCLUSION Endovascular stroke therapy with CS is feasible, can be performed safely and is faster than with GA.

Erratum to: Intravenous injection of gadobutrol in an epidemiological study group did not lead to a difference in relative signal intensities of certain brain structures after 5 years.

Purpose To investigate if application of macrocyclic gadolinium-based contrast agents in volunteers is associated with neuronal deposition detected by magnetic resonance imaging in a 5-year longitudinal survey.

Intravascular Lymphomatosis Presenting as Rapidly Progressive Dementia

Departments of a Neurology, b Neuropathology, and c Radiology, University of Greifswald, Greifswald , and d Department of Psychiatry II, University of Ulm, Günzburg , Germany chomotor agitation. Neurologic examination revealed mild paresis of the left leg with a positive Babinski sign. Laboratory examination showed normal blood cell counts and normal serum chemistry except for elevated lactate dehydrogenase (5.69 mol/l) and erythrocyte sedimentation rate (25 mm/h). Serologic vasculitis parameters were negative. Cerebrospinal fl uid (CSF) analysis showed a lymphocytic pleocytosis of 7 cells/ l; atypical cells were not detected. Total CSF protein (1,190 mg/l) and albumin CSF/serum ratio (21.0) were elevated. There was no intrathecal immunoglobulin synthesis, oligoclonal bands were negative. Microbiological examinations did not reveal viral or bacterial infection of the central nervous system (CNS). The neuronal and glial destruction markers neuron-specifi c enolase (62.5 g/l) and S-100 (4.95 g/l) were markedly increased. Electroencephalography showed an alpha rhythm that was blocked on eye opening and bilateral temporal slowing without epileptiform discharges. Doppler and duplex sonographic studies of extracranial and vertebrobasilar arteries did not reveal vascular occlusions or hemodynamically relevant stenoses. Transcranial Doppler ultrasound studies of bilateral middle and posterior cerebral arteries (MCA, PCA) showed normal Doppler peak systolic fl ow velocities (v max MCA approx. 70 cm/s, v max PCA approx. 50 cm/s bilaterally); waveform analysis did not indicate an increase in distal vascular resistance (resistance index [7] , MCA approx. 0.55). FLAIR and T 2 -weighted MRI revealed several small hyperintense periventricular lesions and a cortical-subcortical lesion in the left temporal lobe ( fi g. 1 A, B), which was also hyperintense on diffusion-weighted images. Additional lesions in the left cerebellar hemisphere showed moderate, homogenous contrast enhancement ( fi g. 1 C). Time-of-fl ight (TOF) MRA showed severely reduced fl ow signal in the M2 segments of both MCAs and in the distal segments of both PCAs without major irregularities in the proximal parts ( fi g. 1 D). Before MRI results were available, treatment with acyclovir was initiated until herpes encephalitis could be ruled out by negative PCR results. On psychopharmacological treatment with haloperidol, episodic agitation and hallucinations improved, while the cognitive defi cits and hemiparesis persisted unchanged. After MRI results had been obtained, cerebral vasculitis was considered to be the most likely diagnosis. Awaiting cerebral angiography, the patient died from massive pulmonary artery embolism on hospital day 10.

Intravenous Thrombolysis and Passes of Thrombectomy as Predictors for Endovascular Revascularization in Ischemic Stroke

BACKGROUND Patient selection for endovascular revascularization treatment (ERT) in acute ischemic stroke depends on the expected benefit-risk ratio. As rapid revascularization is a major determinant of good functional outcome, we aimed to identify its predictors after ERT. METHODS Consecutive stroke patients from a single stroke center with distal internal carotid artery-, proximal middle cerebral artery- or T-occlusions treated with ERT were retrospectively selected. We assessed admission noncontrast computed tomography and computed tomography angiography for thrombus location, thrombus load (clot burden score), and collateral status. Clinical data were extracted from medical charts. Univariate and multivariate regression analyses were performed to identify predictors of revascularization (thrombolysis in cerebral infarction ≥2b) after ERT. RESULTS A total of 63 patients were identified (median age, 73 years; interquartile range: 62-77; 40 females). Sixteen patients (25.4%) underwent intravenous thrombolysis (ivT) before ERT. Twenty-two patients (34.9%) had additional intra-arterial application of recombinant tissue plasminogen activator. The overall recanalization rate was 66.7%, and 9.5% had symptomatic intracranial bleeding. In-hospital mortality was 15%, and 30% reached good functional outcome at discharge. In the univariate analysis, preceding ivT and the number of passes for thrombectomy (dichotomized ≤2 versus >2) were associated with recanalization. There was a trend for number of thrombectomy passes (as continuous variable) and multimodal ERT. In the multivariate regression analysis, ivT prior to ERT and passes of thrombectomy were identified as independent predictors for recanalization. CONCLUSION ivT and lower passes of thrombectomy are associated with recanalization after ERT for ischemic stroke with proximal vessel occlusions.

Diameter assessment of the third ventricle with transcranial sonography in patients with multiple sclerosis.

Diameter measurement of the third ventricle with magnetic resonance imaging (MRI) and recently also with transcranial sonography (TCS) has emerged as a surrogate marker for brain atrophy and disease progression in multiple sclerosis (MS). This study aims to evaluate TCS measurements of the third ventricle diameter in a clinical routine setting against MRI.

Perfusion CT scanning and CT angiography in the evaluation of extracranial-intracranial bypass grafts.

OBJECT Extracranial-intracranial (EC-IC) bypass surgery remains an important treatment alternative for patients with occlusive cerebrovascular disease. The aim of the present study was to use perfusion CT and CT angiography (CTA) to evaluate cerebral hemodynamics and bypass patency in patients with occlusive cerebrovascular disease before and after EC-IC bypass surgery. METHODS Ten patients underwent perfusion CT and CTA before and after bypass surgery. Preoperative and postoperative digital subtraction angiography served as the diagnostic gold standard. An artery bypass was established from the superficial temporal artery to a cortical branch of the middle cerebral artery. Perfusion CT scanning was performed at the level of the basal ganglia. Color-coded perfusion maps of cerebral blood volume, cerebral blood flow, and time to peak were calculated. RESULTS Preoperative perfusion CT showed significant prolonged time to peak and reduced cerebral blood flow of the affected hemisphere. Postoperative neurological deterioration did not develop in any patient. Computed tomography angiography provided adequate evaluation of the anastomoses as well as the course and caliber of the bypass and confirmed bypass patency in all patients. Postoperative perfusion CT showed improved cerebral hemodynamics with a return to nearly normal perfusion parameters. CONCLUSIONS Computed tomography angiography is a noninvasive and reliable tool for evaluating patients with EC-IC bypass. Perfusion CT allows monitoring of hemodynamic changes after bypass surgery. The combination of both modalities enables noninvasive anatomical and functional analysis of superficial temporal artery-middle cerebral artery anastomoses using a single CT protocol. Hemodynamic evaluation of patients with occlusive cerebrovascular disease before and after surgery may improve the prediction of outcome and may help identify patients in whom a bypass procedure can be performed.

Quality management in a radiological practice: experiences with a certification for DIN EN ISO 9001:2000.

This paper describes the introduction of a total quality management system in a radiological practice. Certification was based on DIN EN ISO 9001:2000. The implementation of the quality management system had to overcome a number of barriers, for instance, legal obligations of a partnership association, leadership problems, and the fear to loose all hindered implementation. The knowledge of these barriers induces a faster and cheaper implementation of a quality management system in a radiological practice as a foundation of improved quality and competitiveness.

A case of hippocampal laminar necrosis following complex partial status epilepticus.

Cortical laminar necrosis (CLN) is a metabolic injury pattern usually observed after cerebral hypoxia, hypoglycemia, or ischemia. We report serial magnetic resonance imaging findings in a patient with complex partial status epilepticus (SE) developing a band‐like, T1‐hyperintense lesion consistent with CLN along the surface of the left hippocampus without concurrent other causes of CLN. This observation suggests a direct pathogenetic link between SE and CLN involving combined damage to neurons and glia.

Combined immunoradiotherapy induces long-term remission of CNS relapse of peripheral, diffuse, large-cell lymphoma after allogeneic stem cell transplantation: case study.

Relapse of peripheral non-Hodgkins lymphoma (NHL) in the central nervous system commonly has a poor prognosis. Graft-versus-leukemia effects (GvL) contribute substantially to eradication of hematological malignancies after allogeneic stem cell transplantation. Few data are available describing GvL activity within the brain. We report the case of a man allografted for peripheral NHL. On day +83 after transplantation a CNS relapse of the lymphoma occurred. The brain was irradiated with 44 Gy, anti-CD20 antibodies were given, and the immunosuppression was withdrawn. Subsequently, limited-stage, chronic graft-versus-host disease occurred. The lymphoma regressed completely, and the patient has been in continuous complete remission for 30 months. The favorable course suggests substantial contribution of immunomodulation to excellent outcome.