[Comparison of superselective intraarterial fibrinolysis with conservative therapy. Use in patients with acute non-arteritic central retinal artery occlusion]. / Vergleich der superselektiven intraarteriellen Fibrinolyse mit konservativer Therapie. Einsatz bei Patienten mit akutem nichtarteriitischem Zentralarterienverschluss.

The results of conservative treatment for central retinal artery occlusion (CRAO) vary considerably and although local intraarterial fibrinolysis (LIF) is a promising treatment, outcomes have not been compared in randomized trials. The prospective randomized multicenter study by the European Assessment Group for Lysis in the Eye (EAGLE) is the first clinical trial to compare treatment outcomes of conservative standard treatment (CST) and LIF for acute non-arteritic CRAO. Patients (age 18-75 years) with CRAO present for less than 20 h and best-corrected visual acuity (BCVA) <0.5 logMAR were randomized to either CST or LIF group. Primary endpoint was BCVA after 1 month and secondary endpoint was safety. Mean BCVA (logMAR) improved significantly in both groups and did not differ between the groups. Because of similar efficacy and the higher rate of adverse events in the LIF group the study was halted after the first interim analysis. Due to the similar outcomes of the two therapies and the higher rate of adverse reactions associated with LIF superselective lysis cannot be recommended for the management of acute CRAO.

Clinical and angiographic risk factors for stroke and death within 30 days after carotid endarterectomy and stent-protected angioplasty: a subanalysis of the SPACE study.

BACKGROUND: Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are used to prevent ischaemic stroke in patients with stenosis of the internal carotid artery. Better knowledge of risk factors could improve assignment of patients to these procedures and reduce overall risk. We aimed to assess the risk of stroke or death associated with CEA and CAS in patients with different risk factors. METHODS: We analysed data from 1196 patients randomised to CAS or CEA in the Stent-Protected Angioplasty versus Carotid Endarterectomy in Symptomatic Patients (SPACE) trial. The primary outcome event was death or ipsilateral stroke (ischaemic or haemorrhagic) with symptoms that lasted more than 24 h between randomisation and 30 days after therapy. Six predefined variables were assessed as potential risk factors for this outcome: age, sex, type of qualifying event, side of intervention, degree of stenosis, and presence of high-grade contralateral stenosis or occlusion. The SPACE trial is registered at Current Controlled Trials, with the international standard randomised controlled trial number ISRCTN57874028. FINDINGS: Risk of ipsilateral stroke or death increased significantly with age in the CAS group (p=0.001) but not in the CEA group (p=0.534). Classification and regression tree analysis showed that the age that gave the greatest separation between high-risk and low-risk populations who had CAS was 68 years: the rate of primary outcome events was 2.7% (8/293) in patients who were 68 years old or younger and 10.8% (34/314) in older patients. Other variables did not differ between the CEA and CAS groups. INTERPRETATION: Of the predefined covariates, only age was significantly associated with the risk of stroke and death. The lower risk after CAS versus CEA in patients up to 68 years of age was not detectable in older patients. This finding should be interpreted with caution because of the drawbacks of post-hoc analyses.

CT perfusion predicts secondary cerebral infarction after aneurysmal subarachnoid hemorrhage.

OBJECTIVE: To prospectively assess the diagnostic accuracy of CT perfusion (CTP) and transcranial Doppler sonography (TCD) for the prediction of secondary cerebral infarction (SCI) after aneurysmal subarachnoid hemorrhage (SAH). METHODS: During 2 weeks after SAH, 38 consecutive patients completed an average of 3.5 CT/CTP and 10.7 TCD examinations at regular intervals as required by the study protocol. SCI was defined as delayed infarction on native CT between 3 and 14 days after SAH and developed in n = 14 patients (n = 24 without SCI). Analysis was based on examination dates before SCI. Common measures of diagnostic accuracy were calculated for qualitative CTP (visual color-map ratings from two blinded observers) and TCD assessments (mean flow velocity >120 cm/s in anterior, middle, and posterior cerebral artery territories). Quantitative measures, which for CTP were obtained from cortical a priori regions of interest corresponding to the vascular territories, were analyzed by binary logistic regression. RESULTS: Time of prediction for SCI by CTP was at a median of 3 days (range 2 to 5 days) before manifestation of complete infarction on native CT. Visual assessment of time-to-peak (TTP) color maps performed best for the prediction of SCI with 0.93 sensitivity (95% CI: 0.7 to 1.0) and 0.67 specificity (95% CI: 0.53 to 0.7). On quantitative analysis, the odds ratio (OR) for 1 second of side-to-side delay in TTP was 1.4 (p = 0.01, Wald chi(2) = 8.57, CI: 1.07 to 1.82). Daily TCD measures were not significantly related to SCI at any time before complete infarction on native CT. CONCLUSIONS: Time to peak as indicated by CT perfusion is a sensitive and early predictor of secondary cerebral infarction.

[Neuroradiological imaging in patients with sensorineural hearing loss prior to cochlear implantation]. / Neuroradiologische Diagnostik bei Patienten mit sensorineuralem Hörverlust vor Cochlea-Implantation.

Cochlear implantation (CI) is an established technique for enabling speech perception in patients suffering from severe bilateral sensorineural hearing loss (SNHL). Thorough preoperative radiological assessment is essential for correctly evaluating the indication for surgery and safely performing cochlear implantation. CT and conventional and functional MRI are available for radiological assessment. Therefore, knowledge of the most frequent congenital syndromal, non-syndromal, and acquired malformations of inner ear structures is fundamental. This article provides information about imaging techniques prior to CI and relevant malformations of the inner ear. Safety aspects for patients with a cochlear implant undergoing MR imaging are also discussed.

Fatal recurrent subarachnoid hemorrhage after complete endovascular aneurysm occlusion.

Endovascular treatment of aneurysms has become an alternative to the neurosurgical approach. Here, we describe a patient presenting with a subarachnoid hemorrhage (SAH) due to a basilar tip aneurysm, which was completely occluded with coils. Fourteen days later the patient died due to massive recurrent SAH. Histologic evaluation showed aneurysm rerupture with coil dislocation in the subarachnoid space. This is a rare histologically documented case of fatal recurrent hemorrhage early after coil embolization of cerebral aneurysms.

Cerecyte coils in the treatment of intracranial aneurysms: a preliminary clinical study.

BACKGROUND AND PURPOSE: Recanalization remains a major drawback in the endovascular treatment of intracranial aneurysms. Here, we report on our preliminary clinical experience with a new bioactive coil. PATIENTS AND METHODS: In a prospective study, 25 aneurysms were treated in 24 patients. Endovascular occlusion of the aneurysm was performed by using a novel polyglycol acid-loaded coil (Cerecyte). Mean aneurysm volume was 114.7 mm(3), with a mean dome height of 5.2 mm and a neck width of 2.8 mm. The primary goal of this study was to assess the safety of this new polymer-loaded coil in terms of periprocedural, technical, or angiographic complications. The secondary scope was to evaluate treatment efficacy regarding primary aneurysm occlusion, packing attenuation, and recanalization at follow-up angiography at 6 months. RESULTS: There were no major technical or angiographic complications resulting in permanent morbidity. Complete initial occlusion of the aneurysm was accomplished in 17 patients, and a neck remnant was present in 8 patients. All aneurysms with complete initial occlusion remained stable at 6 months. Progression of a neck remnant without need for retreatment was noted in 2 patients, whereas 5 neck remnants turned to complete occlusion. Thus, complete occlusion rate at 6 months was 88%. CONCLUSION: In this preliminary study the use of Cerecyte coils was safe, with an incidence of procedural complications comparable with that of bare platinum coils. Although most of the aneurysms in this study were small, the immediate and 6-month follow-up angiographic results are encouraging so that in our opinion, a larger clinical trial is warranted.

30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised non-inferiority trial.

BACKGROUND: Carotid endarterectomy is effective in stroke prevention for patients with severe symptomatic carotid-artery stenosis, and carotid-artery stenting has been widely used as alternative treatment. Since equivalence or superiority has not been convincingly shown for either treatment, we aimed to compare the two. METHODS: 1200 patients with symptomatic carotid-artery stenosis were randomly assigned within 180 days of transient ischaemic attack or moderate stroke (modified Rankin scale score of < or =3) carotid-artery stenting (n=605) or carotid endarterectomy (n=595). The primary endpoint of this hospital-based study was ipsilateral ischaemic stroke or death from time of randomisation to 30 days after the procedure. The non-inferiority margin was defined as less than 2.5% on the basis of an expected event rate of 5%. Analyses were on an intention-to-treat basis. This trial is registered at Current Controlled Trials with the international standard randomised controlled trial number ISRCTN57874028. FINDINGS: 1183 patients were included in the analysis. The rate of death or ipsilateral ischaemic stroke from randomisation to 30 days after the procedure was 6.84% with carotid-artery stenting and 6.34% with carotid endarterectomy (absolute difference 0.51%, 90% CI -1.89% to 2.91%). The one-sided p value for non-inferiority is 0.09. INTERPRETATION: SPACE failed to prove non-inferiority of carotid-artery stenting compared with carotid endarterectomy for the periprocedural complication rate. The results of this trial do not justify the widespread use in the short-term of carotid-artery stenting for treatment of carotid-artery stenoses. Results at 6-24 months are awaited.

[Treatment of carotid cavernous fistulas]. / Behandlung von A. carotis-Sinus cavernosus-Fisteln.

The diagnosis and treatment of carotid cavernous fistulas (CCF) is an interdisciplinary challenge for both ophthalmologists and interventional neuroradiologists. According to the clinical signs and symptoms the tentative diagnosis is made by the ophthalmologist. It is the task of the neuroradiologist to ascertain this diagnosis by intra-arterial angiography. If a fistula is suspected this invasive diagnostic procedure is indispensable, not only to establish the diagnosis but also to classify those types of fistula with an unfavourable spontaneous course possibly resulting in intracranial haemorrhage. The indication for therapy is based on the clinical symptoms and the angiographic findings. In a number of cases no therapy is required. Since a fistula may change over time, these patients have to be under close ophthalmological surveillance. In many patients a conservative therapeutic approach with manual compression of the carotid artery is sufficient as a fIrst step. Invasive treatment is performed via the endovascular approach in almost all cases. Direct CCF are predominantly treated transarterially with detachable balloons and/or coils. Recently, intracranial stents have been used increasingly. The embolisation of indirect CCF is most effective using the transvenous access with coils. There are several approaches to the cavernous sinus. The interventional occlusion of CCF is nowadays a very effective treatment associated with a comparatively high cure rate and low incidence of complications. By close cooperation between ophthalmologists and neuroradiologists the patients can be protected against visual loss, the development of a secondary glaucoma, and, most importantly, against intracranial haemorrhage.

Differential diagnosis of suprasellar tumors in children.

In contrary to the adult age the most common suprasellar tumors in children are with decreasing frequency craniopharyngiomas, chiasmatic/hypothalamic low-grade gliomas, germinomas and lesions attributable to a Langerhans cell histiocytosis. For differential diagnostic purposes also the rare hypothalamic hamartoma and meningeal metastases in the infundibular recess of the third ventricle are included. The typical aspects of the various tumors on computed tomography (CT) and magnetic resonance imaging (MRI) together with important clinical differences are illustrated. On the basis of imaging results and clinical symptoms differential diagnosis between the various tumor entities should be feasible in many cases. Of course, only in strictly defined cases like typical chiasmatic/hypothalamic and optic pathway gliomas or bilocular germ cell tumors a histological confirmation is dispensable.

Subdural enhancement on postoperative spinal MRI after resection of posterior cranial fossa tumours.

In malignant brain tumours which may disseminate staging, usually by cranial and spinal MRI is necessary. If MRI is performed in the postoperative period pitfalls should be considered. Nonspecific subdural contrast enhancement on spinal staging MRI is rarely reported after resection of posterior fossa tumours, which may be mistaken for dissemination of malignancy. We investigated the frequency of spinal subdural enhancement after posterior cranial fossa neurosurgery in children. We reviewed 53 postoperative spinal MRI studies performed for staging of paediatric malignant brain tumours, mainly infratentorial primitive neuroectodermal tumours 2-40 days after surgery. There was contrast enhancement in the spinal subdural space in seven cases. This was not seen in any of eight patients who had been operated upon for a supratentorial tumour. After resection of 45 posterior cranial fossa tumours the frequency of subdural enhancement was 15.5%. MRI showing subdural enhancement was obtained up to 25 days postoperatively. No patient with subdural enhancement had cerebrospinal fluid (CSF) examinations positive for tumour cells or developed dissemination of disease in the CSF. Because the characteristic appearances of subdural contrast enhancement, appropriate interpretation is possible; diagnosis of neoplastic meningitis should rarely be impeded. Because of the striking similarity to that in patients with a low CSF-pressure syndrome and in view of the fact that only resection of tumours of the posterior cranial fossa, usually associated with obstructive hydrocephalus, was followed by this type of enhancement one might suggest that rapid changes in CSF pressure are implicated, rather the effects of blood introduced into the spinal canal at surgery.

[Differentiation of atypical Parkinson syndrome and delineation from idiopathic Parkinson syndrome with routine magnetic resonance tomography]. / Differenzierung atypischer Parkinson-Syndrome und ihre Abgrenzung vom idiopathischen Parkinson-Syndrom mit Hilfe der Routine-Magnetresonanztomographie.

Atrophy of frontal lobe, midbrain, pons, and cerebellum was studied in 16 patients with progressive supranuclear palsy (PSP), 14 with multiple system atrophy of striatonigral type (MSA-P), 20 with idiopathic Parkinson's disease (IPS), and 12 age-matched healthy controls using axial T2-weighted MR images (1.5 Teslar). With <16 mm, the PSP group showed significantly lower anteroposterior midbrain diameters than the IPS, MSA-P, and control groups. We conclude that measurement of the anteroposterior diameter of the midbrain with axial T2-weighted MRI is a useful feature and should be incorporated into the diagnostic criteria for PSP. In addition to the typical slit hyperintensity in margin of putamen and decreased signal intensity in dorsolateral putamen, we found cerebellar atrophy in 64% of patients with MSA-P. Before now, this was considered a typical sign of multiple system atrophy of cerebellar type (MSA-C). The use of this feature in the differential diagnosis of both types of multiple system atrophy is debatable.

[Differential infratentorial brain tumor diagnosis in children]. / Differenzialdiagnose infratentorieller Hirntumoren bei Kindern.

With the exception of the first year of life, infratentorial brain tumors are more frequent in the first decade than tumors in the supratentorial compartment. In particular these are cerebellar low-grade astrocytomas, medulloblastomas, brainstem gliomas and ependymomas of the fourth ventricle. The morphology on MRI and CT and the mode of dissemination permit differential diagnosis in many cases. To allow correct stratification into different treatments in possibly disseminating malignant brain tumors, knowledge of the status of dissemination is essential, and therefore not only cranial but also spinal MRI is indispensable for staging. If the spinal MRI is performed in the immediate postoperative period, knowledge of the normal non-specific purely postoperative changes, often seen as enhancement in the subdural spinal spaces, is necessary in order to avoid misinterpretation as meningial seeding. The differential diagnosis of pediatric infratentorial brain tumors and the morphology of subdural enhancement are illustrated with typical images. The natural history of the most frequent tumors and its importance for treatment decisions is discussed in light of the literature.

Painful vascular compression syndrome of the sciatic nerve caused by gluteal varicosities.

The authors report three patients with chronic sciatic pain without focal neurologic deficit. Sitting or lying on the affected side provoked pain, and standing and walking relieved it. MRI revealed varicotic gluteal vessels compressing the sciatic nerve. Decompression of the nerve resulted in complete and permanent pain relief. Sciatic or buttock pain in patients with varicosities and pain provocation in the sitting or lying position suggests this neurovascular compression syndrome.

Embolisation of intracranial meningiomas without subsequent surgery.

In an open, prospective study, we embolised intracranial meningiomas in seven patients, without subsequent surgery. Follow-up over a mean of 20 months included serial neurological examination, MRI and MR spectroscopy. Clinically, embolisation had no adverse effects. Symptomatic patients showed clinical improvement. On MRI marked tumour shrinkage occurred after embolisation in six patients, and was most pronounced during the first 6 months. In a young boy the tumour was unchanged despite complete angiographic devascularisation. Embolisation without subsequent surgery may cause substantial tumour shrinkage and thus be used in selected in patients. However, thorough follow-up is mandatory to ascertain the effects of embolisation.