Surgical or Endovascular Treatment of MCA Aneurysms: An Agreement Study.

BACKGROUND AND PURPOSE: MCA aneurysms are still commonly clipped surgically despite the recent development of a number of endovascular tools and techniques. We measured clinical uncertainty by studying the reliability of decisions made for patients with middle cerebral artery (MCA) aneurysms. MATERIALS AND METHODS: A portfolio of 60 MCA aneurysms was presented to surgical and endovascular specialists who were asked whether they considered surgery or endovascular treatment to be an option, whether they would consider recruitment of the patient in a randomized trial, and whether they would provide their final management recommendation. Agreement was studied using κ statistics. Intrarater reliability was assessed with the same, permuted portfolio of cases of MCA aneurysm sent to the same specialists 1 month later. RESULTS: Surgical management was the preferred option for neurosurgeons (n = 844/1320; [64%] responses/22 raters), while endovascular treatment was more commonly chosen by interventional neuroradiologists (1149/1500 [76.6%] responses/25 raters). Interrater agreement was only "slight" for all cases and all judges (κ = 0.094; 95% CI, 0.068-0.130). Agreement was no better within specialties or with more experience. On delayed requestioning, 11 of 35 raters (31%) disagreed with themselves on at least 20% of cases. Surgical management and endovascular treatment were always judged to be a treatment option, for all patients. Trial participation was offered to patients 65% of the time. CONCLUSIONS: Individual clinicians did not agree regarding the best management of patients with MCA aneurysms. A randomized trial comparing endovascular with surgical management of patients with MCA aneurysms is in order.

[Impact of anamnestic information and neurological deficits on the detection rate of secondary headaches]. / Einfluss von Anamnese und neurologischer Untersuchung auf die Detektionsrate sekundärer Kopfschmerzursachen.

PURPOSE: Headaches are a very common symptom and imaging is important to rule out symptomatic causes. For clinical differentiation between primary and secondary headaches an exact anamnesis and neurological examination are important. The aim of this study is therefore to identify anamnestic and neurological information that is associated with secondary headaches. Moreover, this study gives an overview of the causes and differential diagnoses of secondary headaches. METHODS: We performed a retrospective analysis of 239 patients ≥18 years with headaches who had undergone computed tomography or magnetic resonance imaging. The impact of basic characteristics such as age and gender as well as anamnestic (pain intensity, thromboembolic risk profile) and clinical information (neurological deficit, papilledema, reduced vigilance) was tested by χ2 test at the significance level p < 0.05. RESULTS: In all, 27 of the included patients (11.3%) showed intracranial pathologies that required treatment. The most frequent pathologies were intracranial hypertension (9 patients), cerebral mass lesions (7 patients) and thrombosis of the cranial sinus/veins (3 patients). There was a significant association of a pathologic imaging finding and neurological deficits (p = 0.001) and a papilledema (p < 0.001). Reduced vigilance, pain intensity and thromboembolic risk factors as well as age and gender showed no significant association. CONCLUSIONS: A neurological deficit and especially papilledema are hints towards secondary headaches and should result in computed tomography or magnetic resonance imaging. Other factors such as reduced vigilance, pain intensity, age and gender have no relevant impact on the occurrence of intracranial pathologies.

Impact of the Implementation of Thrombectomy with Stent Retrievers on the Frequency of Hemicraniectomy in Patients with Acute Ischemic Stroke.

BACKGROUND: The increasing use of endovascular treatments has led to higher recanalization rates and better clinical outcomes compared with intravenous thrombolysis alone. Stent retrievers represent the latest development for recanalization of large vessel occlusions. Decompressive hemicraniectomy has proved beneficial in patients suffering from rising intracranial pressure after malignant stroke. AIMS AND/OR HYPOTHESIS: We investigated the effect of the implementation of stent retriever treatment on the frequency of hemicraniectomy as a surrogate marker for infarct size and thus for poor neurological outcome. METHODS: Patients with acute ischemic stroke were retrospectively studied. We compared the frequency of hemicraniectomy following proximal artery occlusion of the internal carotid artery and middle cerebral artery main stem in the years before (2009 and 2010) and after (2012 and 2013) introducing stent retrievers. RESULTS: Overall, 497 patients with proximal arterial occlusion were included in the study. Of 253 patients admitted in the years 2009 and 2010 44 (17.4 %) and of 244 patients admitted in 2012 and 2013, 20 (8.2 %) received a hemicraniectomy. This decrease in the proportion of hemicraniectomies was statistically significant (p < 0.01). CONCLUSIONS: The findings in this study illustrate a significantly reduced rate of hemicraniectomies in patients with proximal artery occlusions after implementation of thrombectomy with stent retriever. Hereby, we could show a significant reduction of malignant infarctions after thrombectomy with stent retriever.

Undetected Dural Leaks Complicated by Accidental Drainage of Cerebrospinal Fluid (CSF) can Lead to Severe Neurological Deficits.

PURPOSE: Intracranial hypotension has been reported as a complication of accidental drainage after surgical treatment in several cases. Application of negative pressure systems (wound drains, VAC(®)-therapy, chest tube drainage) had typically led to severe intracranial hypotension including intracranial hemorrhage and tonsillar herniation. In the last year the authors observed 2 cases of accidental spinal drainage of CSF in patients with neurological deficits, regressing after reduction of the device suction. MATERIAL AND METHODS: We conducted a systematic PubMed-based research of the literature to study the variety and frequency of the reported symptoms from 1st of January 1980 until 1st of October 2015. RESULTS: Reviewing the literature 24 relevant citations including 27 reported cases of posttraumatic or postoperative loss of CSF leading to neurological symptoms were identified. All 15 reported cases in which a negative pressure suction device had been applied showed severe neurological and radiological symptoms such as coma or brain herniation and intracranial hemorrhage. In all cases patients recovered rapidly after removal of the suction device. Milder symptoms were observed in the patients without negative pressure suction, mainly only presenting with headaches or cranial nerve involvement.Additionally, we give an overview about current recommendations regarding cranial and spinal imaging to rule out dural laceration and cranial hypotension. CONCLUSION: Patients with dural laceration complicated by accidental drainage of CSF can present with life-threatening conditions. Increasing use of negative pressure suction devices makes the reported condition an important differential diagnosis. A precise radiological examination can help to rule out dural laceration and intracranial hypotension. KEY POINTS: • Undetected dural laceration complicated by negative pressure suction drains can induce life-threatening symptoms.• Increasing use of negative pressure suction devices makes the reported condition an important differential diagnosis for radiologists Citation Format: • Sporns PB, Schwindt W, Cnyrim CD et al. Undetected Dural Leaks Complicated by Accidental Drainage of Cerebrospinal Fluid (CSF) can Lead to Severe Neurological Deficits. Fortschr Röntgenstr 2016; 188: 451 - 458.