Contralateral Stenosis and Echolucent Plaque Morphology are Associated with Elevated Stroke Risk in Patients Treated with Asymptomatic Carotid Artery Stenosis within a Controlled Clinical Trial (SPACE-2).

BACKGROUND: Asymptomatic carotid artery stenosis (ACS) has a low risk of stroke. To achieve an advantage over noninterventional best medical treatment (BMT), carotid endarterectomy (CEA) or carotid artery stenting (CAS) must be performed with the lowest possible risk of stroke. Therefore, an analysis of risk-elevating factors is essential. Grade of ipsilateral and contralateral stenosis as well as plaque morphology are known risk factors in ACS. METHODS: The randomized, controlled, multicenter SPACE-2 trial had to be stopped prematurely after recruiting 513 patients. 203 patients were randomized to CEA, 197 to CAS, and 113 to BMT. Within one year, risk factors such as grade of stenosis and plaque morphology were analyzed. RESULTS: Grade of contralateral stenosis (GCS) was higher in patients with any stroke (50%ECST vs. 20%ECST; p=0.012). Echolucent plaque morphology was associated with any stroke on the day of intervention (OR 5.23; p=0.041). In the periprocedural period, any stroke was correlated with GCS in the CEA group (70%ECST vs. 20%ECST; p=0.026) and with echolucent plaque morphology in the CAS group (6% vs. 1%; p=0.048). In multivariate analysis, occlusion of the contralateral carotid artery (CCO) was associated with risk of any stroke (OR 7.00; p=0.006), without heterogeneity between CEA and CAS. CONCLUSION: In patients with asymptomatic carotid artery stenosis, GCS, CCO, as well as echolucent plaque morphology were associated with a higher risk of cerebrovascular events. The risk of stroke in the periprocedural period was increased by GCS in CEA and by echolucent plaque in CAS. Due to small sample size, results must be interpreted carefully.

Endovascular treatment of basilar tip aneurysms in the era of endosaccular flow disruption: a comparative study.

PURPOSE: This study aims to compare endosaccular flow disruptor (EFD) for treatment of basilar tip aneurysm (BTA) with coiling in terms of safety and efficacy. METHODS: We retrospectively reviewed patients treated with an EFD for BTAs at our institution between 2013 and 2019 to standard coiling from the same period (control group). Patient demographics, aneurysm characteristics, procedural data, complications and clinical and angiographic outcome were compared between groups. RESULTS: Twenty-three (56%) patients were treated with an EFD and eighteen (44%) patients were treated with coiling. Average aneurysm size was 8 mm in the EFD group and 6.9 mm in the coiling group, respectively (P = 0.2). Average fluoroscopy time, treatment DAP and air kerma were 33 min, 76 Gycm2 and 1.7 Gy in the EFD group and 81 min, 152 Gycm2 and 3.8 Gy in the coiling group, respectively (P < 0.001). In the EFD group, clinically relevant thromboembolic complications occurred in one patient (4%) vs. in 5 patients (28%) in the coiling group (P = 0.07). In each group, 4 patients had an unfavourable outcome at discharge (P = 0.7). Adequate occlusion rates were 96% in the EFD group and 100% and coiling group. Six (26%) patients were prescribed long-term antiplatelet therapy in the EFD group vs. eleven (61%) patients in the coiling group (P = 0.02). CONCLUSION: Both treatment concepts provided similar technical success and safety. However, procedure time, radiation exposure and a need for long-term antiaggregation were lower with EFD.

Patient reported long-term outcome after endovascular therapy of indirect dural carotid cavernous fistulas.

PURPOSE: Patient-reported long-term follow-up after endovascular treatment of indirect carotid cavernous fistulas is important, but rarely addressed in literature. We report on this issue with a special focus on the patient's view and its impact on the indication evaluation process. METHODS: We retrospectively reviewed the records of all patients (n = 33) with a minimum follow-up interval of at least 36 and up to 166 months after endovascular treatment of an indirect carotid cavernous fistula (Barrow B-D) at our institution (treated from 01/2003 to 06/2015). We determined treatment details including primary therapy success and complication rate and quote the patient's subjective perception of the long-term treatment success using a standardized interview form. RESULTS: As a primary result the fistula was completely occluded in 25/33 cases (76%), while a downgrading was achieved in 8/33 (24%) of the cases. Secondary occlusion was observed in three out of eight patients (38%). In the long-term interview (response rate: 91%, median follow-up interval: 114 months) 87% of the patients reported high satisfaction with the long-term therapy result. Endovascular treatment achieved a sustainable relief from all eye-related symptoms in 89% and from pulsatile tinnitus in 57% of the cases. CONCLUSIONS: In addition to good results in terms of angiographic and clinical cure, endovascular treatment is also perceived as beneficial by most of the patients. This is another important argument in favor of an endovascular treatment.

Endovascular therapy of direct dural carotid cavernous fistulas - A therapy assessment study including long-term follow-up patient interviews.

PURPOSE: Endovascular embolization nowadays is a well-established treatment option for direct carotid cavernous fistulas (dCCF, Barrow Type A). There are many publications on the complication and success rates of this method. However, little is known on the patients´ opinion on the treatment result after several years. We report on this issue also including the "pioneer patients" treated almost two decades ago. METHODS: We retrospectively reviewed the records of all patient (n = 25) with a more than 24 months follow-up interval after endovascular treatment of a dCCF at our institution from 01/1999 to 08/2018. We determined primary therapy success, complication rate, state of the fistula in the last imaging follow-up and quoted the patient's subjective perception of the long-term treatment success using a standardized interview form. RESULTS: Occlusion rate in the last imaging follow up was 96% (24/25) with a complication rate of 8% (2/25). The response rate on our interview request was 96% (24/25) with a rate of considered feedback of 84% (21/25 patients). Duration of our observation interval for the patient reported outcome was 143 months / 11 years (median, range: 35-226 m / 2-18 y). Most of them (21/25, 84%) felt they benefited from the treatment. CONCLUSIONS: Endovascular supply of dCCF is a highly effective treatment method leading to a sustainable therapy success with long-lasting stable subjective benefit even to our "pioneer patients" treated almost two decades ago.

Preoperative Digital Subtraction Angiography in Incidental Unruptured Intracranial Aneurysms : How Much is too Much?

PURPOSE: Digital subtraction angiography (DSA) is deemed necessary to precisely visualize intracranial aneurysms and define individual treatment strategies. In patients with unruptured intracranial aneurysms (UIA) who were diagnosed by MRI, a four-vessel DSA is usually performed to detect additional aneurysms. This study aimed to evaluate whether the evaluation of all vessels beyond the aneurysm-harboring artery is really necessary. MATERIAL AND METHODS: Patients with an UIA that was detected on MRA (TOF/ceMRA) were prospectively included. All patients underwent a four-vessel DSA (including 3D-DSA) and two experienced neuroradiologists independently analyzed the MRI sequences before DSA. The number of aneurysms, size and anatomic localization were documented and correlated with the angiographic findings. RESULTS: The DSA revealed a total of 134 aneurysms in 106 patients. Overall sensitivity and negative predictive value of MRA were 95.6% and 95.6%, respectively. In patients with multiple (≥2) aneurysms, 4 very small aneurysms <3 mm in the A2 segment, posterior communicating artery (PcomA), extradural internal carotid artery (ICA) were missed with MRI alone. In one patient with an ICA aneurysm, an additional small MCA bifurcation aneurysm was overlooked by MRA but detected by DSA. The periprocedural complication rate was 0.9%. CONCLUSION: The rate of aneurysms that were detected by DSA but not by MRA was very low, thus potentially justifying visualization of the vessel harboring aneurysm alone; however, the four-vessel angiography detected further small aneurysms in patients with multiple aneurysms and therefore seems to be indicated in this specific subgroup. This approach has the potential to reduce the risk of complications, the intervention time and thus radiation exposure.

Acute basilar thrombosis: Recanalization following intravenous thrombolysis is dependent on thrombus length.

INTRODUCTION: We investigated whether thrombus length measured in Computed Tomography Angiography (CTA) is predictive of the success rate of intravenous thrombolysis (IVT) in acute basilar occlusion and whether recanalization can be achieved by additional mechanical endovascular thrombectomy. METHODS: In 51 patients with acute basilar thrombosis thrombus length was measured on CTA images before intravenous thrombolysis (IVT) with rt-PA was started. After 114 minutes on average success of IVT was evaluated either by CTA or DSA. Patients with persistent basilar occlusion and no major brainstem infarction on CT underwent endovascular recanalization. RESULTS: 87% of patients had no recanalization of basilar artery after IVT alone. The average thrombus length was 15 mm in patients with persistent basilar occlusion after IVT and 7 mm in patients with recanalization after IVT. Thrombi longer than 13 mm did not resolve after IVT alone and 80% of thrombi shorter than 13 mm did not resolve either. 41 patients were transferred to endovascular recanalization; endovascular therapy was performed successfully in 90% (37 / 41). CONCLUSIONS: Recanalization rates in acute basilar occlusion after IVT alone are low and dependent on thrombus length. Additional mechanical endovascular thrombectomy showed to be a very successful recanalization therapy.

Intracranial Aneurysms Treated by Flow-Diverting Stents: Long-Term Follow-Up with Contrast-Enhanced Magnetic Resonance Angiography.

PURPOSE: Long-term data on aneurysm treatment with flow-diverting stents are still sparse, and follow-up protocols differ widely between institutions. We present long-term results, with a focus on the usefulness of contrast-enhanced MR angiography (ceMRA). MATERIALS AND METHODS: Interventions and follow-up imaging of patients with aneurysms treated by flow-diverting stents ("Pipeline," "Silk" and "FRED" models) without additional coiling were analyzed. All MRI scans included dedicated two-phase ceMRA. Aneurysm occlusion rates, size of the aneurysmal sac and complications were evaluated on MRI and digital subtraction angiography (DSA), where available. The ability of ceMRA to depict aneurysm occlusion and stent patency was graded on a three-point scale. RESULTS: Twenty-five patients with 102 MRI scans were included. The median duration of follow-up was 830 days. Aneurysm occlusion rates were 52% at 3 months (10 of 19 patients), 72% at 6 months (18/25) and 84% overall (21/25). Shrinkage of the aneurysmal sac was found in 19 patients (76%) and in 12 cases to <50% of the original size (48%). CeMRA assessability of aneurysmal occlusion was graded as good in all cases. When compared to DSA (18 cases), ceMRA had a sensitivity of 100% and specificity of 91% regarding aneurysm remnant detection. Assessability of the stent lumen varied and was limited in most cases. CONCLUSIONS: Flow-diverter treatment achieves high occlusion rates and can cause major aneurysm shrinkage. CeMRA is highly valuable regarding imaging of the aneurysmal sac. There are limitations regarding the assessability of the stent lumen on ceMRA. LEVEL OF EVIDENCE: Level 4, Case Series.

Long-Term Functional Outcome of Symptomatic Unruptured Intracranial Aneurysms in an Interdisciplinary Treatment Concept.

OBJECTIVE: In symptomatic unruptured intracranial aneurysms (UIAs), data on long-term functional outcome are sparse in the literature, even in the light of modern interdisciplinary treatment decisions. We therefore analyzed our in-house database for prognostic factors and long-term outcome of neurologic symptoms after microsurgical/endovascular treatment. METHODS: Patients treated between 2000 and 2016 after interdisciplinary vascular board decision were included. UIAs were categorized as symptomatic in cases of cranial nerve or brainstem compression. Symptoms were categorized as mild/severe. Long-term development of symptoms after treatment was assessed in a standardized and independent fashion. RESULTS: Of 98 symptomatic UIAs (microsurgery/endovascular 43/55), 84 patients presented with cranial nerve (NII-VI) compression and 14 patients with brainstem compression symptoms. Permanent morbidity occurred in 9% of patients. Of 119 symptoms (mild/severe 71/48), 60.4% recovered (full/partial 22%/39%) and 29% stabilized by the time of last follow-up; median follow-up was 19.5 months. Symptom recovery was higher in the long-term compared with that at discharge (P = 0.002). Optic nerve compression symptoms were less likely to improve compared with abducens nerve palsies and brainstem compression. Prognostic factors for recovery were duration and severity of symptoms, treatment modality (microsurgery) and absence of ischemia in the multivariate analysis. CONCLUSIONS: This recent study presents for the first time a detailed analysis of relevant prognostic factors for long-term recovery of cranial nerve/brainstem compression symptoms in an interdisciplinary treatment concept, which was excellent in most patients, with lowest recovery rates in optic nerve compression. Symptom recovery was remarkably higher in the long-term compared with recovery at discharge.

Standards of practice in interventional neuroradiology.

The growing importance of INR has resulted in the need to define and promote professional standards of clinical practice. Several professional organizations have published guidelines recently for the neurointerventional treatment of cerebrovascular diseases, including technical and personal recommendations, but detailed definitions of technical and organizational conditions needed for the safe and effective performance of such treatments are lacking. To fill this gap ESNR, ESMINT and the UEMS Division for Neuroradiology established a working group, to develop a consensus paper on "Standards of Practice in Interventional Neuroradiology". This document is the result of the Consensus Working Group and has following review gained approval by the Executive Boards of ESNR and ESMINT and by the members of the UEMS Division for Neuroradiology in 2017.

Radiomic Analysis Reveals Prognostic Information in T1-Weighted Baseline Magnetic Resonance Imaging in Patients With Glioblastoma.

OBJECTIVES: The aim of this study was to investigate whether radiomic analysis with random survival forests (RSFs) can predict overall survival from T1-weighted contrast-enhanced baseline magnetic resonance imaging (MRI) scans in a cohort of glioblastoma multiforme (GBM) patients with uniform treatment. MATERIALS AND METHODS: This retrospective study was approved by the institutional review board and informed consent was waived. The MRI scans from 66 patients with newly diagnosed GBM from a previous prospective study were analyzed. Tumors were segmented manually on contrast-enhanced 3-dimensional T1-weighted images. Using these segmentations, P = 208 quantitative image features characterizing tumor shape, signal intensity, and texture were calculated in an automated fashion. On this data set, an RSF was trained using 10-fold cross validation to establish a link between image features and overall survival, and the individual risk for each patient was predicted. The mean concordance index was assessed as a measure of prediction accuracy. Association of individual risk with overall survival was assessed using Kaplan-Meier analysis and a univariate proportional hazards model. RESULTS: Mean overall survival was 14 months (range, 0.8-85 months). Mean concordance index of the 10-fold cross-validated RSF was 0.67. Kaplan-Meier analysis clearly distinguished 2 patient groups with high and low predicted individual risk (P = 5.5 × 10). Low predicted individual mortality was found to be a favorable prognostic factor for overall survival in a univariate Cox proportional hazards model (hazards ratio, 1.038; 95% confidence interval, 1.015-1.062; P = 0.0059). CONCLUSIONS: This study demonstrates that baseline MRI in GBM patients contains prognostic information, which can be accessed by radiomic analysis using RSFs.

Endovascular therapy of low- and intermediate-grade intracranial lateral dural arteriovenous fistulas: a detailed analysis of primary success rates, complication rates, and long-term follow-up of different technical approaches.

OBJECTIVE Sinus-preserving (SP) embolization techniques augment endovascular treatment options for intracranial lateral dural arteriovenous fistulas (DAVFs). The authors aimed to perform a retrospective comparison of their primary success rates, complication rates, and long-term follow-up with those of sinus-occluding (SO) treatment variants in the collective of low- and intermediate-grade lateral DAVFs (Cognard Types I-IIb). METHODS Clinical symptoms, complication rates, and Cognard grading prior to and after endovascular DAVF treatment using different technical approaches was retrospectively analyzed in 36 patients with lateral DAVF Cognard Types I-IIb. The long-term success rate was determined by a standardized questionnaire. RESULTS The SO approaches offered a higher rate of definitive fistula occlusion (93% SO vs 71% SP) but were accompanied by a significantly higher complication rate (33% or 20% SO vs 0% SP). The patients interviewed reported very high satisfaction with their health in long-term follow-up in both groups. CONCLUSIONS A higher rate of definitive fistula occlusion in the SO group was attained at the price of a significantly higher complication rate. The SP approaches offered a good primary success rate in combination with a very low complication rate. Despite some limitations of the data (e.g., a small sample size) the authors thus recommend an SP variant as the primary therapeutic option for the endovascular treatment of low- and intermediate-grade DAVFs. The SO approaches should be restricted to cases in which SP treatment does not achieve a downgrading to no worse than Cognard Type IIa.

Visualization of Liliequist's membrane prior to endoscopic third ventriculostomy.

PURPOSE: Endoscopic third ventriculostomy (ETV) is an effective treatment in patients with obstructive hydrocephalus caused by aqueductal stenosis. Operative failure may occur if an unnoticed membrane below the floor of the third ventricle is present, such as Liliequist's membrane (LM). To analyze how often LM can be visualized by high-resolution heavily T2-weighted 3D-MRI prior to ETV, and to find out potential reasons for diagnostic failure. MATERIALS AND METHODS: Preoperative 3D-MR images of 37 consecutive patients (19 female, median 42 years) were retrospectively analyzed. Visualization of three LM segments (sellar, diencephalic, mesencephalic), dimensions of the space below the third ventricle, and extent of hydrocephalus were measured. Image quality was scored (score 1[poor] to 3[excellent]). Preoperative imaging findings were compared with intraoperative findings. RESULTS: Patients were subdivided into group 1 (no segment of LM identified, n = 18), and group 2 (at least one segment of LM was identified, n = 19). The sellar segment of LM was most often positively identified (10 out of 19 cases). The mean distance between the pons and the sella/clivus was significantly shorter in group 1 than in group 2 (3.7 vs. 6.2 mm; p < 0.01). Other variables, such as the distance between tip of the pons and the mamillary bodies as well as the image quality, were not significantly different between both groups. Intraoperatively, LM was present in 78 % of group 2 patients, and in 28 % of group 1 patients, respectively (p < 0.03). CONCLUSIONS: LM can be detected in about half of patients prior to ETV. Reduced PSD influences visualization of LM.

Ruptured basilar artery perforator aneurysms--treatment regimen and long-term follow-up in eight cases.

INTRODUCTION: Basilar artery (BA) perforator aneurysms may lead to severe subarachnoid hemorrhage (SAH). The acute management is uncertain. The anatomic approach is challenging both for coiling and clipping, and flow diverter stenting may be dangerous due to the required antiplatelet therapy. We report on our experiences in eight patients. METHODS: We retrospectively analyzed eight patients with ruptured BA perforator aneurysm, including clinical characteristics, imaging data, treatment regimen, clinical course, and long-term outcome. RESULTS: Patients presented with major SAH and World Federation of Neurosurgical Societies (WFNS) scores of I in three, II in two, and V in three cases. In four patients, the aneurysm was detected in the initial angiography, in four only in follow-up angiography. Five patients were treated conservatively and three patients had endovascular therapy. In the conservative group, the aneurysm spontaneously thrombosed in three cases. One patient suffered from a re-SAH and stayed permanently dependent due to an associated perforator stroke (modified Rankin Scale (mRS) 5). The remaining four patients recovered well (mRS 0 and 1 in two cases, each) including three patients also exhibiting perforator strokes. Regarding the endovascular group, one parent vessel was an angioma feeder and embolized with Onyx. The second aneurysm spontaneously thrombosed periinterventionally. The third patient underwent coiling. Two parent vessels were occluded postinterventionally, resulting in perforator strokes. Final mRS scores were 0, 2, and 2, respectively. CONCLUSION: Conservative management of ruptured BA aneurysms might be a first-line treatment option with common spontaneous aneurysm occlusion, low rate of re-SAH, and promising clinical outcome.

Interdisciplinary treatment of unruptured intracranial aneurysms: impact of intraprocedural rupture and ischemia in 563 aneurysms.

This study was conducted to determine the risk factors and the clinical impact of intraprocedural aneurysm rupture (IAR) and periprocedural ischemia in the treatment of symptomatic and asymptomatic unruptured intracranial aneurysms (UIAs). A single-center retrospective data analysis of 563 UIAs treated between 2000 and 2010 was conducted. Treatment assignment was made on the basis of individual aneurysmal criteria in an interdisciplinary neurovascular conference with attending neurosurgeons, neuroradiologists and neurologists. In 363 microsurgical and 200 endovascular procedures, the permanent morbidity rate was 4.9 and 6 %. The overall mortality rate was 0.7 %-no procedure-related death occurred in microsurgery, and four patients had fatal outcomes after endovascular treatment. IAR occurred in 34 (9.4 %) microsurgical and 8 (4 %) endovascular procedures (p = 0.03). Risk factors for IAR were age, aneurysm diameter, symptomatic aneurysms, hypertension and smoking in microsurgery. IAR was associated with significantly worse outcome at discharge after microsurgical and at discharge and follow-up after endovascular procedures and was followed by fatal outcome in four endovascular cases. Periprocedural ischemia (12.1 vs. 9 %) resulted in significantly worse outcome in both groups. Risk factors for periprocedural ischemia were IAR during microsurgery, aneurysm diameter, symptomatic aneurysms and smoking in either group. Treatment of UIAs can be conducted with an equivalent low rate of permanent morbidity for clipping and coiling-treatment of symptomatic aneurysms elevates the procedural risk. IAR was less frequent during coiling, but was associated with relevant mortality. IAR and periprocedural ischemia represent significant treatment-associated risks, which should be taken into account in interdisciplinary treatment planning and patient counseling.

Superficial siderosis is a warning sign for future intracranial hemorrhage.

Supratentorial superficial siderosis (SS) is a frequent imaging marker of cerebral amyloid angiopathy (CAA). It is most probably caused by focal subarachnoid hemorrhages (fSAHs). Based on single-case observations, it has been proposed that such fSAHs might be a predisposing factor for future intracranial hemorrhage. Here we tested the hypothesis if a SS as a residue of fSAHs must be regarded as a warning sign for future intracranial hemorrhage. Fifty-one consecutive patients with SS and no apparent cause other than possible or probable CAA were identified through a database search and followed-up for a median interval of 35.3 months (range 6-120 months). Main outcome measures were rate and location of new intracranial hemorrhages. Twenty-four patients (47.1 %) had experienced any new intracranial hemorrhage, 18 patients (35.3 %) had an intracerebral hemorrhage (ICH), and in 13 of them (25.5 %), the hemorrhage was located at the site of pre-existing siderosis. Six patients (11.7 %) had developed a new subarachnoid hemorrhage (SAH), four of them at the site of siderosis. Patients with SS are at substantial risk for subsequent intracranial hemorrhage. SS can be considered a warning sign of future ICH or SAH, which frequently occur adjacent to pre-existing SS. Prospective studies are needed to confirm these findings.

Aneurysmal subarachnoid hemorrhage in elderly patients: long-term outcome and prognostic factors in an interdisciplinary treatment approach.

The number of elderly patients with aneurysmal subarachnoid hemorrhage (SAH) is increasing with the aging of the population. However, management recommendations based on long-term outcome data and analyses of prognostic factors are scarce. Our study focused exclusively on elderly patients aged ≥ 60 years at the onset of SAH. Patients were selected from an in-house database and compared in cohorts of age 60-69, 70-79, and ≥ 80, regarding pre-existing medical conditions, treatment, clinical course including complications, and outcome. A multivariate analysis was conducted to identify prognostic factors for death and disability. A total of 256 patients (138 aged 60-69, 93 aged 70-79, 25 aged ≥ 80) with putative aneurysmal SAH who had been admitted to our hospital between January 1, 1996 and June 30, 2007 were extracted. The median follow-up of our total cohort was 35.5 months (range <1-154 months). Endovascular or conservative aneurysm treatment was applied more often with increasing age (p < 0.006). The 1-year survival rate was 78, 65, and 38 % in the three age groups, respectively (p = 0.0002); most of the patients died from the initial hemorrhage or from medical complications. Patients aged <70 with an initial World Federation of Neurosurgical Societies (WFNS) score of I-III showed the best clinical recovery. WFNS score, age, and clipping/coiling were extracted as prognostic factors from the Cox model. Elderly patients who get admitted with a good WFNS score (I-III) seem to benefit from aggressive treatment whereas caution seems to be warranted particularly in patients ≥ 70 years of age who get admitted in a WFNS score of IV and V because of their limited short- and long-term prognosis.

Value of "functional" magnetic resonance imaging in the diagnosis of ligamentous affection at the craniovertebral junction.

INTRODUCTION: Objective of this investigation was to evaluate the rotational mobility at the craniocervical junction and changes in the width of the subarachnoid space during head rotation in healthy volunteers using Magnetic Resonance Imaging (MRI). MATERIALS AND METHODS: In 30 healthy volunteers axial 3mm Half-Fourier Acquisition Single-Shot Turbo Spin-Echo (HASTE) sequences were obtained with the subject's head in neutral position, and in maximal rotation to the left and right respectively. All MRI examinations were evaluated by two neuroradiologists in consensus. The ranges of axial rotation at C0-C2 as well as the width of the subarachnoid space in neutral, and in maximal rotated position were measured. Student's t-tests were used to compare group differences. RESULTS: Total range of right-to-left-rotation at C0-C2 was 59-183° with mean rotation to the right and left side of 70° (±12.7°) and 75° (±13.0°). Difference between degrees of rotation to both sides was on average 4.9° (±7.1°) with a significantly greater rotational range to the left compared to the right. In neutral position, distance between the dura and the ventral wall of the cervical spinal cord was 1.6-4.2mm. In active rotation interface between dura and myelon was evident in 19 volunteers with unilateral contact in 7, and bilateral contact in 12 cases. CONCLUSIONS: High variablity of rotational mobility at the craniocervical junction and attenuation of width of the subarachnoid space during head rotation are frequent findings in an asymptomatic population. Our results indicate that the assessment of these parameters is of limited diagnostic value in patients with whiplash-associated disorders.

Multimodal recanalization therapy in acute basilar artery occlusion: long-term functional outcome and quality of life.

BACKGROUND AND PURPOSE: Multimodal recanalization therapy in patients with acute basilar artery occlusion provides high recanalization rates. A substantial subset of treated patients survives with only minor or moderate functional handicap. However, long-term functional outcome and quality of life in these patients have rarely been systematically analyzed. METHODS: In this monocentric retrospective study, we analyzed mortality, long-term functional outcome (modified Rankin Scale), and quality of life (36-Item Short-Form Health Survey questionnaire) in all consecutive patients who had been treated for acute basilar artery occlusion in our institution between December 2002 and December 2009. RESULTS: Ninety-one patients (57 male; median age, 65 years; range, 20-89 years) were treated by multimodal recanalization therapy. This included intravenous thrombolysis (n=32) with consecutive on-demand intra-arterial therapy (n=23) or intra-arterial therapy alone (n=59). The overall recanalization rate was 89%. After a median observation time of 4.2 years (range, 0.5-7.4 years), the mortality rate was 59%. Among the 35 survivors, 26 patients (74%) had a good or moderate long-term functional outcome (modified Rankin Scale ≤3). Health-related quality of life was better than that of unselected patients with stroke. Backward stepwise logistic regression identified intravenous thrombolysis (P=0.002) and female sex (P=0.001) as predictors of favorable functional long-term outcome (modified Rankin Scale ≤3). Coma at admission (Glasgow Coma Scale ≤8) was associated with poor outcome (modified Rankin Scale ≥4; P=0.036). CONCLUSIONS: Long-term survival is achieved in approximately 40% of patients with basilar artery occlusion treated with multimodal recanalization therapy. Approximately 75% of the survivors have a favorable functional long-term outcome with an acceptable quality of life.

Effect of magnetic resonance imaging field strength on delineation and signal intensity of alar ligaments in healthy volunteers.

STUDY DESIGN: A prospective study of healthy volunteers. OBJECTIVE: To evaluate the influence of magnetic resonance imaging (MRI) field strength on the delineation and signal intensity of alar ligaments (AL) in healthy volunteers. SUMMARY OF BACKGROUND DATA: The fact that AL physiologically show morphologic variabilities is well established. However, presence and etiology of high-signal intensities within the AL as well as the influence of the MRI field strength on the signal characteristics of AL are still not completely understood. METHODS.: Coronal and sagittal 2-mm proton-density weighted sequences were acquired in 50 healthy volunteers using different MRI field strengths (1 T, 1.5 T, 3 T). Delineation and signal characteristics of AL were evaluated by 2 neuroradiologists independently. Differences concerning delineation and signal intensity between the MRI scanners, inter rater reliability between the 2 readers, and intrarater reliability at different time points were calculated. RESULTS: Delineation of AL was significantly better both on 3 T and 1.5 T than on 1 T (P = 0.05) in sagittal as well as in coronal view. In coronal view delineation was significantly better on 3 T than on 1.5 T, whereas in sagittal view no significant difference was evident when comparing 1.5 T and 3 T. Concerning signal intensity of AL in sagittal view, there was no significant difference between the 3 different field strengths. Inter-rater and intrarater agreements were fair to moderate with respect to delineation as well as signal intensity of AL. CONCLUSION: 1.5 T and 3 T significantly improve the delineation of AL when compared with lower field strength (1 T), but signal intensity of the AL in healthy volunteers is not influenced by the field strength. Increased signal is present in asymptomatic subjects on both low- and high-field magnetic resonance systems. Accordingly, the pathologic relevance of increased signal intensity of the AL, regardless of field strength, may not be indicative of traumatic AL injury.

Preceding intravenous thrombolysis facilitates endovascular mechanical recanalization in large intracranial artery occlusion.

BACKGROUND AND AIMS: Acute occlusions of the large intracranial arteries are relatively resistant to intravenous thrombolysis. Therefore, multimodal approaches combining intravenous thrombolysis with endovascular mechanical recanalization are increasingly being applied. In this setting, intravenous thrombolysis may facilitate subsequent mechanical thrombectomy. To test this hypothesis, we analyzed the influence of intravenous thrombolysis on net intervention time in subsequent endovascular mechanical recanalization. METHODS: In this retrospective single-center analysis, we compared net intervention time with and without preceding intravenous thrombolysis in patients treated by endovascular mechanical recanalization between 01/2003 and 06/2010. The net intervention time was defined as the interval between the onset of endovascular thrombus manipulation and successful vessel recanalization. RESULTS: We identified 65 eligible patients, 35 of whom were treated by intravenous thrombolysis before mechanical therapy. Recanalization was achieved in 26 patients with (74%) and 23 patients without preceding intravenous thrombolysis (77%). In the case of successful recanalization, the net intervention time was significantly shorter in patients with preceding intravenous thrombolysis (24·8 ± 22·8 vs. 44·2 ± 40·5 min; P<0·05). This difference remained significant after restricting the analysis to the patients treated by the Penumbra Stroke System(©) (n=32). After three-months, patients with preceding intravenous thrombolysis were more likely to be functionally independent (modified Rankin Scale≤2) than those without (P<0·05). CONCLUSIONS: Our findings suggest that preceding intravenous thrombolysis may reduce the intervention time in patients treated by endovascular mechanical recanalization. However, due to the retrospective design of our study, these findings have to be interpreted with caution and need confirmation in a larger patient population.