Risk of postoperative neurological exacerbation in patients with infective endocarditis and intracranial haemorrhage.

OBJECTIVES: Cardiac surgery in patients with infective endocarditis (IE) and preoperative intracranial haemorrhage (pre-ICH) is a highly debatable issue, and guidelines are still not well defined. The goal of this study was to investigate the effect of cardiac surgery and its timing on the clinical outcomes of patients with IE and pre-ICH. METHODS: We did a single-centre retrospective analysis of data from patients with preoperative brain imaging who had surgery for left-sided IE between January 2007 and May 2018. RESULTS: Among the 363 patients included in the study, 34 had pre-ICH. Hospital mortality was similar between the patients with and without pre-ICH (29% vs 27%, respectively; P = 0.84). Unadjusted, postoperative neurological deterioration appeared higher in patients with pre-ICH (24% vs 17%; P = 0.35). In multivariable analysis, pre-ICH did not qualify as an independent predictor for either postoperative neurological deterioration [odds ratio 1.10, 95% confidence interval (CI) 0.44-2.73; P = 0.84] or hospital mortality (odds ratio 1.02, 95% CI 0.43-2.40; P = 0.96). Postoperative partial thromboplastin time was significantly elevated in 4 patients with relevant post-ICH compared with those patients without relevant post-ICH (65.5 vs 37.6, respectively; P = 0.004). CONCLUSIONS: Pre-ICH was not an independent predictor for postoperative neurological deterioration or hospital mortality in patients with IE. Postoperative coagulation management seems to be crucial in patients with IE with ICH. Although this is to date the largest monocentric study addressing surgical decision and timing, the number of patients with pre-ICH was low. Therefore, these conclusions should be regarded with caution; randomized clinical trials are needed.

Experiences from treating seven adult 5q spinal muscular atrophy patients with Nusinersen.

BACKGROUND: The antisense oligonucleotide Nusinersen recently became the first approved drug against spinal muscular atrophy (SMA). It was approved for all ages, albeit the clinical trials were conducted exclusively on children. Hence, clinical data on adults being treated with Nusinersen is scarce. In this case series, we report on drug application, organizational demands, and preliminary effects during the first 10 months of treatment with Nusinersen in seven adult patients. METHODS: All patients received intrathecal injections with Nusinersen. In cases with severe spinal deformities, we performed computed tomography (CT)-guided applications. We conducted a total of 40 administrations of Nusinersen. We evaluated the patients with motor, pulmonary, and laboratory assessments, and tracked patient-reported outcome. RESULTS: Intrathecal administration of Nusinersen was successful in most patients, even though access to the lumbar intrathecal space in adults with SMA is often challenging. No severe adverse events occurred. Six of the seven patients reported stabilization of motor function or reduction in symptom severity. The changes in the assessed scores did not reach a significant level within this short time period. CONCLUSIONS: Treating adult SMA patients with Nusinersen is feasible and most patients consider it beneficial. It demands a complex organizational and interdisciplinary effort. Due to the slowly decreasing motor functions in adult SMA patients, long observation phases for this recently approved treatment are needed to allow conclusions about effectiveness of Nusinersen in adults.

Encephalitis with radial perivascular emphasis: Not necessarily associated with GFAP antibodies.

OBJECTIVE: Autoimmune steroid-responsive meningoencephalomyelitis with linear perivascular gadolinium enhancement in brain MRI is regarded as glial fibrillary acidic protein (GFAP) astrocytopathy characterized by anti-GFAP antibodies (ABs). We questioned whether anti-GFAP ABs are necessarily associated with this syndrome. METHODS: Two patients with a strikingly similar disease course suggestive of autoimmune GFAP astrocytopathy are reported. Clinical examination, MRI, laboratory, and CSF analysis were performed. Neuropathologic examination of brain tissue was obtained from one patient. Serum and CSF were additionally tested using mouse brain slices, microglia-astrocyte cocultures, and a GFAP-specific cell-based assay. RESULTS: Both patients presented with subacute influenza-like symptoms and developed severe neurocognitive and neurologic deficits and impaired consciousness. MRIs of both patients revealed radial perivascular gadolinium enhancement extending from the lateral ventricles to the white matter suggestive of autoimmune GFAP astrocytopathy. Both patients responded well to high doses of methylprednisolone. Only one patient had anti-GFAP ABs with a typical staining pattern of astrocytes, whereas serum and CSF of the other patient were negative and showed neither reactivity to brain tissue nor to vital or permeabilized astrocytes. Neuropathologic examination of the anti-GFAP AB-negative patient revealed infiltration of macrophages and T cells around blood vessels and activation of microglia without obvious features of clasmatodendrosis. CONCLUSIONS: The GFAP-AB negative patient had both a striking (para)clinical similarity and an immediate response to immunotherapy. This supports the hypothesis that the clinical spectrum of steroid-responsive meningoencephalomyelitis suggestive of autoimmune GFAP astrocytopathy may be broader and may comprise also seronegative cases.

Endovascular brachytherapy in the femoropopliteal segment using 192Ir and 188Re.

This report presents a review of the literature on endovascular brachytherapy (EVBT) after percutaneous transluminal angioplasty (PTA) in the femoropopliteal segment. We summarize the pathophysiological changes induced by PTA and EVBT within the vessel wall, technical considerations regarding various radiation sources and their application, the impact of stents on the radial dose profile, recommendations for dosimetry of beta and gamma sources, results of experimental and clinical trials, and the medication required before, during, and after EVBT. We aim to help to identify patients who are eligible for EVBT, to choose an appropriate technical approach, and to initiate adequate antiplatelet and anticoagulant therapy.

Colobomas of the iris and choroid and high signal intensity cerebral foci on T2-weighted magnetic resonance images in Klinefelter's syndrome.

A 5-year-old boy presented with ocular anomalies including microphthalmos, colobomas of the iris, choroid, and optic nerve head, and strabismus. Magnetic resonance imaging of the head showed multiple bilateral asymmetric high signal intensity foci in the subcortical and periventricular white matter. Genetic counseling disclosed a 47,XXY karyotype.

Differentiation of white, mixed, and red thrombi: value of CT in estimation of the prognosis of thrombolysis phantom study.

PURPOSE: To test with serial computed tomographic (CT) scans whether white, mixed, and red thrombi could be differentiated according to their CT attenuation. MATERIALS AND METHODS: Platelet-enriched plasma and whole blood were mixed to produce samples with hematocrit levels of 0, 0.005, 0.03, 0.15, and 0.35. A thrombin solution was added, and after 2 hours the retracted clots were transferred into polyethylene tubes with a length of 4 cm and an inner diameter of 3 mm. Ten probes of each sample were placed into a plastic box filled with a solution of gelatin, gadopentetate dimeglumine, and distilled water. Ten tubes filled with gelatin served as control. With this phantom, the CT numbers of white, mixed, and red thrombi were measured over 144 hours. CT was performed with a multisection scanner and a collimation of 0.5 mm. Statistical analyses were performed for differences between groups and over time. RESULTS: The CT numbers of white, mixed, and red thrombi differed significantly (P <.05) for most time measurements, except for white and mixed thrombi, which had a low hematocrit level at 24 and 144 hours (P >.05). CONCLUSION: With CT it appears feasible to differentiate thrombi according to their hematocrit level and thus estimate the effectiveness of thrombolysis.

New method of embolus preparation for standardized embolic stroke in rabbits.

BACKGROUND AND PURPOSE: Although thromboembolic stroke is caused by red, white, or mixed clots, the emboli previously used in animal studies on thrombolysis were more often red than white. Because this might be one of the reasons why thrombolysis is less effective in patients than in experimental stroke, we developed a new method of preparing highly standardized red and fibrin-rich white emboli. METHODS: The middle cerebral artery of 20 rabbits was embolized with either red or fibrin-rich white autologous emboli. Cerebral perfusion was monitored by MRI. RESULTS: Red emboli consisted of closely packed erythrocytes within a sparse fibrin net and white emboli of a dense mass of fibrin with only few other blood cells. Infarct volumes were 26+/-4% (mean+/-SD) of the ischemic hemisphere with red and 27+/-6% with white emboli. The relative regional cerebral blood volume dropped below 50% 90 minutes after vascular occlusion with either type of embolus. Late spontaneous lysis and hemorrhagic complications occurred in 37.5% of red but not in white embolus cases. CONCLUSIONS: Emboli prepared by our technique result in standardized cerebral infarctions. Size and composition of the emboli continuously can be adjusted according to the experimental requirements.

More reliable noninvasive visualization of the cerebral veins and dural sinuses: comparison of three MR angiographic techniques.

PURPOSE: To compare the visualization of cerebral veins and dural sinuses at contrast material-enhanced three-dimensional (3D) fast low-angle shot (FLASH) magnetic resonance (MR) angiography, time-of-flight (TOF) MR angiography, and phase-contrast MR angiography. MATERIALS AND METHODS: The authors prospectively compared the two-dimensional source images, multiplanar reconstructed images, and maximum intensity projection angiograms obtained at contrast-enhanced 3D radio-frequency-spoiled FLASH MR angiography in 20 patients with those obtained at TOF and phase-contrast MR angiographic examinations. Two neuroradiologists in consensus determined the number of visualized cortical veins and graded the quality of visualization of veins and sinuses as intense and continuous, faint and continuous, or noncontinuous. Statistical analysis was performed with the nonparametric sign test and the Wilcoxon matched pairs sign rank test. RESULTS: The cortical veins, inferior sagittal sinus, and cavernous sinuses were visualized best with FLASH MR angiography (P <.003). The Trolard and Labbé veins were visualized equally well with the FLASH and TOF sequences. For septal, internal cerebral, and Rosenthal left basal vein visualization, phase-contrast MR angiography was inferior to the FLASH and TOF MR angiographic examinations (P <.05). The quality of visualization of the thalamostriate and Galen veins and of the superior sagittal, rectal, and transverse sinuses was the same at all MR angiographic examinations. CONCLUSION: Three-dimensional FLASH MR angiography depicts some venous structures better than do TOF and phase-contrast MR angiographic examinations. The depiction of other veins is the same with 3D FLASH and TOF sequences.