Telemedical stroke care significantly improves patient outcome in rural areas: Long-term analysis of the German NEVAS network.

BACKGROUND: Comprehensive stroke centers (CSC) offer state-of-the-art stroke care in metropolitan centers. However, in rural areas, sufficient stroke expertise is much scarcer. Recently, telemedical stroke networks have offered instant consultation by stroke experts, enabling immediate administration of intravenous thrombolysis (IVT) on-site and decision on thrombectomy. While these immediate decisions are made during the consult, the impact of the network structures on stroke care in spoke hospitals is still not well described. AIMS: This study was performed to determine if on-site performance in rural hospitals and patient outcome improve over time through participation and regular medical staff training within a telemedical stroke network. METHODS: In this retrospective study, we analyzed data from stroke patients treated in four regional hospitals within the telemedical Neurovascular Network of Southwest Bavaria (NEVAS) between 2014 and 2019. We only included those patients that were treated in the regional hospitals until discharge at home or to neurorehabilitation. Functional outcome (modified Rankin scale) at discharge, mortality rate and periprocedural intracranial hemorrhage served as primary outcome parameters. Door-to-imaging and door-to-needle times were secondary outcome parameters. RESULTS: In 2014-2019, 5,379 patients were treated for acute stroke with 477 receiving IVT. Most baseline characteristics were comparable over time. For all stroke patients, door-to-imaging times increased over the years, but significantly improved for potential IVT candidates and those finally treated with IVT. The percentage of patients with door-to-needle time <30 min increased from 10% to 25%. Clinical outcome at discharge improved for all stroke patients treated in the regional hospitals. Particularly for patients treated with IVT, good clinical outcome (modified Rankin scale 0-2) at discharge increased from 2014 to 2019 by 19% and mortality rates dropped from 13% to 5%. CONCLUSIONS: 24-h/7-day telemedical support and regular on-site medical staff training within a structured telemedicine stroke network such as NEVAS significantly improve on-site stroke care in rural areas, leading to a considerable benefit in clinical outcome. DATA ACCESS STATEMENT: The data that support the findings of this study are available upon reasonable request and in compliance with the local and international ethical guidelines.

Neurologic manifestations of COVID-19 in critically ill patients: results of the prospective multicenter registry PANDEMIC.

BACKGROUND: Neurologic manifestations are increasingly reported in patients with coronavirus disease 2019 (COVID-19). Yet, data on prevalence, predictors and relevance for outcome of neurological manifestations in patients requiring intensive care are scarce. We aimed to characterize prevalence, risk factors and impact on outcome of neurologic manifestations in critically ill COVID-19 patients. METHODS: In the prospective, multicenter, observational registry study PANDEMIC (Pooled Analysis of Neurologic DisordErs Manifesting in Intensive care of COVID-19), we enrolled COVID-19 patients with neurologic manifestations admitted to 19 German intensive care units (ICU) between April 2020 and September 2021. We performed descriptive and explorative statistical analyses. Multivariable models were used to investigate factors associated with disorder categories and their underlying diagnoses as well as to identify predictors of outcome. RESULTS: Of the 392 patients included in the analysis, 70.7% (277/392) were male and the mean age was 65.3 (SD ± 3.1) years. During the study period, a total of 2681 patients with COVID-19 were treated at the ICUs of 15 participating centers. New neurologic disorders were identified in 350 patients, reported by these centers, suggesting a prevalence of COVID-19-associated neurologic disorders of 12.7% among COVID-19 ICU patients. Encephalopathy (46.2%; 181/392), cerebrovascular (41.0%; 161/392) and neuromuscular disorders (20.4%; 80/392) were the most frequent categories identified. Out of 35 cerebrospinal fluid analyses with reverse transcriptase PCR for SARS-COV-2, only 3 were positive. In-hospital mortality was 36.0% (140/389), and functional outcome (mRS 3 to 5) of surviving patients was poor at hospital discharge in 70.9% (161/227). Intracerebral hemorrhage (OR 6.2, 95% CI 2.5-14.9, p < 0.001) and acute ischemic stroke (OR 3.9, 95% CI 1.9-8.2, p < 0.001) were the strongest predictors of poor outcome among the included patients. CONCLUSIONS: Based on this well-characterized COVID-19 ICU cohort, that comprised 12.7% of all severe ill COVID-19 patients, neurologic manifestations increase mortality and morbidity. Since no reliable evidence of direct viral affection of the nervous system by COVID-19 could be found, these neurologic manifestations may for a great part be indirect para- or postinfectious sequelae of the infection or severe critical illness. Neurologic ICU complications should be actively searched for and treated.

Genome-wide Association Study Identifies 2 New Loci Associated With Anti-NMDAR Encephalitis.

BACKGROUND AND OBJECTIVES: To investigate the genetic determinants of the most common type of antibody-mediated autoimmune encephalitis, anti-NMDA receptor (anti-NMDAR) encephalitis. METHODS: We performed a genome-wide association study in 178 patients with anti-NMDAR encephalitis and 590 healthy controls, followed by a colocalization analysis to identify putatively causal genes. RESULTS: We identified 2 independent risk loci harboring genome-wide significant variants (p < 5 × 10-8, OR ≥ 2.2), 1 on chromosome 15, harboring only the LRRK1 gene, and 1 on chromosome 11 centered on the ACP2 and NR1H3 genes in a larger region of high linkage disequilibrium. Colocalization signals with expression quantitative trait loci for different brain regions and immune cell types suggested ACP2, NR1H3, MADD, DDB2, and C11orf49 as putatively causal genes. The best candidate genes in each region are LRRK1, encoding leucine-rich repeat kinase 1, a protein involved in B-cell development, and NR1H3 liver X receptor alpha, a transcription factor whose activation inhibits inflammatory processes. DISCUSSION: This study provides evidence for relevant genetic determinants of antibody-mediated autoimmune encephalitides outside the human leukocyte antigen (HLA) region. The results suggest that future studies with larger sample sizes will successfully identify additional genetic determinants and contribute to the elucidation of the pathomechanism.

Inter-hospital transfer for mechanical thrombectomy within the supraregional stroke network NEVAS.

BACKGROUND: Telemedicine stroke networks are mandatory to provide inter-hospital transfer for mechanical thrombectomy (MT). However, studies on patient selection in daily practice are sparse. METHODS: Here, we analyzed consecutive patients from 01/2014 to 12/2018 within the supraregional stroke network "Neurovascular Network of Southwest Bavaria" (NEVAS) in terms of diagnoses after consultation, inter-hospital transfer and predictors for performing MT. Degree of disability was rated by the modified Rankin Scale (mRS), good outcome was defined as mRS ≤ 2. Successful reperfusion was assumed when the modified thrombolysis in cerebral infarction (mTICI) was 2b-3. RESULTS: Of 5722 telemedicine consultations, in 14.1% inter-hospital transfer was performed, mostly because of large vessel occlusion (LVO) stroke. A total of n = 350 patients with LVO were shipped via NEVAS to our center for MT. While n = 52 recanalized spontaneously, MT-treatment was performed in n = 178 patients. MT-treated patients had more severe strokes according to the median National institute of health stroke scale (NIHSS) (16 vs. 13, p < 0.001), were more often treated with intravenous thrombolysis (64.5% vs. 51.7%, p = 0.026) and arrived significantly earlier in our center (184.5 versus 228.0 min, p < 0.001). Good outcome (27.5% vs. 30.8%, p = 0.35) and mortality (32.6% versus 23.5%, p = 0.79) were comparable in MT-treated versus no-MT-treated patients. In patients with middle cerebral artery occlusion in the M1 segment or carotid artery occlusion good outcome was twice as often in the MT-group (21.8% vs. 12.8%, p = 0.184). Independent predictors for performing MT were higher NIHSS (OR 1.096), higher ASPECTS (OR 1.28), and earlier time window (OR 0.99). CONCLUSION: Within a telemedicine network stroke care can successfully be organized as only a minority of patients has to be transferred. Our data provide clinical evidence that all MT-eligible patients should be shipped with the fastest transportation modality as possible.

Brainstem encephalitis in neuroborreliosis: typical clinical course and distinct MRI findings.

OBJECTIVE: In this retrospective observational study and referring to a historical case presented in 2009, we searched for typical clinical and imaging features of brainstem encephalitis in neuroborreliosis. METHODS: In addition to the historical case we describe five affected patients. RESULTS: All patients had a very similar prolonged clinical course with unspecific symptoms such as wasting, fatigue and headache. Brainstem signs were irregularly observed. MRI showed symmetrical brainstem alterations in all patients. In coronary FLAIR imaging these changes formed a figure resembling a Philippine tarsier. CONCLUSIONS: A subset of patients with neuroborreliosis develops a brainstem encephalitis with a typical clinical course and distinct MRI findings.

Telling friend from foe in emergency vertigo and dizziness: does season and daytime of presentation help in the differential diagnosis?

Distinguishing between serious (e.g., stroke) and benign (e.g., benign paroxysmal positional vertigo, BPPV) disorders remains challenging in emergency consultations for vertigo and dizziness (VD). A number of clues from patient history and clinical examination, including several diagnostic index tests have been reported recently. The objective of the present study was to analyze frequency and distribution patterns of specific vestibular and non-vestibular diagnoses in an interdisciplinary university emergency room (ER), including data on daytime and season of presentation. A retrospective chart analysis of all patients seen in a one-year period was performed. In the ER 4.23% of all patients presented with VD (818 out of 19,345). The most frequent-specific diagnoses were BPPV (19.9%), stroke/transient ischemic attack (12.5%), acute unilateral vestibulopathy/vestibular neuritis (UVH; 8.3%), and functional VD (8.3%). Irrespective of the diagnosis, the majority of patients presented to the ER between 8 a.m. and 4 p.m. There are, however, seasonal differences. BPPV was most prevalent in December/January and rare in September. UVH was most often seen in October/November; absolute and relative numbers were lowest in August. Finally, functional/psychogenic VD was common in summer and autumn with highest numbers in September/October and lowest numbers in March. In summary, daytime of presentation did not distinguish between diagnoses as most patients presented during normal working hours. Seasonal presentation revealed interesting fluctuations. The UVH peak in autumn supports the viral origin of the condition (vestibular neuritis). The BPPV peak in winter might be related to reduced physical activity and low vitamin D. However, it is likely that multiple factors contribute to the fluctuations that have to be disentangled in further studies.

Drip and ship for mechanical thrombectomy within the Neurovascular Network of Southwest Bavaria.

OBJECTIVE: To determine feasibility and safety of stroke care organization within our Neurovascular Network of Southwest Bavaria (NEVAS) in a rural area with distances of up to 100 kilometers, we compared patients who underwent mechanical thrombectomy (MT) in large vessel occlusion admitted directly to our center (direct to center [DTC]) to patients who were transferred for MT via NEVAS (drip and ship [DS]). METHODS: This is a retrospective analysis of prospectively collected data of all MT patients between January 2015 and May 2018. Successful recanalization was defined as a thrombolysis in cerebral infarction score of 2b-3. Symptomatic intracerebral hemorrhage (sICH) was defined according to European Cooperative Acute Stroke Study 3. Modified Rankin Scale (mRS) score of 0-2 at 3 months indicated good outcome. RESULTS: MT was performed in 410 patients: 221 DTC and 189 DS. Median NIH Stroke Scale (NIHSS) score was 16 and premorbid mRS score was 0. Thrombolysis was applied in 62.2% with the same time from symptom onset in both groups (94.5 vs 95 minutes). Successful recanalization (79.3% vs 77.8%) and NIHSS score reduction from admission to discharge (16-7 vs 17-6) were comparable. Time delay from onset to revascularization was 96 minutes in DS (212 vs 308 minutes, p = 0.001). At follow-up, DTC patients had a trend to better outcome (33.5% vs 24.3%, p = 0.056). Neither sICH (6.3% vs 5.9%, p = 0.840) nor mortality (31.2% vs 34.4%, p = 0.387) differed between the groups. CONCLUSION: DS patients benefit from MT without relevant safety concerns, but with a trend to unfavorable outcome compared to DTC patients. These results suggest that DS is suitable to provide MT in rural areas where DTC is not possible.

Clinical Significance of Intraluminal Contrast Enhancement in Patients with Spontaneous Cervical Artery Dissection: A Black-Blood MRI Study.

Purpose Recent studies have suggested that intraluminal thrombi show contrast enhancement on carotid black-blood T1w MRI. The aim of this study was to evaluate the significance of intraluminal contrast enhancement (iCE) regarding symptom status in patients with spontaneous cervical artery dissection (sCAD). Methods 33 consecutive patients (19 men) with sCAD received a brain MRI (DIFF, T2w, T2*w, FLAIR) and a multi-sequence 3T-MRI with fat-saturated high-resolution black-blood T1w-sequences pre- and post-contrast, contrast-enhanced MR angiography and TOF images of carotid and vertebral arteries. Presence/absence of iCE, vessel occlusion and vessel wall hematoma (hyperintense in T1w pre-contrast) were analysed by two radiologists in consensus decision. Results 44 of 132 analysed vessels had a vessel wall hematoma, consistent with sCAD. In 17 of 44 dissected vessels an acute ischemic stroke was found. 16 of 17 (94.1 %) vessels ipsilateral to ischemic stroke demonstrated iCE, compared to 9 of 44 (20.4 %) dissected vessels without stroke (P< 0.001). The presence/absence of iCE resulted in a sensitivity, specificity, positive and negative predictive value and accuracy for ischemic stroke of 0.94, 0.67, 0.64, 0.95, and 0.77, respectively, and an odds ratio of 32.0. Conclusion iCE, which is suggestive of intraluminal thrombus formation, is strongly correlated with ischemic symptoms in patients with sCAD. Key points · Intraluminal contrast enhancement is associated with cerebral ischemia in corresponding vessel territories in patients with cervical artery dissection.. · Our results suggest that intraluminal contrast enhancement represents intraluminal thrombus formation.. · Black-blood imaging might be useful to identify those patients with cervical artery dissection at higher risk for initial or recurrent stroke.. Citation Format · Coppenrath E, Lenz O, Sommer N et al. Clinical Significance of Intraluminal Contrast Enhancement in Patients with Spontaneous Cervical Artery Dissection: A Black-Blood MRI Study. Fortschr Röntgenstr 2017; 189: 624 - 631.

Long-term Neurological Outcome and Quality of Life after World Federation of Neurosurgical Societies Grades IV and V Aneurysmal Subarachnoid Hemorrhage in an Interdisciplinary Treatment Concept.

BACKGROUND: Detailed data on long-term functional outcome of patients with World Federation of Neurosurgical Societies (WFNS) grades IV and V aneurysmal subarachnoid hemorrhages (aSAH) are still scarce. OBJECTIVE: Assessment of long-term outcome of WFNS IV and V aSAH patients. METHODS: Functional outcome and quality of life were assessed by the modified Rankin scale (mRS) and the 36-item short-form health survey in consecutively treated aSAH WFNS IV and V patients between 2005 and 2010. Scores from the 36-item short-form health survey were compared to a healthy German population. Prognostic factors were analyzed by uni- and multivariate models. RESULTS: One hundred and seven eligible patients (median age: 53.0 years) were identified. After interdisciplinary consensus on optimal treatment, aneurysms were obliterated either by clipping (n = 35) or by coiling (n = 72). Ten patients were lost to long-term follow-up; the median clinical follow-up period was 3.2 years for the remaining 97 cases. Twenty-five of 97 died during the acute hospital phase and another 10 patients over the follow-up period leaving 62 long-term survivors. At the end of clinical follow-up, 40/97 patients, including 40/62 of long-term survivors, reached functional independence (mRS ≤ 2). Twelve of 97 patients were moderately (mRS = 3), 10/97 patients were severely disabled (mRS ≥ 4). Younger age (≤ 53 years; P = .001) and radiological absence of cerebral infarction ( P = .03) were the strongest predictors for favorable outcome. Quality of life was perceived to be only moderately reduced compared to the healthy control group. CONCLUSION: Poor-grade aSAH is not necessarily associated with poor long-term functional outcome; after aneurysm repair ∼60% of patients survived and among long-term survivors ∼ 60% regained functional independence.

Severe Cerebral Venous and Sinus Thrombosis: Clinical Course, Imaging Correlates, and Prognosis.

BACKGROUND: Severe cerebral venous-sinus thrombosis (CVT) is a rare disease, and its clinical course, imaging correlates, as well as long-term prognosis have not yet been investigated systematically. METHODS: Multicenter retrospective study. Inclusion criteria were CVT, Glasgow coma scale ≤9, and treatment in the intensive care unit. Primary outcome was death or dependency, assessed by a modified Rankin Score (mRS) >2 at last follow-up. RESULTS: 114 patients were included. At last follow-up (median 2.5 years), 38 patients (33.3 %) showed no or minor residual symptoms (mRS = 0 or 1), 12 (10.5 %) had a mild (mRS = 2), 13 (11.4 %) a moderate (mRS = 3), 12 (10.5 %) a severe disability (mRS = 4 or 5), and 39 (34.2 %) had died. In bivariate analysis, predictors of poor outcome were any signs of mass effect on imaging, clinical deterioration after admission, and age. In contrast, clinical symptoms on admission and parenchymal lesions per se, such as edema, infarction, or hemorrhage were not predictive. Multivariate predictors of poor outcome were an increase in National Institutes of Health Stroke Scale ≥3 after admission [odds ratio (OR) 6.7], bilateral motor signs in the further course (OR 9.2), and midline shift (OR 5.1). CONCLUSION: The outcome of severe CVT is almost equally divided between severe impairment or death and survival with no or only mild handicap. Specifically, space-occupying mass effect and associated neurologic deterioration seem to determine a poor outcome. Therefore, early detection and treatment of mass effect should be the focus of critical care.

Regional differences in the cerebral blood flow velocity response to hypobaric hypoxia at high altitudes.

Symptoms of acute mountain sickness (AMS) may appear above 2,500 m altitude, if the time allowed for acclimatization is insufficient. As the mechanisms underlying brain adaptation to the hypobaric hypoxic environment are not fully understood, a prospective study was performed investigating neurophysiological changes by means of near infrared spectroscopy, electroencephalograpy (EEG), and transcranial doppler sonography at 100, 3,440 and 5,050 m above sea level in the Khumbu Himal, Nepal. Fourteen of the 26 mountaineers reaching 5,050 m altitude developed symptoms of AMS between 3,440 and 5,050 m altitude (Lake-Louise Score ⩾3). Their EEG frontal beta activity and occipital alpha activity increased between 100 and 3,440 m altitude, i.e., before symptoms appeared. Cerebral blood flow velocity (CBFV) in the anterior and middle cerebral arteries (MCAs) increased in all mountaineers between 100 and 3,440 m altitude. During further ascent to 5,050 altitude, mountaineers with AMS developed a further increase in CBFV in the MCA, whereas in all mountaineers CBFV decreased continuously with increasing altitude in the posterior cerebral arteries. These results indicate that hypobaric hypoxia causes different regional changes in CBFV despite similar electrophysiological changes.

Diagnostic and Prognostic Impact of pc-ASPECTS Applied to Perfusion CT in the Basilar Artery International Cooperation Study.

BACKGROUND AND PURPOSE: The posterior circulation Acute Stroke Prognosis Early CT Score (pc-APECTS) applied to CT angiography source images (CTA-SI) predicts the functional outcome of patients in the Basilar Artery International Cooperation Study (BASICS). We assessed the diagnostic and prognostic impact of pc-ASPECTS applied to perfusion CT (CTP) in the BASICS registry population. METHODS: We applied pc-ASPECTS to CTA-SI and cerebral blood flow (CBF), cerebral blood volume (CBV), and mean transit time (MTT) parameter maps of BASICS patients with CTA and CTP studies performed. Hypoattenuation on CTA-SI, relative reduction in CBV or CBF, or relative increase in MTT were rated as abnormal. RESULTS: CTA and CTP were available in 27/592 BASICS patients (4.6%). The proportion of patients with any perfusion abnormality was highest for MTT (93%; 95% confidence interval [CI], 76%-99%), compared with 78% (58%-91%) for CTA-SI and CBF, and 46% (27%-67%) for CBV (P < .001). All 3 patients with a CBV pc-ASPECTS < 8 compared to 6/23 patients with a CBV pc-ASPECTS ≥ 8 had died at 1 month (RR 3.8; 95% CI, 1.9-7.6). CONCLUSION: CTP was performed in a minority of the BASICS registry population. Perfusion disturbances in the posterior circulation were most pronounced on MTT parameter maps. CBV pc-ASPECTS < 8 may indicate patients with high case fatality.

Severe depression as the sole symptom of affective focal status epilepticus.

Depression as well as fear, joy and anger have been described as the semiological features of focal epileptic seizures. When emotions present as the sole symptoms of epileptic seizures, they may easily be misdiagnosed as a psychiatric disorder. We describe a patient with affective focal status epilepticus, secondary to limbic encephalitis, in which depression was the only clinical manifestation. Through EEG correlates the epileptic nature of depression could be proven. Furthermore, we discuss the association between epilepsy and depression, as well as the link between ictal depression and suicidal rates.

Mechanical thrombectomy in basilar artery thrombosis: technical advances and safety in a 10-year experience.

PURPOSE: Multiple endovascular devices have been used for mechanical thrombectomy (MT) in basilar artery occlusion (BAO) for >10 years. Based on a single-center experience during the course of one decade, we present data on safety and efficacy of previous MT devices compared with modern stent retriever and suction thrombectomy. MATERIALS AND METHODS: Eighty-one patients (29 women, 52 men, mean age 61.5 years, range 17-90) with angiographically confirmed BAO that had been treated by MT between 2001 and 2011 were retrospectively evaluated. Patients in group 1 (n = 60) had been treated between 2001 and 2008 with different devices available at that time. Patients in group 2 (n = 21) had been treated by modern stent retriever or local suction devices between 2008 and 2011. Recanalization rate, needle to recanalization time, procedure-related complications, and distal embolization of thrombotic material were recorded and compared. RESULTS: Recanalization rates of 95% were high in both groups. Procedure-related dissection (n = 5) and subarachnoid hemorrhage (n = 9) occurred in group 1 but not in group 2 (p < 0.016). Needle-to-recanalization time was less than half in group 2 compared with group 1 (54.6 vs. 132.3 min, p < 0.01). Frequency of distal embolization was comparable in both groups (47%). CONCLUSION: High recanalization rates have been achieved since the introduction of MT in BAO. However, modern stent retriever and suction devices allow for safer and more rapid recanalization compared with previous MT devices.

Rehabilitation outcome of patients with severe and prolonged disorders of consciousness after aneurysmal subarachnoid hemorrhage (aSAH).

OBJECTIVES: Our objectives were to evaluate rehabilitation outcome of aSAH survivors with severe disorders of consciousness (DOC) and to examine potential predictors of long-term outcome. Severe DOC includes patients in a vegetative state (VS) and in a minimally conscious state (MCS). PATIENTS AND METHODS: This is a retrospective single-center cohort study of consecutive aSAH patients with severe and prolonged DOC upon admission to neurorehabilitation. Clinical assessments started right after discharge from ICU, a median of 26 days after the aSAH. Two different outcome criteria were used, one addressing the functional aspect (assessed by the Functional Independence Measure [FIM]) the other one addressing the level of consciousness ("behavioral outcome", assessed by the Coma Remission Scale [CRS]). Improved outcome was defined by an increase in FIM scores of at least 22 points (minimal clinically important difference) or by reaching a full score of 24 points on the CRS. Separate least square linear regression models were calculated to examine potential predictors for functional and behavioral outcome. RESULTS: Out of 63 patients, 19.0% and 39.7% of the patients achieved an improved functional and behavioral outcome, respectively. Age and level of consciousness upon admission to neurorehabilitation were independent prognostic factors for both outcome definitions. Both groups reached the better outcome category after a median of 11 and 9 weeks, respectively. In an individual patient, the longest delay to achievement of improved functional outcome was 30 weeks and to favorable behavioral outcome was 22 weeks after rehabilitation admission. CONCLUSION: About one-third of severely affected aSAH patients with DOC regained at least a favorable behavioral status during early neurorehabilitation. It is interesting to note that in our study population, the beginning of clinical improvement took up to 6 months after aSAH.

Early cranioplasty may improve outcome in neurological patients with decompressive craniectomy.

PRIMARY OBJECTIVE: Decompressive craniectomy is an effective therapy to relieve intractable intracranial hypertension following acute brain injury. However, little is known about the optimal timing for cranioplasties in the sub-acute phase. The objective of the present study was to analyse the effect of cranioplasty timing on neurological outcomes. RESEARCH DESIGN: Single-centre observational study. METHODS AND PROCEDURES: One hundred and forty-seven consecutive patients with decompressive craniectomy and cranioplasty during the course of inpatient neurorehabilitation were identified by means of a retrospective hospital database search. This database contains the following prospectively-entered weekly scores: Barthel-Index (BI), Functional Independence Measure (FIM) and Coma Remission Scale (CRS). Additional clinical data were taken retrospectively from patient charts. Regression analysis was used to identify factors that influenced the end-of-rehabilitation outcome. MAIN OUTCOMES AND RESULTS: Patients with shorter delays to cranioplasty (<86 days) had a better functional outcome than patients with longer delays of >85 days (60 ± 29.5 versus 25 ± 24.1 BI points; p < 0.01, respectively). Age, pre-operative BI and CRS scores were additional independent outcome factors. Complication rates were not different between early and late cranioplasty groups. CONCLUSIONS: Patients with decompressive craniectomy for management of intracranial hypertension may benefit from early cranioplasty.

Black blood MRI in suspected large artery primary angiitis of the central nervous system.

OBJECTIVES: Single case reports suggest that black blood MRI (T1-weighted fat and blood suppressed sequences with and without contrast injection; BB-MRI) may visualize intracranial vessel wall contrast enhancement (CE) in primary angiitis of the central nervous system (PACNS). In this single-center observational pilot study we prospectively investigated the value of BB-MRI in the diagnosis of large artery PACNS. METHODS: Patients with suspected large artery PACNS received a standardized diagnostic program including BB-MRI. Vessel wall CE was graded (grade 0-2) by two experienced readers blinded to clinical data and correlated to the final diagnosis. RESULTS: Four of 12 included patients received a final diagnosis of PACNS. All of them showed moderate (grade 1) to strong (grade 2) vessel wall CE at the sites of stenosis. A moderate (grade 1) vessel wall CE grade was also observed in 6 of the remaining 8 patients in whom alternative diagnoses were made: arteriosclerotic disease (n = 4), intracranial dissection (n = 1), and Moyamoya disease (n = 1). CONCLUSIONS: Our pilot study demonstrates that vessel wall CE is a frequent finding in PACNS and its mimics. Larger trials will be necessary to evaluate the utility of BB-MRI in the diagnostic workup of PACNS.

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.