Long-term impact of perfusion CT data after subarachnoid hemorrhage.

INTRODUCTION: Dynamic perfusion computed tomography (PCT) has been established as a diagnostic instrument for the detection of vasospasm after subarachnoid hemorrhage (SAH). The purpose of this study was to assess the prognostic impact of PCT parameters after SAH on the long-term outcome of patients. METHODS: Three hundred twelve patients were retrospectively interrogated with a questionnaire 23.06 ± 14.33 months after spontaneous subarachnoid hemorrhage. The modified Rankin scale (mRS) was determined, respectively. Scheduled PCT data sets from the first days after ictus were available for all patients. RESULTS: The maximum mean transit time over several examinations per hemisphere (MTTPEAK) values were significantly correlated (p ≤ 0.001, r = 0.422) with the clinical long-term outcome (mRS). Corresponding to our linear regression analysis, MTTPEAK is the second most important regressor (behind clinical severity of the initial hemorrhage) for the prediction of long-term mRS. An MTTPEAK threshold of 3.98 s (identified by receiver operating characteristic analysis, area under the curve = 0.75) predicted an unfavorable long-term outcome (mRS ≥ 2) with a sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of 67.3, 74.3, 84.5, 52.1, and 69.6 %, respectively. CONCLUSION: The presented data corroborate the relevance of PCT data for the clinical long-term outcome of SAH patients. By identification of patients who are at risk for a bad outcome and may need escalation of therapy, risk-benefit analysis is supported.

Peripheral neuropathy: assessment of proximal nerve integrity by diffusion tensor imaging.

INTRODUCTION: We investigated the utility of diffusion tensor imaging (DTI) for detecting neuropathic changes in proximal nerve segments in patients with peripheral neuropathy. METHODS: Twenty-one individuals with (n = 11) and without (n = 10) peripheral neuropathy underwent DTI of a defined sciatic nerve segment. Patients and controls were evaluated by clinical examination and nerve conduction studies at baseline and 6 months after the initial DTI scan. RESULTS: The mean fractional anisotropy (FA) value was significantly lower in sciatic nerves from patients with peripheral neuropathy as compared with controls. Sciatic nerve FA values correlated with clinical disability scores and electrophysiological parameters of axonal damage at baseline and 6 months after MRI scan. CONCLUSIONS: DTI-derived FA values are a sensitive measure to discriminate healthy from functionally impaired human sciatic nerve segments. DTI of proximal nerve segments may be useful for estimating the proximal axonal degeneration burden in patients with peripheral neuropathies.

Proof of principle: supramarginal resection of cerebral metastases in eloquent brain areas.

BACKGROUND: Cerebral metastases are not sharply delimitatable; therefore, microsurgical circumferential stripping of intracerebral metastases is often insufficient for preventing local tumor recurrence. Supramarginal resection significantly improves local tumor control but was suggested not to be suitable for metastases in eloquent brain areas. Therefore, we retrospectively analyzed a series of patients with cerebral metastases situated in eloquent areas for newly occurring neurologic deficits after supramarginal resection performed as awake surgery. METHODS: A retrospective analysis was performed for all patients who underwent supramarginal resection for a cerebral metastasis performed as awake surgery between June 2011 and April 2012. All metastases were localized in eloquent brain areas. Pre- and postsurgical neurologic status was documented as well as data regarding the primary cancer and histopathologic data. Postoperative MRI within 72 h was scheduled routinely to verify complete resection. RESULTS: A total of 19 patients underwent awake surgery for a cerebral metastasis in eloquent brain areas. Surgery was well tolerated in all patients. Neurologic symptoms improved in five patients after surgery. In three patients, neurologic deficits existing before surgery worsened. The postoperative median National Institute of Health Stroke Scale (NIHSS) score did not differ from the preoperative value. CONCLUSIONS: Awake surgery is a feasible tool for metastases in eloquent areas, minimizing postoperative neurologic deficits and morbidity. Therefore, eloquently situated metastases may also be eligible for supramarginal resection. Further studies are needed in order to analyze the benefit of this method in achieving better tumor control.

Is it a glioblastoma? In dubio pro 5-ALA!

BACKGROUND: Differential diagnosis of unclear contrast-enhancing cerebral lesions includes cerebral metastases as well as malignant glioma. In the majority of cases, a definite preoperative diagnosis by neuroradiological assessment alone cannot be made. Since the introduction of 5-ALA-induced fluorescence-guided resection in the treatment of glioblastoma (GBM), the preoperative putative diagnosis of metastasis vs. GBM triggers a specific preoperative preparation of the patients. We analyzed the patient population with known cancer outside the central nervous system who underwent surgery for an assumed cerebral metastasis and for whom the intraoperative diagnosis was corrected to a malignant glioma. METHODS: Retrospective analysis of patients with a known primary cancer who were operated on for an assumed cerebral metastasis, which turned out to be a GBM. The patients were treated at our center between January 2008 and June 2011. RESULTS: We identified ten patients who underwent surgery for an assumed cerebral metastasis and for whom the diagnosis was corrected intraoperatively to a malignant glioma by frozen section. The median age was 68 years (41-82 years). The female-to-male ratio was 2:8. In all patients, the final histopathological analysis of the intracerbral tumors revealed a glioblastoma, while the patients suffered from diverse primary carcinomas. CONCLUSION: A malignant glioma should always be considered as a differential diagnosis of an unclear contrast-enhancing cerebral lesion even for patients with a known malignancy. Furthermore, we make the case for a more liberal indication for 5-ALA.

Metacarpophalangeal joints in rheumatoid arthritis: delayed gadolinium-enhanced MR imaging of cartilage--a feasibility study.

PURPOSE: To evaluate the feasibility of delayed gadolinium-enhanced magnetic resonance (MR) imaging of the cartilage of metacarpophalangeal (MCP) joints in patients with rheumatoid arthritis (RA) compared with that in control subjects. MATERIALS AND METHODS: Institutional review board approval and informed consent were obtained. Thirty-one MCP joints in 10 patients with RA (mean age, 59 years; range, 35-77 years) and six healthy volunteers (mean age, 51 years; range, 30-71 years) were examined with delayed gadolinium-enhanced MR imaging of cartilage. Sagittal images of the second and third MCP joints (hereafter, MCP II and MCP III) were acquired with a three-dimensional dual-flip-angle gradient-echo sequence at 3.0 T. B(1) field inhomogeneity-corrected T1 maps were calculated, and delayed gadolinium-enhanced MR imaging of cartilage values for phalangeal and metacarpal cartilage were determined. In addition, cartilage thickness was measured. A nonparametric Mann-Whitney U test was used to assess differences between groups. RESULTS: Phalangeal and metacarpal delayed gadolinium-enhanced MR imaging of cartilage values in patients with RA (MCP II: 388 msec ± 105 [standard deviation] and 342 msec ± 79, respectively; MCP III: 409 msec ± 96 and 371 msec ± 89, respectively) were significantly lower than in control subjects (MCP II: 598 msec ± 62 and 560 msec ± 51, respectively; MCP III: 586 msec ± 57 and 561 msec ± 80, respectively). Cartilage thickness of both joints was comparable in patients with RA (MCP II: 1.28 mm ± 0.50, MCP III: 1.17 mm ± 0.24) and control subjects (MCP II: 1.42 mm ± 0.33, MCP III: 1.18 mm ± 0.26). CONCLUSION: Delayed gadolinium-enhanced MR imaging of cartilage of the MCP joints is feasible at 3.0 T. Delayed gadolinium-enhanced MR imaging of cartilage may help to assess cartilage degeneration in morphologically normal-appearing MCP II and III cartilage in patients with RA.