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Ronald Seidel,1 Marc Tietke,2 Oliver Heese,3 Uwe Walter4 1Asklepios Medical Center, Department of Anesthesiology and Intensive Care, Schwedt, Germany; 2Helios Medical Center, Department of Neuroradiology, Schwerin, Germany; 3Helios Medical Center, Department of Neurosurgery, Schwerin, Germany; 4University Medical Center Rostock, Department of Neurology, Rostock, GermanyCorrespondence: Ronald SeidelAsklepios Medical Center, Department of Anesthesiology and Intensive Care, Am Klinikum 1, Schwedt, 16303, GermanyTel +49 3332 534521Email ronald-seidel@t-online.deAbstract: Thoracic epidural analgesia (TEA) is a standard procedure in multimodal analgesia applied in major thoracic and abdominal surgeries. Two cases are presented with serious complications related to TEA. In both cases, earlier reaction of the treating physicians to patient-reported sensory symptoms could have prevented the complicated course. The first case was a 73-year-old patient with bronchial carcinoma who underwent right lower lobe resection. In this case, dabigatran 150 mg/d (indication: permanent atrial fibrillation) had been discontinued 72 hours before surgery, and enoxaparin 80 mg (every 12 hours) had been started 11 hours after surgery. An epidural hematoma developed postoperatively. Magnetic resonance imaging (MRI) was performed only after paraplegia had developed the next day. Unfortunately, delayed hematoma evacuation could not prevent persistent paraplegia in this case, which was complicated by hospital-acquired pneumonia with sepsis and acute renal failure. The second case was a 39-year-old patient with ulcerative colitis and an initially undetected malposition of the epidural catheter. Immediately after test bolus injection, the patient reported paresthesia and overall discomfort, which however could not be safely attributed to either the test dose or the already started general anesthesia. The patient could only be extubated after stopping the epidural infusion. Accidental re-start of epidural infusion led to coma, conjugate eye deviation, and respiratory arrest, necessitating re-intubation. Computed tomography (CT) ruled out intracerebral pathology and showed a catheter position centrally in the spinal canal. Fortunately, no neurological deficits were detected after catheter removal.Keywords: epidural analgesia, dabigatran, paraplegia, perioperative complications

Clinically differentiating between autoimmune and neurodegenerative disorders can often pose a diagnostic challenge. The differential diagnosis of rapidly progressing neurological and cognitive symptoms includes central nervous system tumours, cerebral vasculitis, and inflammatory, autoimmune, or paraneoplastic encephalopathies. Rarer neurodegenerative diseases such as Creutzfeldt-Jakob disease should also be considered. Detection of treatable causes, such as autoimmune disorders, remains important when potentially occurring in conjunction with Creutzfeldt-Jakob disease. The following report describes a rare case in which autoimmune encephalopathy and prion disease were considered as possible comorbidities., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Purpose. Spondylodiscitis as a rare disease has increased in recent years; there are only a few recommendations regarding the diagnostics and treatment. The objective of this retrospective study was to characterise these patients and identify factors for a favourable healing process - with an emphasis on antibiotic therapy. Methodology. Findings/treatment regimens for all patients with spondylodiscitis treated at a tertiary care hospital in 2012/2013 were recorded. The patients were classified into two groups, depending on the healing process. Results. Fifty-seven patients met the clinical/radiological criteria for spondylodiscitis. The main symptom was massive back pain, combined with a moderate CRP elevation (median 96 mg l -1 ), and occasionally fever (39 %). CT-guided aspiration - in addition to blood cultures - improved the detection rate for the causative pathogen from 49 to 82 %. Thirty patients had a favourable clinical course; 25 had an unfavourable clinical course (prolonged clinical course, recurrence, death). Pathogen-specific antibiotic therapy had a decisive effect on the clinical course: initial high-dose intravenous therapy for at least 14 days was associated significantly more often with a favourable clinical course (90 vs 30 % after 24 months, P <0.001). Fourteen days after the start of treatment, marked pain reduction and a CRP reduction of at least 50 % were good prognostic parameters and markers of effective antibiotic therapy. Conclusion. Pathogen detection and establishment of an optimal antibiotic regimen are cornerstones of successful conservative therapy for spondylodiscitis. Targeted initial intravenous therapy for at least 14 days with a bactericidal antibiotic leads to a better clinical course.

Introduction: Using balloon-expandable stents (BES) for treatment of intracranial stenoses, high inflation pressures and rigidity of the device are regarded as major drawbacks limiting feasibility and safety of the procedure. Self-expanding stents (SES) were developed to facilitate lesion access and to allow for less aggressive dilatation. We analyzed data of the INTRASTENT multicentric registry to assess whether self-expanding stents significantly reduced peri-interventional complication rates., Methods: Records of intracranial stent procedures were entered consecutively into the registry. Datasets were divided into two groups according to the type of stent used. For outcome measurement, we chose three categories: TIA/minor stroke [modified Rankin score (mRS) <2], disabling stroke, and patient death. Clinical outcome was compared between BES and SES. We analyzed types of adverse events occurring in each group in addition., Results: Of 409 atherosclerotic lesions, 254 were treated with BES and 155 with SES. Technical success rates were 97.6% and 98.7%, respectively. Adverse event rates were 4.9%, 3.7%, and 0.8% for TIA/nondisabling stroke, disabling stroke, and death in the BES group compared with 5.3%, 6.0%, and 4.0% in the SES group. The differences were not statistically significant. We observed more perforator strokes after use of BES, but thromboembolic events occurred more often in the SES treatment group., Conclusion: Data of the INTRASTENT registry do not support the hypothesis that introduction of SES lowered the overall complication rate of intracranial stent procedures. There might be an advantage using self-expanding stents in vessel segments with important perforating arteries.

Background and Purpose: We sought to evaluate how accurately length and volume of thrombotic clots occluding cerebral arteries of patients with acute ischemic stroke can be assessed from nonenhanced CT (NECT) scans reconstructed with different slice widths., Methods: NECT image data of 58 patients with acute ischemic stroke with vascular occlusion proven by CT angiography were reconstructed with slice widths of 1.25 mm, 2.5 mm, 3.75 mm, and 5 mm. Thrombus lengths and volumes were quantified based on these NECT images by detecting and segmenting intra-arterial hyperdensities. The results were compared with reference values of thrombus length and volume obtained from CT angiography images using Bland-Altman analysis and predefined levels or tolerance to find NECT slice thicknesses that allow for sufficiently accurate thrombus quantification., Results: Thrombus length can be measured with high accuracy using the hyperdense middle cerebral artery sign detected in NECT images with slice thicknesses of 1.25 mm and 2.5 mm. We found mean deviations from the reference values and limits of agreement of -0.1 mm+/-0.6 mm with slice widths of 1.25 mm and 0.1 mm+/-0.7 mm for slice widths of 2.5 mm. Thrombus length measurements in NECT images with higher slice width and all evaluated thrombus volume measurements exhibited severe dependence on the level and did not match the accuracy criteria., Conclusions: The length of the hyperdense middle cerebral artery sign as detected on thin-slice NECT reconstructions in patients with acute ischemic stroke can be used to quantify thrombotic burden accurately. Thus, it might qualify as a new diagnostic parameter in acute stroke management that indicates and quantifies the extent of vascular obliteration.

Since its development in the late 1980s the discussion of risk and benefit of carotid artery stenting (CAS) compared to carotid endarterectomy (CEA) is still ongoing. In this discussion the increasing technical inventions in CAS like PDs, different stent designs and materials and their effect upon the complication rates are playing increasingly important roles. We present a review of mono- or oligocentre studies with greater collectives, one review study and multi centre studies SPACE I, EVA-3S and preliminary data from the ICSS-trial, in which subgroups of patients were treated with or without protection devices. Despite the results of several retrospective studies mostly with historic comparator cohorts rather than concurrent the results of the most recent multi centre prospective randomized trials seem to show a benefit for unprotected stenting. The complication rates for protected vs. unprotected groups in SPACE I showed 8.3% vs. 6.5% and the pooled data from SPACE I and EVA-3S 8.1% vs. 7.3%. A subgroup analysis of SPACE I aiming at the impact of the stent design on peri-interventional complication rate shows that the pOE rate was significantly lower in patients treated with a closed cell stent (5.7%, 95% CI: 3.7-8.3%) than in those treated with an open cell stent (11.0%, 95% CI: 6.2-17.8%) (P=0.047). The most recent data from prospective multi centre trials support the presumption that PDs do not reduce, but may increase the periinterventional complication rate. Whereas many older single centre studies promoting PDs do show conceptual problems. The stent design appears to have a more important impact on the resulting complications in CAS, than the PDs.

Purpose: The transbrachial approach as an alternative access site for carotid artery stenting (CAS) has mainly been published as case reports. This paper evaluates transbrachial CAS at our institute for the past 5 years and refers to the complications and results of this method., Materials and Methods: From January 2003 to April 2008, we performed 299 CAS of which 12 (4%, 11 male, 1 female) were performed with a transbrachial approach. The average age of these patients was 67.4 years (+/- 9.75). The average degree of stenosis of the treated carotid artery was assessed by Doppler ultrasound (81.5% +/- 10.66) and digital subtraction angiography (DSA) using the NASCET criteria (75.9% +/- 9.75). 9 / 12 patients (75%) were treated because of symptomatic stenosis., Results: The transbrachial approach was performed in 8 patients because of high-grade stenosis of the femoral and/or iliac arteries. 4 patients showed severe elongation of the aortic arch. 11 of 12 (92%) of the transbrachial CAS were performed successfully. The approach was judged to be only slightly more challenging than puncture of the femoral artery. No minor or major complications occurred at the access site. 3 of 11 patients (27%) showed residual stenosis after CAS of 24% (+/- 7.78)., Conclusion: The transbrachial approach for CAS is rarely required compared to the transfemoral approach. Especially in cases of femoral or iliac artery stenosis and severe elongated and calcified aortic arches, it is an elegant alternative approach with rare complications.

Proteus syndrome is a rare condition that involves atypical growth of the bones, skin and head and a variety of other symptoms. Only a few authors have reported on the craniofacial manifestations so far. The authors present a case of a 7-year-old girl with Proteus syndrome in which the facial skeleton showed unilateral overgrowth. The analysis of the radiological evaluation revealed a bialveolar prognathism, a skeletal class III, a dolicocephalic growth pattern and a left convex face scoliosis. On the left side, the lesser wing of the sphenoid was elevated and the ethmoidal cell complex was hypertrophic. The left ramus and body of the mandible were enlarged. The asymmetric dental development with a precocious dental age on the affected side was the most striking feature on the panoramic view. Early diagnosis and therapy depend on clinical evaluation and imaging. Therefore, further evaluations on the craniofacial features of patients with Proteus syndrome are necessary in order to establish a list of characteristic symptoms.

Purpose: Two intraoral CCD sensor systems were compared with respect to image quality and interobserver agreement., Materials and Methods: Forty intraoral images from each of the sensors (Trophy RVG5, Sirona Sidexis) were examined by 4 observers in terms of anatomical landmarks and general image quality. The images were divided into 2 groups--filtered and unfiltered. Kappa values for interobserver agreement were calculated for all assessed points., Results: The Trophy sensor showed better image quality in the filtered group, and the Sirona sensor demonstrated good image quality in the unfiltered group. Moderate to substantial interobserver agreement was achieved. The use of filters increased edge artefacts. Sensor specific artefacts in the Trophy system were observed.