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Postpartum mood disorder is one of the best-kept secrets within society and scientific research. Postpartum depression occurs in about 19% of all pregnancies. About two-thirds of maternal depression can be detected by simple means and treated early during pregnancy. Especially the first pregnancy can mean a major life transition for the pregnant woman and her partner. In addition to medical treatment, the smooth development of pregnancy and birth needs sufficient social and emotional support. Prenatal Bonding (BA), a method inaugurated by the Hungarian psychoanalysts Jenoe Raffai and Gyoergy Hidas, leads to fundamental improvements of pregnancy and giving birth. Preterm birth and postpartum mood disorders can be reduced to a large extent without medication. Birth may be conducted with more comfort and less medical intervention. Mother and baby can experience a stable bonding long before birth.

Prenatal Bonding (BA) provides the possibility of creating an intense bonding between mother and baby, of being witness to the development of the fetus in the womb, and of realizing the early growth of his/her personality. In this respect, the method is at the same time an instrument of pre- and perinatal research, an empowerment of bonding between mother and fetus and of great help to give birth much more easily. After birth the baby has a remarkable degree of self-esteem and good access to his/her personal potential. Frequent effects of Prenatal Bonding (BA) are a far-reaching reduction of preterm birth, a substantial decrease of obstetrical interventions and caesarean sections, a reduction of birth trauma, and on the side of the mother a prevention of postpartum depression. Breastfeeding is easy to manage from the beginning.

This document sets out standards for training in interventional neuroradiology (INR) in Europe. These standards have been developed by a working group of the European Society of Neuroradiology (ESNR) and the European Society of Minimally Invasive Neurological Therapy (ESMINT) on the initiative and under the umbrella of the Division of Neuroradiology/Section of Radiology of the European Union of Medical Specialists (UEMS). For this document, the text of guidelines proposed and published earlier by the previous board of UEMS’s Division of Neuroradiology1 2 was used and modified with the consensus of all involved parties. It is well recognized that there are a number of structural and operational differences in the healthcare systems, appointment procedures, and training systems in the various European countries. This document takes into consideration the health system and demographic realities of Europe. At present, the national laws in each of the EU member states regulate the professional activity of each country. Thus, it is important to build a comprehensive INR core curriculum and training program that can be used in the individual countries according to their organization and laws, and that complies with international treaties, the UN Declarations on Human Rights, and the WMA International Code of Medical Ethics. The INR curriculum should constitute a uniform training program, approved by all the European countries, which can be incorporated in a pre-existing national program or serve as the basis for the development of a new program, according to the national regulations. In this document the INR training program will be referred to as ' particular qualification' in INR. A considerable number of specialists in Europe are performing all or some of the INR activities detailed in this training charter. These specialists will have the acquired right to continue this practice. This document is complemented with another, the 'Standards …

IMPORTANCE: Achieving complete reperfusion is a key determinant of good outcome in patients treated with mechanical thrombectomy (MT). However, data on treatments geared toward improving reperfusion after incomplete MT are sparse. OBJECTIVE: To determine whether administration of intra-arterial urokinase is safe and improves reperfusion after failed or incomplete MT. DESIGN, SETTING, AND PARTICIPANTS: This observational cohort study included a consecutive sample of patients treated with second-generation MT from January 1, 2010, through August 4, 2017. Data were collected from the prospective registry of a tertiary care stroke center. Of 1274 patients screened, 69 refused to participate, and 993 met the observational studies inclusion criteria of a large vessel occlusion in the anterior circulation. Data were analyzed from September 1, 2017, through September 20, 2019. INTERVENTION: One hundred patients received intra-arterial urokinase after failed or incomplete MT using manual microcatheter injections. MAIN OUTCOMES AND MEASURES: Primary safety outcome was the occurrence of symptomatic intracranial hemorrhage (sICH) according to the Prolyse in Acute Cerebral Thromboembolism II criteria. Secondary end points included 90-day mortality and 90-day functional independence (defined as modified Rankin Scale score of ≤2). Efficacy was evaluated angiographically, applying the Thrombolysis in Cerebral Infarction (TICI) scale. RESULTS: After exclusion of patients with posterior circulation strokes and those treated with intra-arterial thrombolytics only, 993 patients were included in the final analyses (median age, 74.6 [interquartile range, 62.6-82.2] years; 505 [50.9%] women). Additional intra-arterial urokinase was administered in 100 patients (10.1%). The most common reason for administering intra-arterial urokinase was incomplete reperfusion (TICI

Cerebral oximetry using near-infrared spectroscopy (NIRS) allows for continuous monitoring of cerebral perfusion and immediate treatment of hemodynamic perturbations. In configurations used in current clinical practice, NIRS optodes are placed on the patient`s forehead and cerebral oxygen saturation (ScO2 ) is determined in bilateral frontal cortical samples. However, focal cerebral ischemic lesions outside of the NIRS field of view may remain undetected. The objective of this observational case-series study was to investigate ScO2 measurements in patients with acute iatrogenic stroke not located in the frontal cortical region. Adult patients undergoing cardiac surgery with cardiopulmonary bypass or interventional cardiology procedures and suffering stroke in the early postoperative period were identified from the Bernese Stroke Registry and analyzed for their intraoperative ScO2 values and brain imaging data. Main outcome measures were the ScO2 values, computed tomography and magnetic resonance imaging findings. In six patients, the infarct areas were localized in the vascular territories of the posterior and/or dorsal middle cerebral arteries. One patient had watershed stroke and another one excellent collaterals resulting in normal cerebral blood volume and only subtle decrease of cerebral blood flow in initially critically perfused watershed brain areas. Intraoperative ScO2 values were entirely unremarkable or nonindicative for brain damage. Our results indicate that uneventful intraoperative NIRS monitoring does not exclude severe cerebral ischemia due to the limited field of view of commercially available NIRS devices. False negative NIRS may occur as a consequence of stroke localized outside the frontal cortex.

OBJECTIVECerebral hyperperfusion syndrome (CHS) is a rare but devastating complication of carotid endarterectomy (CEA). This study sought to determine whether quantitative hemodynamic assessment using MR angiography can stratify CHS risk.METHODSIn this prospective trial, patients with internal carotid artery (ICA) stenosis were randomly selected for pre- and postoperative quantitative phase-contrast MR angiography (QMRA). Assessment was standardized according to a protocol and included Doppler/duplex sonography, MRI, and/or CT angiography and QMRA of the intra- and extracranial supplying arteries of the brain. Clinical and radiological data were analyzed to identify CHS risk factors.RESULTSTwenty-five of 153 patients who underwent CEA for ICA stenosis were randomly selected for pre- and postoperative QMRA. QMRA data showed a 2.2-fold postoperative increase in blood flow in the operated ICA (p < 0.001) and a 1.3-fold increase in the ipsilateral middle cerebral artery (MCA) (p = 0.01). Four patients had clinically manifested CHS. The mean flow increases in the patients with CHS were significantly higher than in the patients without CHS, both in the ICA and MCA (p < 0.001). Female sex and a low preoperative diastolic blood pressure were the clearest clinical risk factors for CHS, whereas the flow differences and absolute postoperative flow values in the ipsilateral ICA and MCA were identified as potential radiological predictors for CHS.CONCLUSIONSCerebral blood flow in the ipsilateral ICA and MCA as assessed by QMRA significantly increased after CEA. Higher mean flow differences in ICA and MCA were associated with the development of CHS. QMRA might have the potential to become a noninvasive, operator-independent screening tool for identifying patients at risk for CHS.

BACKGROUND AND PURPOSE Randomized controlled trials have shown that bridging endovascular therapy (EVT) after intravenous thrombolysis (IVT) therapy improves outcome in patients with stroke with large-artery anterior circulation stroke compared with IVT alone. It remains unknown whether IVT adds any benefit to EVT in these patients. The aim of this study was to assess recanalization rates and thrombus dislocation before initiation of EVT in patients receiving bridging therapy. METHODS All patients in the Bernese stroke registry (2008-2015) in whom bridging therapy was considered were included in this analysis. Relevant recanalization before EVT, thrombus dislocation and increase in thrombus load between initial and control imaging were assessed retrospectively. RESULTS A total of 319 patients were included. Relevant recanalization before EVT occurred in 8.8% and thrombus dislocation in 7.2% of patients before EVT. Recanalization rates were significantly higher in distal compared with large and more proximal vessel occlusions of the anterior circulation (occlusion of internal carotid artery, 5.4%; middle cerebral artery segment M1, 8.1%; middle cerebral artery segment M2, 17.6%) and in drip-and-ship patients compared with mother-ship patients. In multivariable regression analysis the occlusion site was the only independent predictor of relevant recanalization before EVT (P = 0.046). CONCLUSIONS Relevant recanalization after IVT and prior to EVT in patients receiving bridging therapy was highly dependent on the occlusion site. These findings suggest that future randomized controlled trials should consider occlusion site and treatment paradigm to specify patients who benefit most from bridging therapy in comparison to EVT or IVT alone.

Background Asymmetric inferior petrosal sinuses (IPS) are not infrequently encountered during bilateral IPS sampling. There is little data on whether IPS symmetry influences success in predicting the adenoma side in patients with ACTH-dependent Cushing's syndrome (CS). Objective To assess the influence of IPS drainage patterns on detection of an adenoma in CS. Methods Retrospective single-center cohort analysis reviewing records of patients with CS and negative MRI findings who subsequently underwent BIPSS. Results BIPSS was performed in 38 patients with a mean age of 45 ± 15 years. The overall technical success rate was 97% for bilateral cannulation. Asymmetric IPS were observed in 11 (39%) patients with Cushing's disease (CD). A side-to-side ACTH ratio was not significantly different between patients with symmetric outflow and those with asymmetric outflow at baseline (8.6 ± 2.7 versus 16.4 ± 6.0; P = 0.45), but ratios were significantly different after ovine corticotropin-releasing hormone (oCRH) stimulation (6.0 ± 2.5 versus 35.7 ± 22.5; P = 0.03). BIPSS correctly predicted the side of the adenoma in 25 (96%) patients with CD. Prediction was better when the venous outflow was symmetric (100%) rather than asymmetric (93%), although the difference was not significant (P = 0.42). Remission from CS was achieved in 32 patients (87%), independent of the symmetry of IPS. Conclusions Bearing in mind the sample size of this audit, asymmetric IPS at least do not seem to diminish the accuracy of diagnosis of ACTH-dependent CS, nor do they influence the clinical outcome.

Purpose Knowledge about the localization and outcome of iatrogenic dissection (ID) during endovascular treatment of acute ischemic stroke (AIS) is limited. We aimed to determine the frequency, clinical aspects and morphology of ID in endovascular AIS treatment and to identify predictors of this complication. Methods Digital subtraction angiography (DSA) of ID carried out during endovascular treatment between January 2000 and March 2012 have been re-evaluated. The ID localization and morphology were analyzed and related to the interventional techniques. Baseline clinical and radiological findings, treatment modality and outcome were compared with patients without ID. Results Out of 866 patients 18 (2%) suffered an ID (44% female, median age 64 years). Localization was extracranial in 15 (83%, 14 internal carotid artery and 1 vertebral artery) and intracranial in 3 (17%; 1 vertebrobasilar dissection and 2 in the anterior circulation). Of the IDs 5 (28%) resulted in a high-degree, 3 (17%) in a moderate, 5 (28%) in a mild and 5 (28%) in no stenosis and 8 IDs were stented in the acute phase. At 3 months 7 (42%) patients had a favorable outcome (modified Rankin score mRS ≤ 2) and 6 (33%) patients had died. Patients with ID had a different stroke etiology (p = 0.041), were more likely to be smokers (44% versus 19%, p = 0.015) and were more likely to be treated with mechanical thrombectomy (100% versus 60%, p < 0.001). Although two ID patients had relevant complications, the outcome did not differ between the groups. Conclusion The occurrence of ID is a rare complication of endovascular AIS treatment associated with smoking and mechanical thrombectomy. Electronic supplementary material The online version of this article (10.1007/s00062-017-0639-z) contains supplementary material, which is available to authorized users.

INTRODUCTION: The aim of this retrospective study was to evaluate the clinical outcome of patients with spinal dural arteriovenous fistulas (SDAVFs) that were treated with surgery, catheter embolization, or surgery after incomplete embolization. METHODS: The study included 21 consecutive patients with SDAVFs of the thoracic, lumbar, or sacral spine who were treated in our institution from 1994 to 2007. Thirteen patients were treated with catheter embolization alone. Four patients underwent hemilaminectomy and intradural interruption of the fistula. Four patients were treated by endovascular techniques followed by surgery. The clinical outcome was assessed using the modified Aminoff-Logue scale (ALS) for myelopathy and the modified Rankin scale (MRS) for general quality of life. Patient age ranged from 44 to 77 years (mean 64.7 years). RESULTS: Surgical as well as endovascular treatment resulted in a significant improvement in ALS (-62.5% and -31.4%, respectively, p < 0.05) and a tendency toward improved MRS (-50% and -32%, respectively) scores. Patients that underwent surgery after endovascular treatment due to incomplete occlusion of the fistula showed only a tendency for improvement in the ALS score (-16.7%), whereas the MRS score was not affected. CONCLUSION: We conclude that both endovascular and surgical treatment of SDAVFs resulted in a good and lasting clinical outcome in the majority of cases. In specific situations, when a secondary neurosurgical approach was required after endovascular treatment to achieve complete occlusion of the SDAVF, the clinical outcome was rather poor. The best first line treatment modality for each individual patient should be determined by an interdisciplinary team.

Diffusion-weighted imaging (DWI) allows us to image the motion of tissue water. This has been used to demonstrate acute ischaemia. Diffusion imaging is also sensitive to water movement along neuronal tracts. Our objective was to map brain maturation in vivo using maps of apparent diffusion coefficient (ADC). We studied 22 children without neurological disease aged between 2 and 720 days. MRI was performed at 1.5 tesla. Multislice single-shot echoplanar DWI was performed at b 0 and 1000 s/mm(2). ADC maps were generated automatically and measurements were performed in the basal ganglia, frontal and temporal white matter and the pons. There was a decrease over time in water diffusion in the areas examined, most marked in the frontal (0.887-1.898 x 10(-3) mm(2)/s) and temporal (1.077-1.748 x 10(-3) mm(2)/s)lobes. There was little change, after an initial decrease, in the basal ganglia (0.690-1.336 x 10(-3) mm(2)/s). There was a difference in water diffusion between the anterior (0.687-1.581 x 10(-3) mm(2)/s) and posterior (0.533-1.393 x 10(-3) mm(2)/s) pons. These changes correlate well with those observed in progressive myelination: the increased water content probably reflects incomplete myelination and the decrease with time in water motion reflects the increase in myelinated brain.

Introduction: The optimal management of patients with symptomatic severe ostial vertebral artery stenosis (OVAS) is currently unclear. We analyzed the long-term outcome of consecutive patients with OVAS who received either medical treatment (MT) or vertebral artery stenting (VAS). Methods: Thirty-nine (>70%) patients with severe OVAS were followed for a mean period of 2.8years. The decision for VAS (n = 10) or MT (n = 29) was left to the clinician. The Kaplan-Meier method was used to assess the risk of recurrent stroke, transient ischemic attack (TIA), or death over the study period. Results: Patients in the VAS group were significantly younger and more likely to have bilateral VA disease (P = 0.04 and P = 0.02). VAS was successfully performed in all ten patients. The periprocedural risk within 30days was 10% (one TIA). The overall restenosis rate was 10%. One restenosis occurred after 9months in a patient treated with bare-metal stent. At 4years of follow-up, VAS showed a nonsignificant trend toward a lower risk for the combined endpoint of TIA and stroke in posterior circulation compared to medical treatment (10% vs. 45%, P = 0.095; relative risk (RR) = 0.24, 95% confidence interval (CI) 0.031-1.85). Patients with bilateral VA disease had a significantly lower recurrence risk after VAS compared with medical treatment (0% vs. 91% at 4years, P = 0.004; RR 0.10, 95% CI 0.022-0.49) Conclusion: VAS was performed without permanent complications in this small series of patients with symptomatic severe OVAS. The long-term benefit seems to be confined to patients with bilateral but not to those with unilateral VA disease

Zusammenfassung : Der Augenpatient, in dessen Diagnostik und Therapie der Radiologe involviert ist, leidet gewöhnlich unter ständigem Tränenträufeln, der Epiphora. Die Epiphora ist ein häufiges Krankheitsbild und wird bei ca. 3% aller Patienten einer ophthalmologischen Praxis diagnostiziert. Epiphora ist entweder die Folge einer Überproduktion oder einer Abflussstörung von Tränenflüssigkeit infolge einer Obstruktion im Tränengangsystem. Epiphora wird am häufigsten durch Stenosen oder Verschlüsse des Tränengangsystems verursacht. Die Obstruktion ist meist im Bereich von Saccus und Ductus nasolacrimalis lokalisiert. Während in der Vergangenheit die Therapie ausschließlich operativ mittels Dakryozystorhinostomie erfolgte, wurden mittlerweile interventionelle radiologische Techniken entwickelt, die in bestimmten Fällen eine Alternative darstellen. Um die für den Patienten geeignetste Therapieform zu finden, müssen die genaue Ursache und Lokalisation der Epiphora abgeklärt werden. Hierbei stellt die in digitaler Subtraktionstechnik durchgeführte Dakryozystographie das bildgebende Standardverfahren dar. Im therapeutischen Bereich sind die interventionellen radiologischen Techniken der Dakryozystoplastie gegenüber den operativen Verfahren minimal invasiv, können ambulant und in Lokalanästhesie durchgeführt werden und erhalten die normale Anatomie des Tränenapparats. Zusätzlich kann eine störende Narbenbildung vermieden werden. Bei vergleichbaren technischen und klinischen Erfolgsraten stellt insbesondere die Ballondilatation bei Stenosen eine therapeutische Alternative zur Operation dar. Auch die Stentimplantation ist bereits jetzt eine wertvolle Therapieoption für die Behandlung von Tränenwegsverschlüssen. Die Stentimplantation ist besonders bei den Patienten indiziert, die einer operativen Therapie nicht zugänglich sind oder diese ablehnen

Background and purpose Anemia is associated with worse outcome in stroke, but the impact of anemia with intravenous thrombolysis or endovascular therapy has hardly been delineated. The aim of this study was to analyze the role of anemia on infarct evolution and outcome after acute stroke treatment. Methods 1158 patients from Bern and 321 from Los Angeles were included. Baseline data and 3 months outcome assessed with the modified Rankin Scale were recorded prospectively. Baseline DWI lesion volumes were measured in 345 patients and both baseline and final infarct volumes in 180 patients using CT or MRI. Multivariable and linear regression analysis were used to determine predictors of outcome and infarct growth. Results 712 patients underwent endovascular treatment and 446 intravenous thrombolysis. Lower hemoglobin at baseline, at 24h, and nadir until day 5 predicted poor outcome (OR 1.150–1.279) and higher mortality (OR 1.131–1.237) independently of treatment. Decrease of hemoglobin after hospital arrival, mainly induced by hemodilution, predicted poor outcome and had a linear association with final infarct volumes and the amount and velocity of infarct growth. Infarcts of patients with newly observed anemia were twice as large as infarcts with normal hemoglobin levels. Conclusion Anemia at hospital admission and any hemoglobin decrease during acute stroke treatment affect outcome negatively, probably by enlarging and accelerating infarct growth. Our results indicate that hemodilution has an adverse effect on penumbral evolution. Whether hemoglobin decrease in acute stroke could be avoided and whether this would improve outcome would need to be studied prospectively.

Mechanical thrombectomy provides higher recanalization rates than intravenous or intra-arterial thrombolysis. Finally this has been shown to translate into improved clinical outcome in six multicentric randomized controlled trials. However, within cohorts the clinical outcomes may vary, depending on the endovascular techniques applied. Systems aiming mainly for thrombus fragmentation and lacking a protection against distal embolization have shown disappointing results when compared to recent stent-retriever studies or even to historical data on local arterial fibrinolysis. Procedure-related embolic events are usually graded as adverse events in interventional neuroradiology. In stroke, however, the clinical consequences of secondary emboli have so far mostly been neglected and attributed to progression of the stroke itself. We summarize the evolution of instruments and techniques for endovascular, image-guided, microneurosurgical recanalization in acute stroke, and discuss how to avoid procedure-related embolic complications.

BACKGROUND AND PURPOSE: General anesthesia during endovascular treatment of acute ischemic stroke may have an adverse effect on outcome compared with conscious sedation. The aim of this study was to examine the impact of the type of anesthesia on the outcome of patients with acute ischemic stroke treated with the Solitaire stent retriever, accounting for confounding factors. MATERIALS AND METHODS: Four-hundred one patients with consecutive acute anterior circulation stroke treated with a Solitaire stent retriever were included in this prospective analysis. Outcome was assessed after 3 months by the modified Rankin Scale. RESULTS: One-hundred thirty-five patients (31%) underwent endovascular treatment with conscious sedation, and 266 patients (69%), with general anesthesia. Patients under general anesthesia had higher NIHSS scores on admission (17 versus 13, P < .001) and more internal carotid artery occlusions (44.6% versus 14.8%, P < .001) than patients under conscious sedation. Other baseline characteristics such as time from symptom onset to the start of endovascular treatment did not differ. Favorable outcome (mRS 0–2) was more frequent with conscious sedation (47.4% versus 32%; OR, 0.773; 95% CI, 0.646–0.925; P = .002) in univariable but not multivariable logistic regression analysis (P = .629). Mortality did not differ (P = .077). Independent predictors of outcome were age (OR, 0.95; 95% CI, 0.933–0.969; P < .001), NIHSS score (OR, 0.894; 95% CI, 0.855–0.933; P < .001), time from symptom onset to the start of endovascular treatment (OR, 0.998; 95% CI, 0.996–0.999; P = .011), diabetes mellitus (OR, 0.544; 95% CI, 0.305–0.927; P = .04), and symptomatic intracerebral hemorrhage (OR, 0.109; 95% CI, 0.028–0.428; P = .002). CONCLUSIONS: In this single-center study, the anesthetic management during stent retriever thrombectomy with general anesthesia or conscious sedation had no impact on the outcome of patients with large-vessel occlusion in the anterior circulation.

BACKGROUND AND PURPOSE Some authors use FLAIR imaging to select patients for stroke treatment. However, the effect of hyperintensity on FLAIR images on outcome and bleeding has been addressed in only few studies with conflicting results. METHODS 466 patients with anterior circulation strokes were included in this study. They all were examined with MRI before intravenous or endovascular treatment. Baseline data and 3 months outcome were recorded prospectively. Focal T2 and FLAIR hyperintensities within the ischemic lesion were evaluated by two raters, and the PROACT II classification was applied to assess bleeding complications on follow up imaging. Logistic regression analysis was used to determine predictors of bleeding complications and outcome and to analyze the influence of T2 or FLAIR hyperintensity on outcome. RESULTS Focal hyperintensities were found in 142 of 307 (46.3%) patients with T2 weighted imaging and in 89 of 159 (56%) patients with FLAIR imaging. Hyperintensity in the basal ganglia, especially in the lentiform nucleus, on T2 weighted imaging was the only independent predictor of any bleeding after reperfusion treatment (33.8% in patients with vs. 18.2% in those without; p = 0.003) and there was a non-significant trend for more bleedings in patients with FLAIR hyperintensity within the basal ganglia (p = 0.069). However, there was no association of hyperintensity on T2 weighted or FLAIR images and symptomatic bleeding or worse outcome. CONCLUSION Our results question the assumption that T2 or FLAIR hyperintensities within the ischemic lesion should be used to exclude patients from reperfusion therapy, especially not from endovascular treatment.

BACKGROUND Symptomatic intracerebral hemorrhage (sICH) after bridging thrombolysis for acute ischemic stroke is a devastating complication. We aimed to assess whether the additional administration of aspirin during endovascular intervention increases bleeding rates. METHODS We retrospectively compared bleeding complications and outcome in stroke patients who received bridging thrombolysis with (tPA+ASA) and without (tPA-ASA) aspirin during endovascular intervention between November 2008 and March 2014. Furthermore, we analyzed bleeding complications and outcome in antiplatelet naïve patients with those with prior or acute antiplatelet therapy. RESULTS Baseline characteristics, previous medication, and dosage of rtPA did not differ between 50 tPA+ASA (39 aspirin naïve, 11 preloaded) and 181 tPA-ASA patients (p>0.05). tPA+ASA patients had more often internal carotid artery (ICA) occlusion (p0.1). There were no differences in bleeding complications and mortality among 112 bridging patients with antiplatelet therapy (62 preloaded, 39 acute administration, 11 both) and 117 antiplatelet naïve patients. In a logistic regression analysis, aspirin administration during endovascular procedure was not a predictor of sICH. CONCLUSION Antiplatelet therapy before or during bridging thrombolysis in patients with acute ischemic stroke did not increase the risk of bleeding complications and had no impact on outcome. This finding has to be confirmed in larger studies.

BACKGROUND AND PURPOSE The use of thrombolysis in patients with minor neurological deficits and large vessel occlusion is controversial. METHODS We compared the outcome of patients with low National Institutes of Health Stroke Scale (NIHSS) scores and large vessel occlusions between thrombolysed and non-thrombolysed patients. RESULTS 88 (1.7%) of 5312 consecutive patients with acute (within 24 h) ischaemic stroke had occlusions of the internal carotid or the main stem of the middle cerebral artery and baseline NIHSS scores ≤5.47 (53.4%) were treated without thrombolysis, and 41 (46.6%) received intravenous thrombolysis, endovascular therapy or both. Successful recanalisation on MR or CT angiography at 24 h was more often observed in thrombolysed than in non-thrombolysed patients (78.9% versus 10.5%; p

BACKGROUND The extent of hypoperfusion is an important prognostic factor in acute ischemic stroke. Previous studies have postulated that the extent of prominent cortical veins (PCV) on susceptibility-weighted imaging (SWI) reflects the extent of hypoperfusion. Our aim was to investigate, whether there is an association between PCV and the grade of leptomeningeal arterial collateralization in acute ischemic stroke. In addition, we analyzed the correlation between SWI and perfusion-MRI findings. METHODS 33 patients with acute ischemic stroke due to a thromboembolic M1-segment occlusion underwent MRI followed by digital subtraction angiography (DSA) and were subdivided into two groups with very good to good and moderate to no leptomeningeal collaterals according to the DSA. The extent of PCV on SWI, diffusion restriction (DR) on diffusion-weighted imaging (DWI) and prolonged mean transit time (MTT) on perfusion-imaging were graded according to the Alberta Stroke Program Early CT Score (ASPECTS). The National Institutes of Health Stroke Scale (NIHSS) scores at admission and the time between symptom onset and MRI were documented. RESULTS 20 patients showed very good to good and 13 patients poor to no collateralization. PCV-ASPECTS was significantly higher for cases with good leptomeningeal collaterals versus those with poor leptomeningeal collaterals (mean 4.1 versus 2.69; p=0.039). MTT-ASPECTS was significantly lower than PCV-ASPECTS in all 33 patients (mean 1.0 versus 3.5; p

BACKGROUND AND PURPOSE Patients with prior stroke within 3 months have been mostly excluded from randomized thrombolysis trials mainly because of the fear of an increased rate of symptomatic intracerebral hemorrhage (sICH). The aim of this study was to compare baseline characteristics and clinical outcome of thrombolyzed patients who had a previous stroke within the last 3 months with those not fulfilling this criterion (comparison group). METHODS In all, 1217 patients were included in our analysis (42.2% women, mean age 68.8 ± 14.4 years). RESULTS Patients with previous stroke within the last 3 months (17/1.4%) had more often a basilar artery occlusion (41.2% vs. 10.8%) and less frequently a modified Rankin scale (mRS) score 0-1 prior to index stroke (88.2% vs. 97.3%) and a higher mean time lapse from symptom onset to thrombolysis (321 min vs. 262 min) than those in the comparison group. Stroke severity was not different between the two groups. Rates of sICH were 11.8% vs. 6%. None of the sICHs and only one asymptomatic intracerebral hemorrhage occurred in the region of the former infarct. At 3 months, favorable outcome (mRS ≤ 2) in patients with previous stroke within 3 months was 29.4% (vs. 48.9%) and mortality 41.2% (vs. 22.7%). CONCLUSIONS In patients with prior stroke within the last 3 months, none of the sICHs and only one asymptomatic intracerebral hemorrhage occurred in the region of the former infarct. The high mortality was influenced by four patients, who died until discharge due to acute major index stroke. It is reasonable to include these patients in randomized clinical trials and registries to assess further their thrombolysis benefit-risk ratio.

PURPOSE Computed tomography (CT) accounts for more than half of the total radiation exposure from medical procedures, which makes dose reduction in CT an effective means of reducing radiation exposure. We analysed the dose reduction that can be achieved with a new CT scanner [Somatom Edge (E)] that incorporates new developments in hardware (detector) and software (iterative reconstruction). METHODS We compared weighted volume CT dose index (CTDIvol) and dose length product (DLP) values of 25 consecutive patients studied with non-enhanced standard brain CT with the new scanner and with two previous models each, a 64-slice 64-row multi-detector CT (MDCT) scanner with 64 rows (S64) and a 16-slice 16-row MDCT scanner with 16 rows (S16). We analysed signal-to-noise and contrast-to-noise ratios in images from the three scanners and performed a quality rating by three neuroradiologists to analyse whether dose reduction techniques still yield sufficient diagnostic quality. RESULTS CTDIVol of scanner E was 41.5 and 36.4 % less than the values of scanners S16 and S64, respectively; the DLP values were 40 and 38.3 % less. All differences were statistically significant (p

Background: Over 80% of strokes result from ischemic damage to the brain due to an acute reduction in the blood supply. Around 25-35% of strokes present with large vessel occlusion, and the patients in this category often present with severe neurological deficits. Without early treatment, the prognosis is poor. Stroke imaging is critical for assessing the extent of tissue damage and for guiding treatment. Summary: This review focuses on the imaging techniques used in the diagnosis and treatment of acute ischemic stroke, with an emphasis on those involving the anterior circulation. Key Message: Effective and standardized imaging protocols are necessary for clinical decision making and for the proper design of prospective studies on acute stroke. Clinical Implications: Each minute without treatment spells the loss of an estimated 1.8 million neurons (‘time is brain'). Therefore, stroke imaging must be performed in a fast and efficient manner. First, intracranial hemorrhage and stroke mimics should be excluded by the use of computed tomography (CT) or magnetic resonance imaging (MRI). The next key step is to define the extent and location of the infarct core (values of >70 ml, >1/3 of the middle cerebral artery (MCA) territory or an ASPECTS score ≤7 indicate poor clinical outcome). Penumbral imaging is currently based on the mismatch concept. It should be noted that the penumbra is a dynamic zone and can be sustained in the presence of good collateral circulation. A thrombus length of >8 mm predicts poor recanalization after intravenous thrombolysis.

Object The risk of recurrence of cerebrovascular events within the first 72 hours of admission in patients hospitalized with symptomatic carotid artery (CA) stenoses and the risks and benefits of emergency CA intervention within the first hours after the onset of symptoms are not well known. Therefore, the authors aimed to assess 1) the ipsilateral recurrence rate within 72 hours of admission, in the period from 72 hours to 7 days, and after 7 days in patients presenting with nondisabling stroke, transient ischemic attack (TIA), or amaurosis fugax (AF), and with an ipsilateral symptomatic CA stenosis of 50% or more, and 2) the risk of stroke in CA interventions within 48 hours of admission versus the risk in interventions performed after 48 hours. Methods Ninety-four patients were included in this study. These patients were admitted to hospital within 48 hours of a nondisabling stroke, TIA, or AF resulting from a symptomatic CA stenosis of 50% or more. The patients underwent carotid endarterectomy (85 patients) or CA stenting (9 patients). At baseline, the cardiovascular risk factors of the patients, the degree of symptomatic CA stenosis, and the type of secondary preventive treatment were assessed. The in-hospital recurrence rate of stroke, TIA, or AF ipsilateral to the symptomatic CA stenosis was determined for the first 72 hours after admission, from 72 hours to 7 days, and after 7 days. Procedure-related cerebrovascular events were also recorded. Results The median time from symptom onset to CA intervention was 5 days (interquartile range 3.00–9.25 days). Twenty-one patients (22.3%) underwent CA intervention within 48 hours after being admitted. Overall, 15 recurrent cerebrovascular events were observed in 12 patients (12.8%) in the period between admission and CA intervention: 3 strokes (2 strokes in progress and 1 stroke) (3.2%), 5 TIAs (5.3%), and 1 AF (1.1%) occurred within the first 72 hours (total 9.6%) of admission; 1 TIA (1.1%) occurred between 72 hours and 7 days, and 5 TIAs (5.3%) occurred after more than 7 days. The corresponding actuarial cerebrovascular recurrence rates were 11.4% (within 72 hours of admission), 2.4% (between 72 hours and 7 days), and 7.9% (after 7 days). Among baseline characteristics, no predictive factors for cerebrovascular recurrence were identified. Procedure-related cerebrovascular events occurred at a rate of 4.3% (3 strokes and 1 TIA), and procedures performed within the first 48 hours and procedures performed after 48 hours had a similar frequency of these events (4.5% vs 4.1%, respectively; p = 0.896). Conclusions The in-hospital recurrence of cerebrovascular events was quite low, but all recurrent strokes occurred within 72 hours. The risk of stroke associated with a CA intervention performed within the first 48 hours was not increased compared with that for later interventions. This raises the question of the optimal timing of CA intervention in symptomatic CA stenosis. To answer this question, more data are needed, preferably from large randomized trials.

In this issue, Lockau et al. retrospectively analyze different approaches for endovascular recanalization of tandem occlusions in acute stroke [1]. Starting with stent angioplasty of the carotid occlusion as the first step (stent-first group), they reversed the order of their techniques and performed intracranial thrombectomy prior to stenting of the carotid occlusion (thrombectomy-first group, the so-called upside-down approach). They found advantages and disadvantages with both techniques; however, time of intervention was shorter for the thrombectomy-first group. A higher percentage of thrombectomy-first patients had favorable outcomes after 3 months but the difference was not statistically significant. As discussed in this paper, one of the reasons may be that the thrombectomy-first technique allowsmobilization and removal of the intracranial thrombus during flow arrest, whereas the thrombus becomes more compressed due to increased perfusion pressure following stenting of the carotid artery. This is an article from experts for experts that seek to bring researchers and clinicians together and thereby to improve our approach towards treatment of acute internal carotid artery (ICA) occlusion. This goal is equally or even more challenging than other procedures being developed in the emerging field of interventional neuroradiology. Like embolization of an AVM or coiling of an aneurysm, recanalization in acute stroke is an image-guided endovascular microneurosurgical operation that should be navigated using a biplane or 3D roadmap with a spatial resolution of 150 microns and with a time resolution below 100 ms. For treatment of stroke, however, we must navigate our micro-instruments across the occlusion blindly, without a precise radar picture of our roadmap. Knowledge of the neurovascular anatomy and extensive experience with the whole range of neurointerventional instruments and techniques are preconditions for success. Ischemic strokes resulting from occlusion of the ICA are often severe and have a poor prognosis. Predictors of improved outcome are good intracranial collaterals and recanalization. Intravenous thrombolysis in patients with tandem stenoses achieves low rates of recanalization—between 0 and 20 %—which can be increased to more than 80 % by endovascular treatment. A systematic review of 28 studies found significantly higher rates of favorable outcome in the endovascular group (33.6 % of 584 patients with favorable outcome) as compared to the iv thrombolysis group (24.9 % of 385 patients with favorable outcome; p=0.0004) [2]. A recent literature review of 32 studies dealing with endovascular treatment of 1107 patients with acute ischemic stroke and ICA occlusion confirmed these findings [3]. Ten of these studies included patients with tandem occlusions, with an overall favorable clinical outcome in 43 %; however, the mortality rate was 45 %, and 16 % of patients had symptomatic intracranial hemorrhages. Combined analysis of two studies of patients with tandem occlusions showed a significantly lower death rate for the group treated with intra-arterial thrombolysis and a lower rate of recanalization of the extracranial ICA occlusion (61 % for IA thrombolysis versus 99 % with stenting), whereas the rate of recanalization of intracranial occlusion did not differ significantly (60 versus 78 %) [3]. The current situation regarding thrombolysis treatment is reminiscent of the situation of endovascular treatment of stroke in general, where—fortunately—after a promising start followed by a period of prospective and randomized confusion, the fog is starting to lift. This comment refers to the article available at: http://dx.doi.org/10.1007/ s00234-014-1465-5.

Background and Purpose— The aim of this prospective study was to assess vascular integrity after stent-retriever thrombectomy. Methods— Dissection, contrast medium extravasation, and vasospasm were evaluated in 23 patients after thrombectomy with biplane or 3D-digital subtraction angiography and 3-Tesla vessel wall MRI. Results— Vasospasm was detected angiographically in 10 patients, necessitating intra-arterial nimodipine in 2 of them. Contrast extravasation, intramural hemorrhage, or iatrogenic dissection were not detected on multimodal MRI in any patient even after Y-double stent-retriever technique. Conclusions— Our findings suggest that clinically relevant vessel wall injuries occur rarely after stent-retriever thrombectomy.

Objectives Aim of this study was to compare the utility of susceptibility weighted imaging (SWI) with the established diagnostic techniques CT and fluid attenuated inversion recovery (FLAIR) in their detecting capacity of subarachnoid hemorrhage (SAH), and further to compare the combined SWI/FLAIR MRI data with CT to evaluate whether MRI is more accurate than CT. Methods Twenty-five patients with acute SAH underwent CT and MRI within 6 days after symptom onset. Underlying pathology for SAH was head trauma (n = 9), ruptured aneurysm (n = 6), ruptured arteriovenous malformation (n = 2), and spontaneous bleeding (n = 8). SWI, FLAIR, and CT data were analyzed. The anatomical distribution of SAH was subdivided into 8 subarachnoid regions with three peripheral cisterns (frontal-parietal, temporal-occipital, sylvian), two central cisterns and spaces (interhemispheric, intraventricular), and the perimesencephalic, posterior fossa, superior cerebellar cisterns. Results SAH was detected in a total of 146 subarachnoid regions. CT identified 110 (75.3%), FLAIR 127 (87%), and SWI 129 (88.4%) involved regions. Combined FLAIR and SWI identified all 146 detectable regions (100%). FLAIR was sensitive for frontal-parietal, temporal-occipital and Sylvian cistern SAH, while SWI was particularly sensitive for interhemispheric and intraventricular hemorrhage. Conclusions By combining SWI and FLAIR, MRI yields a distinctly higher detection rate for SAH than CT alone, particularly due to their complementary detection characteristics in different anatomical regions. Detection strength of SWI is high in central areas, whereas FLAIR shows a better detection rate in peripheral areas.

Background and Purpose— Five randomized controlled trials have consistently shown that mechanical thrombectomy (MT) in addition to best medical treatment (±intravenous tissue-type plasminogen activator) improves outcome after acute ischemic stroke in patients with large artery anterior circulation stroke. Whether direct MT is equally effective as combined intravenous thrombolysis with MT (ie, bridging thrombolysis) remains unclear. Methods— We retrospectively compared clinical and radiological outcomes in 167 bridging patients with 255 patients receiving direct MT because of large artery anterior circulation stroke. We matched all patients from the direct MT group who would have qualified for intravenous tissue-type plasminogen activator with controls from the bridging group, using multivariate and propensity score analyses. Functional independence was defined as modified Rankin Scale score of 0 to 2. Results— From February 2009 to August 2014, 40 patients from the direct MT group would have qualified for bridging thrombolysis but were treated with MT only. Clinical and radiological characteristics did not differ from the bridging cohort, except for higher rates of hypercholesterolemia ( P =0.019), coronary heart disease ( P =0.039), and shorter intervals from symptom onset to endovascular intervention ( P =0.01) in the direct MT group. Functional independence, mortality, and intracerebral hemorrhage rates did not differ ( P >0.1). After multivariate matching analysis outcome in both groups did not differ, except for lower rates of asymptomatic intracerebral hemorrhage ( P =0.023) and lower mortality ( P =0.007) in the direct MT group. Conclusions— In patients with large anterior circulation stroke, direct mechanical intervention seems to be equally effective as bridging thrombolysis. A randomized trial comparing direct MT with bridging therapy is warranted.

BACKGROUND Treatment of complex intracranial aneurysms requires strategic pre-interventional or preoperative planning. In addition to modern three-dimensional (3D) rotational angiography, computed tomography angiography (CTA) or magnetic resonance angiogram (MRA), a solid, tangible 3D model may improve anatomical comprehension and treatment planning. A 3D rapid prototyping (RP) technique based on multimodal imaging data was evaluated for use in planning of treatment for complex aneurysmal configurations. METHODS Six patients with complex aneurysms were selected for 3D RP based on CTA and 3D rotational angiography data. Images were segmented using image-processing software to create virtual 3D models. Three-dimensional rapid prototyping techniques transformed the imaging data into physical 3D models, which were used and evaluated for interdisciplinary treatment planning. RESULTS In all cases, the model provided a comprehensive 3D representation of relevant anatomical structures and improved understanding of related vessels. Based on the 3D model, primary bypass surgery with subsequent reconstruction of the aneurysm was then considered advantageous in all but one patient after simulation of multiple approaches. CONCLUSIONS Preoperative prediction of intraoperative anatomy using the 3D model was considered helpful for treatment planning. The use of 3D rapid prototyping may enhance understanding of complex configurations in selected large or giant aneurysms, especially those pretreated with clips or coils.

PURPOSE Arterial spin labeling (ASL) magnetic resonance imaging to assess cerebral blood flow (CBF) is of increasing interest in basic research and in diagnostic applications, since ASL provides similar information to positron emission tomography about perfusion in vascular territories. However, in patients with steno-occlusive arterial disease (SOAD), CBF as measured by ASL might be underestimated due to delayed bolus arrival, and thus increased spin relaxation. We aimed to estimate the extent to which bolus arrival time (BAT) was delayed in patients with SOAD and whether this resulted in underestimation of CBF. METHODS BAT was measured using digital subtraction angiography (DSA) in ten patients with high-grade stenosis of the middle carotid artery (MCA). Regional CBF was assessed with pseudocontinuous ASL. RESULTS BATs were nonsignificantly prolonged in the stenotic hemisphere 4.1±2.0 s compared with the healthy hemisphere 3.3±0.9 s; however, there were substantial individual differences on the stenotic side. CBF in the anterior and posterior MCA territories were significantly reduced on the stenotic hemisphere. Severe stenosis was correlated with longer BAT and lower quantified CBF. CONCLUSION ASL-based perfusion measurement involves a race between the decay of the spins and the delivery of labeled blood to the region of interest. Special caution is needed when interpreting CBF values quantified in individuals with altered blood flow and delayed circulation times. However, from a clinician's point of view, an accentuation of hypoperfusion (even if caused by underestimation of CBF due to prolonged BATs) might be desirable since it indexes potentially harmful physiologic deficits.

BACKGROUND AND PURPOSE: Early stratification of degenerative processes is a prerequisite to warrant therapeutic options in prodromal Alzheimer disease. Our aim was to investigate differences in cerebral macromolecular tissue composition between patients with AD, mild cognitive impairment, and age- and sex-matched healthy controls by using model-based magnetization transfer with a binary spin-bath magnetization transfer model and magnetization transfer ratio at 1.5T. MATERIALS AND METHODS: We investigated patients with de novo AD (n = 18), MCI (n = 18), and CTRLs (n = 18). A region-of-interest analysis of the entorhinal cortex, hippocampal head and body, insula, and temporal neocortex was performed with fuzzy clustering to associate every subregion to a cluster representative for each group. RESULTS: Cluster analysis achieved a concordance of 0.92 (50 of 54 subjects) between a combination of the calculated mMT parameters (kf,kr,T2r,F,T2f) in the entorhinal cortex and the neuropsychological diagnosis. The sensitivity and specificity for the discrimination of AD from MCI reached 1 and 0.94, with a positive predictive value of 0.95 and a negative predictive value of 1. Compared with mMT, the concordance for MTR was 0.83 (45 of 54 subjects) with a lower specificity of 0.5 and positive predictive value of 0.67 to discriminate patients with AD and MCI. CONCLUSIONS: mMT imaging detects macromolecule-related alterations and allows an improved classification of patients with early AD and MCI compared with MTR.

Summary Endovascular stroke treatment is a rapidly evolving field in neurointerventions. The article reviews the evolution of the different mechanical thrombolysis and stenting techniques and their working principles for endovascular vessel recanalization and reviews the data on the outcome after acute stroke treatment.

Rationale and Objectives: A particular arterial spin (ASL) labeling technique, called 3D-single-shot GRASE ASL is discussed with respect to the ability and limits of quantifying perfusion parameters. Materials and Methods: The technique enables the acquisition of perfusion weighted signal at multiple delay times (TI) in one scan. The readout part is a gradient and spin-echo combination (GRASE) that uses switched gradient rephrasing of signals to produce several times as many signals as turbo-spin-echo, which translates into faster imaging time and higher signal-to-noise ratio (SNR) per imaging time. The technique provides the possibility for model based quantification of cerebral blood flow and the determination of the bolus arrival information without use of contrast agent and thus the characterization and determination of regions that are supported by collaterals. Results: Whereas for a quantification of the permeability using ASL the SNR is not high enough, at least qualitative permeability maps can be determined, if an optimal homogenous SNR was guaranteed. This was accomplished in brain regions with a high blood supply, typically given in tumors, and by using a correction for coil sensitivity at the highest possible additional scaling. Conclusion: The single-shot 3D GRASE ASL can provide information about the principal blood supply, the transit delay of the blood flow due to a stenosis or collaterals and a qualitative measure of the permeability.

Prenatal Bonding (Bindungsanalyse by Raffai) provides the possibility of creating an intense bonding between mother and fetus, of being witness to the development of the fetus in the womb and realizing the early growth of the personality. The same way any prenatal dysfunctions can be recognized including the capacity for immediate healing. In this respect the method is at the same time an instrument of preand perinatal research, an empowerment of bonding between mother and fetus and a great help for giving birth much more easily. After birth the baby has a remarkable degree of self-esteem and good access to its personal potential.

Background: Intra-arterial thrombolysis (IAT) can improve clinical outcome in patients with acute basilar artery occlusion (BAO). The purpose of this study was to determine whether the severity of neurological symptoms, the extent of early ischemic damage on pretreatment diffusion-weighted MRI (DWI), and the lesion progression or regression on post-treatment MRI can predict functional outcome in patients with BAO treated with IAT. Methods: Thirty-six BAO patients (13 women, 23 men; mean age 60 years) treated with IAT within 12 h of symptom onset were studied. Early ischemic damage on DWI was assessed by applying 4 DWI scoring systems, including a proposed DWI score developed for this study. The latter was used for evaluation of lesion dynamics on post-treatment MRI. The association of pretreatment DWI, severity of symptoms (National Institutes of Health Stroke Scale, NIHSS, and Glasgow Coma Scale, GCS, scores), vessel recanalization, and lesion progression or regression after IAT with clinical outcome at 3 months was analyzed. Results: Median NIHSS and GCS scores on admission were 17 and 10, respectively. In univariate analysis, NIHSS and GCS scores (on admission) and all 4 DWI scores were significantly associated with clinical outcome. After regression analysis for each DWI score, the DWI score proposed herein was the only score that remained independently associated with clinical outcome at 3 months (p = 0.004). A decrease in DWI score was observed in 3 of 23 patients with post-IAT MRI. Successful recanalization was significantly associated with lesion regression (p = 0.044). Conclusions: BAO patients with less extensive tissue damage on DWI and milder neurological deficits (lower NIHSS and higher GCS) have a better clinical outcome following IAT. The introduced DWI score reliably quantified the pretreatment ischemic damage and was an independent predictor of functional outcome. Lesion regression on DWI score after IAT was associated with vessel recanalization (p = 0.44), but had no impact on clinical outcome.

Purpose Delayed occlusion time in parent artery occlusion of brain-supplying vessels might carry risk for thromboembolic complications. Vascular plug devices are successfully used in cardiopulmonary and peripheral interventions to occlude high-flow lesions and have been adapted for use in neurointerventions. The purpose of the present study was to experimentally evaluate the immediate occlusion time of the AMPLATZER vascular plug (AVP) II—a second-generation cylindrical, self-expandable, resheathable nitinol wire mesh consisting of three lobes—in the carotid artery. Materials and Methods AVP II devices ( N = 12) 6 mm in diameter (length, 6 mm) were deployed through 6-F guiding catheters in the common carotid arteries of two pigs. After device deployment, angiography was performed to measure the time interval until no contrast agent opacification was visible distal to the AVP II, indicating complete flow cessation and occlusion of the distal vessel. Vessel diameters before deployment and after resheathing of the device were measured. Device navigation, positioning, recapturing, vasospasm, and angiographic signs of vessel injury were assessed. Results The mean time to total flow cessation and occlusion was 57.9 seconds (median, 44 s ± 27 [SD]; range, 26–104 s). Device navigation, positioning, and resheathing were successful in all cases. There was neither significant vasospasm nor vessel injury visible on angiography. Conclusions Application and retrieval of the second-generation AVP II are uncomplicated and the device is able to achieve fast and sufficient cessation of flow in a hemodynamically comparable setting to the human carotid artery, indicating some potential to fill a gap in the neurointerventional tool box.

Stroke due to hypoperfusion or emboli is a devastating adverse event of cardiac surgery, but early detection and treatment could protect patients from an unfavorable postoperative course. Hypoperfusion and emboli can be detected with transcranial Doppler of the middle cerebral artery (MCA). The measured blood flow velocity correlates with cerebral oxygenation determined clinically by near-infrared spectroscopy (NIRS) of the frontal cortex. We tested the potential advantage of a spatially extended NIRS in detecting critical events in three cardiac surgery patients with a whole-head fiber holder of the FOIRE-3000 continuous-wave NIRS system. Principle components analysis was performed to differentiate between global and localized hypoperfusion or ischemic territories of the middle and anterior cerebral arteries. In one patient, we detected a critical hypoperfusion of the right MCA, which was not apparent in the frontal channels but was accompanied by intra- and postoperative neurological correlates of ischemia. We conclude that spatially extended NIRS of temporal and parietal vascular territories could improve the detection of critically low cerebral perfusion. Even in severe hemispheric stroke, NIRS of the frontal lobe may remain normal because the anterior cerebral artery can be supplied by the contralateral side directly or via the anterior communicating artery.

BACKGROUND: Vasopressor-induced hypertension is routinely indicated for prevention and treatment of cerebral vasospasm (CVS) after subarachnoid haemorrhage (SAH). Mechanisms underlying patients' clinical improvement during vasopressor-induced hypertension remain incompletely understood. The aim of this study was to evaluate angiographic effects of normovolaemic Norepinephrine (NE)-induced hypertension therapy on the rabbit basilar artery (BA) after SAH. METHODS: Cerebral vasospasm was induced using the one-haemorrhage rabbit model; sham-operated animals served as controls. Five days later the animals underwent follow-up angiography prior to and during NE-induced hypertension. Changes in diameter of the BA were digitally calculated in mean microm +/- SEM (standard error of mean). FINDINGS: Significant CVS of 14.2% was documented in the BA of the SAH animals on day 5 compared to the baseline angiogram on day 0 (n = 12, p < 0.01), whereas the BA of the control animals remained statistically unchanged (n = 12, p > 0.05). During systemic administration of NE, mean arterial pressure increased from 70.0 +/- 1.9 mmHg to 136.0 +/- 2.1 mmHg in the SAH group (n = 12, p < 0.001) and from 72.0 +/- 3.1 to 137.8 +/- 1.3 in the control group (n = 12, p < 0.001). On day 5 after SAH, a significant dilatation of the BA in response to norepinephrine could be demonstrated in both groups. The diameter of the BA in the SAH group increased from 640.5 +/- 17.5 microm to 722.5 +/- 23.7 microm (n = 12, p < 0.05; ). In the control group the diameter increased from 716.8 +/- 15.5 microm to 779.9 +/- 24.1 microm (n = 12, p < 0.05). CONCLUSION: This study demonstrated that NE-induced hypertension causes angiographic dilatation of the BA in the SAH rabbit model. Based on these observations, it can be hypothesised that clinical improvement during vasopressor-induced hypertension therapy after SAH might be explained with cerebral vasodilatation mechanisms that lead to improvement of cerebral blood flow.

Bildgebende Verfahren haben in der Diagnostik und Therapiekontrolle neurologischer und neurochirurgischer Erkrankungen in den letzten 20 Jahren drastisch an Bedeutung gewonnen. Häufig bestehen jedoch Unklarheiten, bei welcher Erkrankung welches bildgebende Verfahren sinnvoll ist, und wann therapeutische bildgestützte Verfahren zum Einsatz kommen sollen. Hierbei hat sich insbesondere gezeigt, dass die Wahl des geeigneten Verfahrens nur dann mit optimaler Sensitivität und Spezifität eingesetzt werden kann, wenn anhand von Anamnese und klinisch-neurologischer Untersuchung die entsprechenden Leitsymptome definiert werden und eine gezielte Indikationsstellung erfolgen kann. Im Folgenden sollen die häufigsten Leitsymptome, die eine bildgebende Abklärung erfordern, dargestellt werden und eine Einschätzung der geeigneten Abklärungsverfahren erfolgen.

Maternal herpes simplex virus encephalitis is a life-threatening condition for the mother and fetus. To treat the maternal disease and prevent infection in the neonate, a multidisciplinary approach is needed. In this Case Study, Sellner and colleagues demonstrate how with early diagnosis, prompt initiation of antiviral treatment, and suitable neurocritical care, a favorable outcome can be achieved in both mother and child. Background A pregnant 25-year-old woman at 32 weeks' gestation was admitted to an emergency unit after her husband had found her drowsy and with her tongue bitten. The day before admission, the patient had developed a fever of 39 °C, was suffering from headaches, was nauseated and had vomited. On admission, she had anterograde and retrograde amnesia, but no somatic neurological deficits were detected. Investigations Routine laboratory testing, lumbar puncture, cerebrospinal fluid analysis, routine bacteriology, brain MRI, and polymerase chain reaction testing for neurotropic viruses including herpes simplex virus types 1 and 2. Diagnosis Maternal herpes simplex virus type 1 encephalitis. Management Antiviral and anticonvulsive therapy, supportive treatment, and cesarean section.

Objectives: (a) The development of a novel analysis method, named Dynamic pixel intensity Histogram Analysis (DHA) allowing for pixel intensity-histogram-model-parameter fitting of arbitrary-shaped regions defined in dynamic-susceptibility-contrast-enhanced (DSCE) difference MR-image time-series, and (b) its prospective application and evaluation for glioma grading. Materials and Methods: For each difference-image, pixel intensity histograms of arbitrary-shaped ROIs were computed and fitted using the Levenberg-Marquardt algorithm. Time-dependent histogram center-position- and width-parameters are computed during bolus-passage. The method was applied to 25 patients with low and high grade gliomas. Results: During bolus outflow-time, histogram-center-position-parameter and histogram-width-parameter reach highest significance levels and discriminate gliomas of different grades. The histogram center-position-parameter discriminated grade-II from grade-III, grade-II from grade-IV but not grade-III from grade-IV. The observed histogram width-parameters discriminated grade-II from grade-III (P < 0.00022), grade-II from grade-IV (P

Retrospective 9-year survey. Clinical presentation of acute myelitis syndromes is variable, and neuroimaging and laboratory findings are not specific enough to establish the diagnosis with certainty. We evaluated the spectrum clinical features and paraclinical findings encountered during diagnostic workup and aiding the diagnosis. Department of Neurology, Inselspital Bern, Switzerland. Charts and magnetic resonance imaging (MRI) of 63 patients discharged with the diagnosis of acute transverse myelitis. The diagnosis was supported by abnormal MRI and cerebrospinal fluid (CSF) findings in 52 patients (82.5%) and suspected in the remaining either because of a spinal cord MRI lesion suggestive of myelitis (n=5), or abnormal CSF findings (n=4), or electrophysiological evidence of a spinal cord dysfunction (n=2). Clinical impairment was mild (ASIA D) in the majority. All patients had sensory disturbances, whereas motor deficit and autonomic dysfunction were less frequent. Neurological levels were mainly located in cervical or thoracic dermatomes. Spinal cord lesions were visualized by MRI in 90.4% of the patients and distributed either in the cervical or thoracic cord, or both. Multiple lesions were present in more than half of the patients, and lateral, centromedullary and posterior locations were most common. A high percentage of multiple sclerosis (MS)-typical brain lesions and CSF findings suggested a substantial number of MS-related myelitis in our cohort. The diagnostic workup of acute myelitis discloses a broad spectrum of CSF or MRI findings, and may be associated with diagnostic uncertainty due to lack of specific CSF or MRI features, or pathological findings.

PURPOSE: To evaluate the diagnostic accuracy of in situ postmortem multislice computed tomography (MSCT) and magnetic resonance imaging (MRI) in the detection of primary traumatic extra-axial hemorrhage. MATERIALS AND METHODS: Thirty forensic neurotrauma cases and 10 nontraumatic controls who underwent both in situ postmortem cranial MSCT and MR imaging before autopsy were retrospectively reviewed. Both imaging modalities were analyzed in view of their accuracy, sensitivity, and specificity concerning the detection of extra-axial hemorrhage. Statistical significance was calculated using the McNemar test. kappa values for interobserver agreement were calculated for extra-axial hemorrhage types and to quantify the agreement between both modalities as well as MRI, CT, and forensics, respectively. RESULTS: Analysis of the detection of hemorrhagic localizations showed an accuracy, sensitivity, and specificity of 89%, 82%, and 92% using CT, and 90%, 83%, and 94% using MRI, respectively. MRI was more sensitive than CT in the detection of subarachnoid hemorrhagic localizations (P = 0.001), whereas no significant difference resulted from the detection of epidural and subdural hemorrhagic findings (P = 0.248 and P = 0.104, respectively). Interobserver agreement for all extra-axial hemorrhage types was substantial (CT kappa = 0.76; MRI kappa = 0.77). The agreement of both modalitites was almost perfect (readers 1 and 2 kappa = 0.88). CONCLUSION: CT and MRI are of comparable potential as forensic diagnostic tools for traumatic extra-axial hemorrhage. Not only of forensic, but also of clinical interest is the observation that most thin blood layers escape the radiological evaluation.

Duplication of the vertebral arteries is a rare developmental anomaly. We report on an asymmetrical bilateral duplication of the extracranial vertebral arteries which was an incidental finding demonstrated by MR angiography in a patient evaluated for middle cerebral artery stroke and internal carotid stenosis. On the right side two separate origins of the vertebral artery arose directly from the subclavian artery, whereas on the left side one leg originated directly from the aortic arch and the other one from the left proximal subclavian artery. To the best of our knowledge, this is the first report on an asymmetrical bilateral duplication of the origins of the extracranial vertebral arteries. The possible embryologic mechanisms and the possible clinical importance of this previously unreported variant are reviewed.

INTRODUCTION: The use of vascular plug devices for the occlusion of high-flow lesions is a relatively new and successful procedure in peripheral and cardiopulmonary interventions. We report on the use and efficiency of the Amplatzer vascular plug in a small clinical series and discuss its potential for occlusion of large vessels and high-flow lesions in neurointerventions. METHODS: Between 2005 and 2007 four patients (mean age 38.5 years, range 16-62 years) were treated with the device, in three patients to achieve parent artery occlusion of the internal carotid artery, in one patient to occlude a high-flow arteriovenous fistula of the neck. The application, time to occlusion, and angiographic and clinical results and the follow-up were evaluated. RESULTS: Navigation, positioning and detachment of the device were satisfactory in all cases. No flow-related migration of the plug was seen. The cessation of flow was delayed by a mean of 10.5 min after deployment of the first device. In the procedures involving vessel sacrifice, two devices had to be deployed to achieve total occlusion. No patient experienced new neurological deficits; the 3-month follow-up revealed stable results. CONCLUSION: The Amplatzer vascular plug can be adapted for the treatment of high-flow lesions and parent artery occlusions in the head and neck. In this small series the use of the devices was uncomplicated and safe. The rigid and large delivery device and the delayed cessation of flow currently limit the device's use in neurointerventions.

Background and Purpose— For selected stroke patients, intra-arterial thrombolysis (IAT) has been shown to be an effective treatment option. However, knowledge of safety and efficacy of IAT in patients with acute stroke as a complication of arterial catheter interventions is limited. Methods— We analyzed clinical radiological findings and functional outcomes in consecutive patients 3 months after treatment with IAT for peri-procedural strokes occurring during neuroendovascular or cardiac catheter interventions. To measure outcome, the modified Rankin scale score was used. Results— Of a total of 432 patients treated with IAT, 12 (4 women and 8 men; mean age, 60 years) were treated because of an ischemic stroke after a neuro-endovascular procedure (n=6) or coronary angiography (n=6). The median baseline National Institutes of Health Stroke Scale score was15. Recanalization was complete (thrombolysis in myocardial infarction grade 3) in 6, partial (thrombolysis in myocardial infarction 2) in 5, and minimal (thrombolysis in myocardial infarction 1) in 1. Nine patients (75%) had a favorable outcome (modified Rankin scale score, 0 to 2), and 3 had a poor outcome (modified Rankin scale score, 3 or 4). All patients with complete recanalization had a favorable outcome, whereas only 3 of 6 patients with partial or minimal recanalization ( P =0.18) had a favorable outcome. Follow-up brain imaging was normal in 2 and showed new ischemic lesions in 10 patients. Two patients (17%) had a symptomatic intracerebral hemorrhage. Conclusion— In acute stroke attributable to arterial catheter interventions, IAT is feasible and has the potential to improve outcome in these patients. A high recanalization rate could be achieved.