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Purpose: Arteriosclerosis of the vascular system is associated with many accompanying diseases. Especially cerebral arteriosclerosis is a main risk factor for ischemic strokes. We want to verify the practicability of intravascular imaging like intravascular ultrasound and optical coherence tomography for the assessment of cerebral vessel walls and plaques. Methods: We examined 18 Circuli arteriosi willisii postmortem. The data contained 48 plaques from 48 different vessel parts. The samples underwent intravascular and histological imaging to conduct a quantitative assessment of vessel wall parameters (healthy vessel wall, thinnest vessel wall, plaque thickness and vessel diameter) as well as to qualitatively evaluate the healthy vessel wall, fibrotic plaques, calcifications and cholesterol deposits in diseased vessels. Results: The comparison showed statistically significant smaller measurements for thinnest vessel walls, normal vessel walls and vessel diameters in histology than in imaging. No statistically significant difference was reached for plaque diameters. Fibrotic plaques were characterized as hyper-intense with dorsal attenuation and calcifications as hypo-intense with dorsal attenuation in optical coherence tomography. In intravascular ultrasound, fibrotic plaques showed a homogeneous echogenicity without distal attenuation and calcifications were depicted as hyperechoic with dorsal sound shadows. Cholesterol deposits were hyper-intense in optical coherence tomography with strongly attenuated signals and in intravascular ultrasound; the deposits were hyper-intense with almost no attenuation. Conclusion: Both intravascular methods allow for plaque characterization and quantification of plaque diameter in cerebral vessel walls. When compared with histology, a statistically significant bias was obtained for the ex vivo measurements of the normal vessel wall diameters. [ABSTRACT FROM AUTHOR]

Summary¶Background. Endoscopy has developed into an integral part of minimally invasive neurosurgery. For further technological innovations, detailed knowledge about the pathological anatomy is essential. The gross anatomy of the cerebral ventricular system has been meticulously investigated with ventriculography and casts. Extensive volumetric measurements based on neuroradiological images have been performed, but only little is known about the surgically relevant linear distances in patients with hydrocephalus. Method. Thirty healthy volunteers and thirty patients suffering from hydrocephalus were scanned with high-resolution 3-D magnetic resonance imaging sequences. The image volumes were sliced identically with the help of Siemens Prominence® software. Individual anatomical measurements of the ventricular system were carried out, mean values and standard deviations were calculated, and different endoscopic approaches were investigated. Findings. In healthy volunteers the measurements confirmed the results obtained from ventriculography and anatomic casts. In hydrocephalic patients the ventricular system was found to be enlarged asymmetrically. The optimal neuroendoscopic approach showed considerable, interindividual variation. Interpretation. This 3-D magnetic resonance imaging study revealed surgically and clinically relevant aspects of the pathologic anatomy of hydrocephalic patients, in comparison to healthy volunteers. Individualized planning of the endoscopic approach appears to be warranted. Finally, the data provided a sound basis for the further development of neuroendoscopes. [ABSTRACT FROM AUTHOR]

Objectives: 3D-visualization of the segmented contacts of directional deep brain stimulation (DBS) electrodes is desirable since knowledge about the position of every segmented contact could shorten the timespan for electrode programming. CT cannot yield images fitting that purpose whereas highly resolved flat detector computed tomography (FDCT) can accurately image the inner structure of the electrode. This study aims to demonstrate the applicability of image fusion of highly resolved FDCT and CT to produce highly resolved images that preserve anatomical context for subsequent fusion to preoperative MRI for eventually displaying segmented contactswithin anatomical context in future studies., Material and Methods: Retrospectively collected datasets from 15 patients who underwent bilateral directional DBS electrode implantation were used. Subsequently, after image analysis, a semi-automated 3D-registration of CT and highly resolved FDCT followed by image fusion was performed. The registration accuracy was assessed by computing the target registration error., Results: Our work demonstrated the feasibility of highly resolved FDCT to visualize segmented electrode contacts in 3D. Semiautomatic image registration to CT was successfully implemented in all cases. Qualitative evaluation by two experts revealed good alignment regarding intracranial osseous structures. Additionally, the average for the mean of the target registration error over all patients, based on the assessments of two raters, was computed to be 4.16 mm., Conclusion: Our work demonstrated the applicability of image fusion of highly resolved FDCT to CT for a potential workflow regarding subsequent fusion to MRI in the future to put the electrodes in an anatomical context., (© 2024. The Author(s).)

This interdisciplinary study examined the relationship between bone density and drilling forces required during trans-pedicular access to the vertebra using fresh-frozen thoraco-lumbar vertebrae from two female body donors (A, B). Before and after biomechanical examination, samples underwent high-resolution CT-quantification of total bone density followed by software-based evaluation and processing. CT density measurements (n = 4818) were calculated as gray values (GV), which were highest in T12 for both subjects (GV maxA  = 3483.24, GV maxB  = 3160.33). Trans-pedicular drilling forces F (Newton N) were highest in L3 (F maxB  = 5.67 N) and L4 (F maxA  = 5.65 N). In 12 out of 13 specimens, GVs significantly (p < 0.001) correlated with force measurements. Among these, Spearman correlations r were poor in two lumbar vertebrae, fair in five specimens, and moderately strong in another five specimens, and highest for T11 (r A  = 0.721) and L5 (r B  = 0.690). Our results indicate that CT-based analysis of vertebral bone density acquired in anatomical specimens is a promising approach to predict the drilling force appearance as surrogate parameter of its biomechanical properties by e.g., linear regression analysis. The study may be of value as basis for biomechanical investigations to improve planning of the optimal trajectory and to define safety margins for drilling forces during robotic-assisted trans-pedicular interventions on the spine in the future., (© 2024. The Author(s).)

Background: Carotid cavernous sinus fistulas (CSCF) are pathological connections of the internal and/or external carotid artery (and/or its branches) to the cavernous sinus. Ophthalmological symptoms and problems occur particularly when drainage is via the superior ophthalmic vein., Material and Methods: Seven eyes of six patients with a high-grade suspicion of CSCF were included in this retrospective monocentric study. Digital subtraction angiography (DSA) was performed in the included patients, where an interventional fistula closure was performed in the case of CSCF. Four of the six patients received a pre- and post-interventional day-night intraocular pressure profile. Furthermore, medical history, symptoms, visual acuity, slit lamp microscopic findings, and DSA findings were evaluated., Results: The most common symptoms reported by patients were red eyes, diplopia, and exophthalmos. When the intraocular pressure (IOP) was measured, 83.33% of the patients showed increased values. The mean IOP in the day-night intraocular pressure profile in the affected eye before intervention was 23.5 (± 2.7) mmHg compared to 14.1 (± 2.3) mmHg in the healthy eye. A significant difference could thus be demonstrated in side comparison (p = 0.0047). The post-interventional measurement showed a mean IOP of 15.3 (± 1.0) mmHg in the affected eye and thus a significant difference to the pre-interventional measurement in the affected eye (p = 0.0018). Four of the six patients with CSCF were taking antiglaucomatous eye drops before the intervention, and two patients after the intervention. The number of antiglaucoma drugs used could also be reduced., Conclusion: Interventional fistula closure is an effective method for treating the secondary increase of IOP in CSCF. Successful closure of the fistula showed a significant reduction in IOP, which was not possible with the sole administration of antiglaucoma drugs. Radius-Maumenee syndrome should be considered as a differential diagnosis., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt vorliegt./The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Dementia as one of the most prevalent diseases urges for a better understanding of the central mechanisms responsible for clinical symptoms, and necessitates improvement of actual diagnostic capabilities. The brainstem nucleus locus coeruleus (LC) is a promising target for early diagnosis because of its early structural alterations and its relationship to the functional disturbances in the patients. In this study, we applied our improved method of localisation-based LC resting-state fMRI to investigate the differences in central sensory signal processing when comparing functional connectivity (fc) of a patient group with mild cognitive impairment (MCI, n = 28) and an age-matched healthy control group (n = 29). MCI and control participants could be differentiated in their Mini-Mental-State-Examination (MMSE) scores (p < .001) and LC intensity ratio (p = .010). In the fMRI, LC fc to anterior cingulate cortex (FDR p < .001) and left anterior insula (FDR p = .012) was elevated, and LC fc to right temporoparietal junction (rTPJ, FDR p = .012) and posterior cingulate cortex (PCC, FDR p = .021) was decreased in the patient group. Importantly, LC to rTPJ connectivity was also positively correlated to MMSE scores in MCI patients (p = .017). Furthermore, we found a hyperactivation of the left-insula salience network in the MCI patients. Our results and our proposed disease model shed new light on the functional pathogenesis of MCI by directing to attentional network disturbances, which could aid new therapeutic strategies and provide a marker for diagnosis and prediction of disease progression., (© 2022 The Authors. Human Brain Mapping published by Wiley Periodicals LLC.)

(1) Background: Astrocytic gliomas present overlapping appearances in conventional MRI. Supplementary techniques are necessary to improve preoperative diagnostics. Quantitative DWI via the computation of apparent diffusion coefficient (ADC) histograms has proven valuable for tumor characterization and prognosis in this regard. Thus, this study aimed to investigate (I) the potential of ADC histogram analysis (HA) for distinguishing low-grade gliomas (LGG) and high-grade gliomas (HGG) and (II) whether those parameters are associated with Ki-67 immunolabelling, the isocitrate-dehydrogenase-1 (IDH1) mutation profile and the methylguanine-DNA-methyl-transferase (MGMT) promoter methylation profile; (2) Methods: The ADC-histograms of 82 gliomas were computed. Statistical analysis was performed to elucidate associations between histogram features and WHO grade, Ki-67 immunolabelling, IDH1 and MGMT profile; (3) Results: Minimum, lower percentiles (10th and 25th), median, modus and entropy of the ADC histogram were significantly lower in HGG. Significant differences between IDH1-mutated and IDH1-wildtype gliomas were revealed for maximum, lower percentiles, modus, standard deviation (SD), entropy and skewness. No differences were found concerning the MGMT status. Significant correlations with Ki-67 immunolabelling were demonstrated for minimum, maximum, lower percentiles, median, modus, SD and skewness; (4) Conclusions: ADC HA facilitates non-invasive prediction of the WHO grade, tumor-proliferation rate and clinically significant mutations in case of astrocytic gliomas.

Background: Treatment of cerebral aneurysms using hemodynamic implants such as endosaccular flow disruptors and endoluminal flow diverters has gained significant momentum during recent years. The intended target zone of those devices is the immediate interface between aneurysm and parent vessel. The therapeutic success is based on the reduction of aneurysmal perfusion and the subsequent formation of a neointima along the surface of the implant. However, a subset of aneurysms-off-centered bifurcation aneurysms involving the origin of efferent branches and aneurysms arising from peripheral segments of small cerebral vessels-oftentimes cannot be treated via coiling or implanting a hemodynamic implant at the neck level for technical reasons. In those cases, indirect flow diversion-a flow diverter deployed in the main artery proximal to the parent vessel of the aneurysm-can be a viable treatment strategy, but clinical evidence is lacking in this regard. Materials and Methods: Five neurovascular centers contributed to this retrospective analysis of patients who were treated with indirect flow diversion. Clinical data, aneurysm characteristics, anti-platelet medication, and follow-up results, including procedural and post-procedural complications, were recorded. Results: Seventeen patients (mean age: 60.5 years, range: 35-77 years) with 17 target aneurysms (vertebrobasilar: n = 9) were treated with indirect flow diversion. The average distance between the flow-diverting stent and the aneurysm was 1.65 mm (range: 0.4-2.4 mm). In 15/17 patients (88.2%), perfusion of the aneurysm was reduced immediately after implantation. Follow-ups were available for 12 cases. Delayed opacification (OKM A3: 11.8%), reduction in size (OKM B1-3: 29.4%) and occlusion (D1: 47.1%) were observable at the latest investigation. Clinically relevant procedural complications and adverse events in the early phase and in the late subacute phase were not observed in any case. Conclusion: Our preliminary data suggest that indirect flow diversion is a safe, feasible, and effective approach to off-centered bifurcation aneurysms and distant small-vessel aneurysms. However, validation with larger studies, including long-term outcomes and optimized imaging, is warranted., Competing Interests: SS has proctoring and consultancy agreements with phenox and Balt international. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Schob, Brill, Siebert, Sponza, Schüngel, Wohlgemuth, Götz, Mucha, Gopinathan, Scheer, Prell, Bohner, Gavrilovic and Skalej.)

There has been an increase in the use of acetylsalicylic acid (ASA, Aspirin®) among patients with stroke and heart disease as well as in aging populations as a means of primary prevention. The potentially life-threatening consequences of a postoperative hemorrhagic complication after neurosurgical operative procedures are well known. In the present study, we evaluate the risk of continued ASA use as it relates to postoperative hemorrhage and cardiopulmonary complications in patients undergoing cerebral aneurysm surgery. We retrospectively analyzed 200 consecutive clipping procedures performed between 2008 and 2018. Two different statistical models were applied. The first model consisted of two groups: (1) group with No ASA impact - patients who either did not use ASA at all as well as those who had stopped their use of the ASA medication in time (> = 7 days prior to operation); (2) group with ASA impact - all patients whose ASA use was not stopped in time. The second model consisted of three groups: (1) No ASA use; (2) Stopped ASA use (> = 7 days prior to operation); (3) Continued ASA use (did not stop or did not stop in time, <7 days prior to operation). Data collection included demographic information, surgical parameters, aneurysm characteristics, and all hemorrhagic/thromboembolic complications. A postoperative hemorrhage was defined as relevant if a consecutive operation for hematoma removal was necessary. An ASA effect has been assumed in 32 out of 200 performed operations. A postoperative hemorrhage occurred in one out these 32 patients (3.1%). A postoperative hemorrhage in patients without ASA impact was detected and treated in 5 out of 168 patients (3.0%). The difference was statistically not significant in either model (ASA impact group vs. No ASA impact group: OR = 1.0516 [0.1187; 9.3132], p = 1.000; RR = 1.0015 [0.9360; 1.0716]). Cardiopulmonary complications were significantly more frequent in the group with ASA impact than in the group without ASA impact (p = 0.030). In this study continued ASA use was not associated with an increased risk of a postoperative hemorrhage. However, cardiopulmonary complications were significantly more frequent in the ASA impact group than in the No ASA impact group. Thus, ASA might relatively safely be continued in patients with increased cardiovascular risk and cases of emergency cerebrovascular surgery., (© 2021. The Author(s).)

Purpose: With the introduction of new devices and the development of approved devices, endovascular techniques are more and more considered as a treatment option for middle cerebral artery aneurysms (MCA). In this study, we present data on ruptured MCA aneurysms that were treated endovascularly in our hospital., Material and Methods: In a retrospective case series of ruptured MCA bifurcation aneurysms, 118 (94%) cases were managed endovascularly between May 2008 and July 2017. Most were managed with coiling (= 62) and the remaining were managed with stent-assisted-coiling (= 35) and endovascular flow disruptor (WEB-device) (= 21). We measured the clinical outcome at the time of discharge and long-term follow-up on the modified Rankin Scale (mRS) and evaluated the rates of periprocedural complications and retreatment., Results: A good clinical outcome (mRS 0-2) at discharge was achieved in 58.5% of these cases. Mortality rate was 19.5%. Nine aneurysms required retreatment. Eighty-three percent demonstrated a good clinical outcome at long-term follow-up (mRS 0-2). In total, 6 (5.1%) procedure-related complications and 10 (8.5%) disease-related complications occurred. No significant difference between reintervention, complications or outcome was found between the employment of different devices (P > 0.05). Endovascular treatment of ruptured MCA aneurysms at our practice showed similar morbidity and mortality to data published about surgical clipping., Conclusion: The endovascular device evolution permits a feasible and safe treatment of ruptured MCA bifurcation aneurysms. Endovascular treatment can therefore be considered as an alternative treatment option to microsurgery for this type of aneurysm.

Background: Galloway-Mowat syndrome (GAMOS) is characterized by neurodevelopmental defects and a progressive nephropathy, which typically manifests as steroid-resistant nephrotic syndrome. The prognosis of GAMOS is poor, and the majority of children progress to renal failure. The discovery of monogenic causes of GAMOS has uncovered molecular pathways involved in the pathogenesis of disease., Methods: Homozygosity mapping, whole-exome sequencing, and linkage analysis were used to identify mutations in four families with a GAMOS-like phenotype, and high-throughput PCR technology was applied to 91 individuals with GAMOS and 816 individuals with isolated nephrotic syndrome. In vitro and in vivo studies determined the functional significance of the mutations identified., Results: Three biallelic variants of the transcriptional regulator PRDM15 were detected in six families with proteinuric kidney disease. Four families with a variant in the protein's zinc-finger (ZNF) domain have additional GAMOS-like features, including brain anomalies, cardiac defects, and skeletal defects. All variants destabilize the PRDM15 protein, and the ZNF variant additionally interferes with transcriptional activation. Morpholino oligonucleotide-mediated knockdown of Prdm15 in Xenopus embryos disrupted pronephric development. Human wild-type PRDM15 RNA rescued the disruption, but the three PRDM15 variants did not. Finally, CRISPR-mediated knockout of PRDM15 in human podocytes led to dysregulation of several renal developmental genes., Conclusions: Variants in PRDM15 can cause either isolated nephrotic syndrome or a GAMOS-type syndrome on an allelic basis. PRDM15 regulates multiple developmental kidney genes, and is likely to play an essential role in renal development in humans., (Copyright © 2021 by the American Society of Nephrology.)

Introduction: A multitude of approaches have been postulated for assessing the risk of intracranial aneurysm rupture. However, the amount of potential predictive factors is not applicable in clinical practice and they are rejected in favor of the more practical PHASES score. For the subgroup of multiple intracranial aneurysms (MIAs), the PHASES score might severely underestimate the rupture risk, as only the aneurysm with the largest diameter is considered for risk evaluation., Methods: In this study, we investigated 38 patients harboring a total number of 87 MIAs with respect to their morphological and hemodynamical characteristics. For the determination of the best suited parameters regarding their predictive power for aneurysm rupture, we conducted three phases of statistical evaluation. The statistical analysis aimed to identify parameters that differ significantly between ruptured and unruptured aneurysms, show smallest possible correlations among each other and have a high impact on rupture risk prediction., Results: Significant differences between ruptured and unruptured aneurysms were found in 16 out of 49 parameters. The lowest correlation were found for gamma, aspect ratio (AR1), aneurysm maximal relative residence time (Aneurysm&#95;RRT&#95;max) and aneurysm mean relative residence time. The data-driven parameter selection yielded a significant correlation of only two parameters (AR1 and the Aneurysm&#95;RRT&#95;max) with rupture state (area under curve = 0.75)., Conclusion: A high number of established morphological and hemodynamical parameters seem to have no or only low effect on prediction of aneurysm rupture in patients with MIAs. For best possible rupture risk assessment of patients with MIAs, only the morphological parameter AR1 and the hemodynamical parameter Aneurysm&#95;RRT&#95;max need to be included in the prediction model., Competing Interests: Conflict of interest statement: The authors declare that there is no conflict of interest., (© The Author(s), 2020.)

The locus coeruleus (LC) is involved in numerous crucial brain functions and several disorders like depression and Alzheimer's disease. Recently, the LC resting-state functional connectivity (rs-fc) has been investigated in functional MRI by calculating the blood oxygen level-dependent (BOLD) response extracted using Montreal Neurological Institute (MNI) space masks. To corroborate these results, we aimed to investigate the LC rs-fc at native space by improving the identification of the LC location using a neuromelanin sensitive sequence. Twenty-five healthy male participants (mean age 24.8 ± 4.2) were examined in a Siemens MAGNETOM Prisma 3 T MRT applying a neuromelanin sensitive T1TSE sequence and functional MRI. We compared the rs-fc of LC calculated by a MNI-based approach with extraction of the BOLD signal at the exact individual location of the LC after applying CompCor and field map correction. As a measure of advance, a marked increase of regional homogeneity (ReHo) of time series within LC could be achieved with the subject-specific approach. Furthermore, the methods differed in the rs-fc to the right temporoparietal junction, which showed stronger connectivity to the LC in the MNI-based method. Nevertheless, both methods comparably revealed LC rs-fc to multiple brain regions including ACC, bilateral thalamus, and cerebellum. Our results are relevant for further research assessing and interpreting LC function, especially in patient populations examined at 3 T MRI., (© 2020 The Authors. Human Brain Mapping published by Wiley Periodicals, Inc.)

Intracranial stents have expanded endovascular therapy options for intracranial aneurysms. The braided Accero stent is available for clinical use since May 2015. To date, no clinical reports on the stent are available. Purpose of this study was the evaluation of the safety and efficacy of the Accero stent in stent-assisted coiling. All patients, in whom implantation of the stent was performed, were included. Primary endpoints were good clinical outcome (mRS ≤ 2) and aneurysm occlusion grades 1 and 2 (Raymond Roy Occlusion Classification). Secondary endpoints were procedural and device-related complications with permanent disability or death, complications in the course, and the recanalization rate. Between September 2015 and August 2018, thirty-four aneurysms were treated with stent-assisted coiling using the Accero. Sixteen aneurysms were untreated, four of these were ruptured. Mild neurological complications occurred in 2/34 (5.9%) treatments. Two stent occlusions occurred during follow-up. No patient had a poor procedure- or device-related outcome. After an average of 15 months of follow-up, 28/30 aneurysms were completely or near-completely occluded. The Accero stent proved to be safe and effective in the treatment of broad-based intracranial aneurysms. The complication rate and the rate of successful aneurysm occlusions are similar to those of other stents.

Objective:  Dural arteriovenous fistulas of the craniocervical junction are rare but the most dangerous of spinal fistulas. The concurrent brainstem edema has been attributed to increased pressure within the venous outflow of the brainstem and upper cord, but the differential diagnosis of brainstem edema is demanding. This report presents the details of clinical findings, magnetic resonance imaging (MRI) , surgical techniques, and follow-up of these fistulas., Methods:  Three cases with dural arteriovenous fistulas and edema of the brainstem and upper cord are described plus a review of the literature. Clinical presentation, radiologic findings, and a follow-up of outcomes are presented., Results:  All three cases with misleading diagnoses at the time of referral experienced variable degrees of tetraparesis with brainstem edema on MRI. Congested veins on MRI raised the suspicion of a vascular origin of the edema. The diagnosis was established with highly specific angiography with microcatheters identifying a feeder from the ascending pharyngeal artery in two cases and a tentorial feeder from the carotid artery in one case. The operation included temporary clipping of the fistula and neuromonitoring. Follow-up confirmed improvement of clinical signs and resolution of the brainstem edema on MRI., Conclusion:  Edema of the brainstem and cervical cord may be caused by a dural arteriovenous fistula of the craniocervical junction. Surgical occlusion may be an efficient option for the complete resolution of radiologic and clinical symptoms., Competing Interests: None declared., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: To assess the vascular and clinical course of acute symptomatic extracranial internal carotid artery (ICA) occlusion. Patients and methods: Patients with an acute ischemic event in the anterior circulation and corresponding extracranial ICA occlusion at CT angiography and/or color-coded duplex sonography underwent recurrent duplex follow-up for detection of spontaneous recanalization. Stroke recurrence and functional outcome 4.5 months after the ischemic index event assessed by modified Rankin scale served as secondary outcome parameters. Results: 133 patients (91 men, mean age 62.3 years, SD 10.8) demonstrated symptomatic occlusion of the extracranial ICA with open intracranial ICA and open middle cerebral artery and were followed-up for spontaneous recanalization. Twenty-eight recanalized spontaneously, 25 to high-grade focal stenosis within 12 days, revealing an early cumulative recanalization rate of 23 %. Detection of recanalization was independently associated with de novo dual anti-platelet therapy (adjusted odds ratio [OR], 3.24; 95 % confidence interval [CI], 1.34 to 7.80). Ischemic recurrence occurred in 16 patients, of which 10 deemed to be embolic and 5 hemodynamic. Spontaneous ICA recanalization and an exhausted cerebrovascular reserve in the hemisphere distal to the occluded ICA were both independently associated with the occurrence of a recurrent ischemic event at Cox regression. An increasing NIHSS score at admission, a decreasing middle cerebral artery flow velocity and an ischemic recurrence independently predicted poor outcome (modified Rankin scale 3 to 6) in multivariate analysis. Conclusions: Acute symptomatic extracranial ICA occlusion is an unstable condition with frequent spontaneous recanalization to severe stenosis and early embolic stroke recurrence, demanding appropriate prevention especially in those patients with only mild deficit.

Purpose: Currently no detailed in vivo imaging of the intracranial vessel wall exists. Ex vivo histologic images can provide information about the intracranial aneurysm (IA) wall composition that is useful for the understanding of IA development and rupture risk. For a 3D analysis, the 2D histologic slices must be incorporated in a 3D model which can be used for a spatial evaluation of the IA's morphology, including analysis of the IA neck., Methods: In 2D images of histologic slices, different wall layers were manually segmented and a 3D model was generated. The nuclei were automatically detected and classified as round or elongated, and a neural network-based wall type classification was performed. The information was combined in a software prototype visualization providing a unique view of the wall characteristics of an IA and allowing interactive exploration. Furthermore, the heterogeneity (as variance of the wall thickness) of the wall was evaluated., Result: A 3D model correctly representing the histologic data was reconstructed. The visualization integrating wall information was perceived as useful by a medical expert. The classification produces a plausible result., Conclusion: The usage of histologic images allows to create a 3D model with new information about the aneurysm wall. The model provides information about the wall thickness, its heterogeneity and, when performed on cadaveric samples, includes information about the transition between IA neck and sac.

The correct placement of needles is decisive for the success of many minimally-invasive interventions and therapies. These needle insertions are usually only guided by radiological imaging and can benefit from additional navigation support. Augmented reality (AR) is a promising tool to conveniently provide needed information and may thus overcome the limitations of existing approaches. To this end, a prototypical AR application was developed to guide the insertion of needles to spinal targets using the mixed reality glasses Microsoft HoloLens. The system's registration accuracy was attempted to measure and three guidance visualisation concepts were evaluated concerning achievable in-plane and out-of-plane needle orientation errors in a comparison study. Results suggested high registration accuracy and showed that the AR prototype is suitable for reducing out-of-plane orientation errors. Limitations, like comparatively high in-plane orientation errors, effects of the viewing position and missing image slices indicate potential for improvement that needs to be addressed before transferring the application to clinical trials.

Purpose: Flow diverter (FD) devices show severe shortening during deployment in dependency of the vessel geometry. Valid information regarding the geometry of the targeted vessel is therefore mandatory for correct device selection, and to avoid complications. But the geometry of diseased tortuous intracranial vessels cannot be measured accurately with standard methods. The goal of this study is to prove the accuracy of a novel virtual stenting method in prediction of the behavior of a FD in an individual vessel geometry., Methods: We applied a virtual stenting method on angiographic 3D imaging data of the specific vasculature of patients, who underwent FD treatment. The planning tool analyzes the local vessel morphology and deploys the FD virtually. We measured in 18 cases the difference between simulated FD length and real FD length after treatment in a landmark-based registration of pre-/post-interventional 3D angiographic datasets., Results: The mean value of length deviation of the virtual FD was 2.2 mm (SD ± 1.9 mm) equaling 9.5% (SD ± 8.2%). Underestimated cases present lower deviations compared with overestimated FDs. Flow diverter cases with a nominal device length of 20 mm had the highest prediction accuracy., Conclusion: The results suggest that the virtual stenting method used in this study is capable of predicting FD length with a clinically sufficient accuracy in advance and could therefore be a helpful tool in intervention planning. Imaging data of high quality are mandatory, while processing and manipulation of the FD during the intervention may impact the accuracy.

Background and Purpose: Mechanical thrombectomy, in addition to intravenous (i.v.) thrombolysis is recommended for treatment of acute stroke in patients with large vessel occlusions (LVO) in the anterior circulation up to 6 h after symptom onset. We compared thrombectomy rates of eight university hospitals of the MIRACUM consortium to analyze the implementation of this guideline in clinical routine., Methods: Anonymized billing data in a standardized format were loaded into a local i2b2 data warehouse by applying already existing extract, transform and load (ETL) routines. A locally executed uniform SQL (structured query language) query delivered aggregated site data for all inpatients with a discharge diagnosis of ischemic stroke (ICD-10 I63) containing counts for type of acute treatment, type of admission and age groups, which were centrally analyzed with R., Results: From 2014 to 2016, the thrombectomy rate almost doubled from a mean of 4.7% to 9.6%, although significant differences between centers exist (range in 2016: 5.8-17%). The number of drip-and-ship procedures increased in 3 out of 8 centers. There was no evidence for a decrease in thrombectomy rates during weekends/holiday or among patients older than 80 years, but this age group is more likely to receive i.v. recombinant tissue plasminogen activator (rtPA)., Conclusion: The observed increase of thrombectomy rates and drip-and-ship procedures without a significant difference between weekdays and weekends or patients of different ages is substantiating a rapid implementation of stroke guidelines within the analyzed neurovascular centers. The prototype of the MIRACUM Data Integration Center already contributes to health services research in Germany.

The accuracy of Monte Carlo (MC) simulations in estimating the computed tomography radiation dose is highly dependent on the proprietary x-ray source information. To address this, this study develops a method to precisely estimate the x-ray spectrum and bowtie (BT) filter thickness of the x-ray source based on physical measurements and calculations. The static x-ray source of the CT localizer radiograph was assessed to measure the total filtration at the isocenter for the x-ray spectrum characterization and the BT profile (air-kerma values as a function of fan angle). With these values, the utilized BT filter in the localizer radiograph was assessed by integrating the measured air kerma in a full 360-deg cycle. The consistency observed between the integrated BT filter profiles and the directly measured profiles pointed to the similarity in the utilized BT filter in terms of thickness and material between the static and rotating x-ray geometries. Subsequently, the measured air kerma was used to calculate the BT filter thickness and was verified using MC simulations by comparing the calculated and measured air-kerma values, where a very good agreement was observed. This would allow a more accurate computed tomography simulation and facilitate the estimation of the dose delivered to the patients.

Purpose: Interaction with radiological image data and volume renderings within a sterile environment is a challenging task. Clinically established methods such as joystick control and task delegation can be time-consuming and error-prone and interrupt the workflow. New touchless input modalities may have the potential to overcome these limitations, but their value compared to established methods is unclear., Methods: We present a comparative evaluation to analyze the value of two gesture input modalities (Myo Gesture Control Armband and Leap Motion Controller) versus two clinically established methods (task delegation and joystick control). A user study was conducted with ten experienced radiologists by simulating a diagnostic neuroradiological vascular treatment with two frequently used interaction tasks in an experimental operating room. The input modalities were assessed using task completion time, perceived task difficulty, and subjective workload., Results: Overall, the clinically established method of task delegation performed best under the study conditions. In general, gesture control failed to exceed the clinical input approach. However, the Myo Gesture Control Armband showed a potential for simple image selection task., Conclusion: Novel input modalities have the potential to take over single tasks more efficiently than clinically established methods. The results of our user study show the relevance of task characteristics such as task complexity on performance with specific input modalities. Accordingly, future work should consider task characteristics to provide a useful gesture interface for a specific use case instead of an all-in-one solution.

Radiofrequency ablation is a valuable tool in the treatment of many diseases, especially cancer. However, controlled heating up to apoptosis of the desired target tissue in complex situations, e.g. in the spine, is challenging and requires experienced interventionalists. For such challenging situations a mathematical model of radiofrequency ablation allows to understand, improve and optimise the outcome of the medical therapy. The main contribution of this work is the derivation of a tailored, yet expandable mathematical model, for the simulation, analysis, planning and control of radiofrequency ablation in complex situations. The dynamic model consists of partial differential equations that describe the potential and temperature distribution during intervention. To account for multipolar operation, time-dependent boundary conditions are introduced. Spatially distributed parameters, like tissue conductivity and blood perfusion, allow to describe the complex 3D environment representing diverse involved tissue types in the spine. To identify the key parameters affecting the prediction quality of the model, the influence of the parameters on the temperature distribution is investigated via a sensitivity analysis. Simulations underpin the quality of the derived model and the analysis approach. The proposed modelling and analysis schemes set the basis for intervention planning, state- and parameter estimation, and control., (Copyright © 2016. Published by Elsevier Inc.)

Computational Fluid Dynamics enables the investigation of patient-specific hemodynamics for rupture predictions and treatment support of intracranial aneurysms. However, due to numerous simplifications to decrease the computations effort, clinical applicability is limited until now. To overcome this situation a clinical research software prototype was tested that can be easily operated by attending physicians. In order to evaluate the accuracy of this prototype, four patient-specific intracranial aneurysms were investigated using four different spatial resolutions. The results demonstrate that physicians were able to generate hemodynamic predictions within several minutes at low spatial resolution. However, depending on the parameter of interest and the desired accuracy, higher resolutions are required, which will lead to an increase of computational times that still look very attractive towards clinical usability. The study shows that the next step towards an applicable individualized therapy for patients harboring intracranial aneurysms can be done. However, further in vivo validations are required to guarantee realistic predictions in future studies.

Purpose: Rupture risk assessment of an intracranial aneurysm (IA) is an important factor for indication of therapy. Until today, there is no suitable objective prediction method. Conventional imaging modalities cannot assess the IA's vessel wall. We investigated the ability of intravascular optical coherence tomography (OCT) as a new tool for the characterization and evaluation of IAs., Materials and Methods: An experimental setup for acquisition of geometrical aneurysm parameters was developed. Object of basic investigation was a silicone phantom with six IAs from patient data. For structural information, three circle of Willis were dissected and imaged postmortem. All image data were postprocessed by medical imaging software., Results: Geometrical image data of a phantom with six different IAs were acquired. The geometrical image data showed a signal loss, e.g., in aneurysms with a high bottleneck ratio. Imaging data of vessel specimens were evaluated with respect to structural information that is valuable for the characterization of IAs. Those included thin structures (intimal flaps), changes of the vessel wall morphology (intimal thickening, layers), adjacent vessels, small vessel outlets, arterial branches and histological information., Conclusion: Intravascular OCT provides new possibilities for diagnosis and rupture assessment of IAs. However, currently used imaging system parameters have to be adapted and new catheter techniques have to be developed for a complete assessment of the morphology of IAs.