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Purpose: To prospectively evaluate emboli detected at transcranial Doppler ultrasonography (US) and outcome of carotid angioplasty and stent placement and compare these findings in patients treated with the use of filtering cerebral protection devices (CPDs) with the findings in patients treated without the use of filtering CPDs., Materials and Methods: This study was approved by the institutional human research committee. Written informed consent was obtained for all patients. Patients were divided into three groups: 161 patients treated before filtering CPDs had become available (group 1), 151 patients treated with filtering CPDs (group 2), and 197 patients treated without CPDs after CPDs had become available (group 3). Clinical end points were cerebral ischemic events and death. Transcranial Doppler US end points included isolated microemboli, microembolic showers, macroemboli, and distal thrombus. The procedure was divided into five phases: wiring, predilation, stent deployment, postdilation, and CPD handling. Data not distributed normally were analyzed with the Mann-Whitney U statistic. For binomial data, the chi(2) test was used. P < .05 indicated statistical significance., Results: For each phase, median and interquartile range (IQR) for isolated microemboli in group 2 versus group 3 were as follows: wiring, 51 (IQR, 31-69) versus 27 (IQR, 15-48); predilation, 19 (IQR, 13-33) versus 13 (IQR, 8-19); stent deployment, 64 (IQR, 46-82) versus 48.5 (IQR, 33.25-66); and postdilation, 24 (IQR, 14-39) versus 16 (IQR, 11-27.5) (P < .001 for each phase). Median and IQR for microembolic showers were as follows: wiring, 0 (IQR, 0-3) versus 0 (IQR, 0-0); predilation, 1.5 (IQR, 0-4) versus 0 (IQR, 0-2); stent deployment, 22 (IQR, 11-36) versus 11 (IQR, 6-17); postdilation, three (IQR, 0-9) versus one (IQR, 0-4); (postdilation phase, P = .001; all other phases, P < .001). Median for isolated microemboli in group 1 versus groups 2 and 3 combined were as follows: predilation, 10 (IQR, 5-22.75) versus 16 (IQR, 9-25) (P = .001); stent deployment, 32 (IQR, 15-58) versus 54 (IQR, 40.5-74) (P < .001); and postdilation, 11 (IQR, 6-19) versus 18 (IQR, 12-33) (P < .001). Median for microembolic showers during stent deployment were six (IQR, 1-14) versus 13 (IQR, 7-26) (P < .001). Five patients died, and five major strokes and 14 minor strokes occurred. Eight macroemboli occurred in unprotected procedures; six distal thrombi occurred in protected procedures., Conclusion: Carotid angioplasty and stent placement yielded more microemboli in patients treated with filtering CPDs than in unprotected procedures. The infrequent occurrence of cerebral sequelae did not allow comprehensive statistical comparison between groups., ((c) RSNA, 2004.)

Objectives: Carotid Artery Stenting (CAS) may be comparable to Carotid Endarterectomy (CEA) as a durable and effective procedure in stroke prevention. Concern remains about the incidence of restenosis after stenting and its management. We evaluated the surgical management of restenosis after CAS., Design: prospective study., Methods: between December 1997 and April 2001, 217 CAS procedures were performed in 217 patients (155 men and 62 women; age 70 years +/- 8.2). After a mean of 8 months post-stenting four patients (two symptomatic, two asymptomatic with contralateral occlusion) with severe haemodynamic in-stent restenosis (90-99%) had surgical reintervention., Results: standard CEA with removal of the stent was performed in all four patients. No major complications occurred. Intima hyperplasia showed to be the predominant mechanism leading to in-stent restenosis. All four surgically treated patients remained asymptomatic and without recurrent restenosis over a mean follow-up time of 13 months (range 3-20 months)., Conclusion: the optimal treatment of in-stent restenosis has yet to be defined, but standard CEA with removement of the stent appears to be feasible.

Objectives: To prospectively document the incidence, location, risk factors for and clinical consequences of restenosis after carotid artery angioplasty and stenting (CAS)., Methods: Serial duplex and neurological examinations were performed in 217 patients one day (n = 216), 3 (n = 189), 12 (n = 129) and 24 (n = 48) months, after CAS. The relationship between patient, lesion and procedure variables and restenosis was determined at 12 months., Results: The prevalence of restenosis > or = 50% was 14, 16, 18, and 21%, respectively, and was only significantly related with loss of proximal stent apposition (odds ratio 3.4, 95% confidence interval: 1.0-11.7, p < 0.05). Four restenoses were symptomatic., Conclusions: Restenosis after CAS is common, unpredictable but infrequently symptomatic.

Purpose: To assess, with magnetic resonance (MR) imaging, the number and size of new brain lesions after carotid angioplasty and stent placement (CAS) and to evaluate the association of these new lesions with neurologic deficits and transcranial Doppler ultrasonographic (US) data., Materials and Methods: Seventy-two consecutive CAS procedures were performed in 72 patients. Patients underwent neurologic examination before, during, immediately after, and 1 day, 3 months, and 1 year after CAS. MR imaging was used before and after CAS to assess the number of symptomatic and silent new infarctions. Two radiologists reviewed all pre- and postintervention MR images. The radiologists were blinded to the clinical data., Results: Postprocedural MR images showed new lesions on the side of stent placement in 11 patients. In six patients, the new lesions were clinically silent. Two patients had a major stroke, one had a minor stroke, and two had transient ischemic attack. In patients who had had transient ischemic attack or stroke before CAS, the frequency of new lesions at postprocedural MR imaging was higher (23%) than in asymptomatic patients (12%); this difference was not statistically significant (P =.29). There was no statistically significant correlation between embolic load as detected with transcranial Doppler US monitoring and the occurrence of either clinical symptoms or new lesions seen at MR imaging., Conclusion: CAS is associated with embolic events. The majority of new lesions seen on postintervention MR images are not detected at neurologic examination., (Copyright RSNA, 2002)

In a five-month-old girl, who for a week had cried and displayed a relapse in the motor development, generalised hypotonia and meningism were found. Eventually, the results of the cerebrospinal fluid analysis and electromyography indicated Guillain-Barré syndrome. She was treated with immunoglobulins and made a quick recovery. Guillain-Barré syndrome is an acute or subacute inflammatory demyelinating polyradiculoneuropathy that can occur at any age. In children, the classic symptoms such as a flaccid paralysis and areflexia are not always predominant. Instead, pain is often the most prominent symptom, along with meningism. These symptoms are often insufficiently recognised in practice and as a result of this, delays in the diagnosis of this potentially life-threatening disease often occur.

Objectives: To analyse four years of CEA with respect to the underlying mechanisms of perioperative stroke and the role of intraoperative monitoring in the prevention of stroke., Patients and Methods: From January 1996 through December 1999, 599 CEAs were performed in 404 men and 195 women (mean age: 65 years, range: 39-88). All operations were performed under general anaesthesia using computerised electroencephalography (EEG) and transcranial Doppler (TCD). Any new or any extension of an existing focal cerebral deficit, as well as stroke-related death were registered. Perioperative strokes were classified by time of onset (intraoperative or postoperative), outcome (minor or major stroke), and side (ipsilateral or contralateral). Stroke aetiology was assessed intraoperatively by means of EEG, TCD, completion arteriography or immediate re-exploration, and postoperatively by duplex sonography, computerised tomography (CT) or magnetic resonance imaging (MRI) of the head., Results: Perioperative stroke or death occurred in 20 (3.3%) patients. In four operations stroke was apparent immediately after surgery. Mechanisms of these strokes were ipsilateral carotid artery occlusion (1) and embolisation (3). In 16 patients stroke developed after a symptom-free interval (2-72 h, mean 18 h) due to occlusion of the internal carotid artery on the side of surgery (9). Other mechanisms were: contralateral occlusion of the internal carotid artery (1), postoperative hyperperfusion syndrome (1), intracerebral haemorrhage (1), and contralateral ischaemia due to prolonged clamping (1). In three procedures the cause was unknown., Conclusions: In our experience most strokes from CEA developed after a symptom-free interval and mainly due to thromboembolism of the operated artery. We suggest the introduction of additional TCD monitoring during the immediate postoperative phase., (Copyright 2001 Harcourt Publishers Limited.)

Unlabelled: Facial palsy is a rare neurological complication of chickenpox. A 5-year-old girl exhibited a right facial palsy followed by the appearance of the characteristic chicken pox exanthem. Subsequently she suffered a left facial palsy. In this patient both pathophysiological mechanisms responsible and their relation to the phase of infection are illustrated., Conclusion: Facial palsy as a complication of chickenpox can result from pre-eruptive haematogenous or neurogenous spread of varicella-zoster virus.

Two patients are presented who during carotid endarterectomy (CEA) temporarily showed an obstruction of the middle cerebral artery (MCA) mainstem by a macroembolus resulting in cerebral ischaemia. Both cases are unusual examples of CEA and selected from a cohort of more than 1,500 operations. During surgery with general anaesthesia, brain function was monitored with computerized electroencephalography (EEG) and transcranial Doppler (TCD) ultrasonography. The simultaneous use of EEG and TCD monitoring allowed us to witness the development of intraoperative cerebral ischaemia and to relate these events to a temporary occlusion of the MCA mainstem by a macroembolus. This is the first life report that describes obstruction of a cerebral artery by arterial embolism resulting in cerebral ischaemia.

Purpose: Carotid endarterectomy (CEA) performed with continuous transcranial Doppler monitoring provides a unique opportunity to determine the number of cerebral microemboli and to relate their occurrence to the surgical technique. The purpose of this study was to assess in CEA the impact of cerebral microembolism on clinical outcome and brain architecture. We also evaluated the influence of the audible transcranial Doppler signal on the surgeon and his or her technique., Methods: In a prospective series of 301 patients, CEA was monitored with electroencephalography and transcranial Doppler ultrasonography of the ipsilateral middle cerebral artery. Preoperative and intraoperative risk factors were entered in a logistic regression analysis program to assess their correlation with cerebral outcome. To evaluate the impact of cerebral microembolism on brain architecture, we compared preoperative and postoperative computed tomography scans or magnetic resonance images of the brain in two subgroups of 58 and 40 patients, respectively., Results: Seven (2.3%) patients had intraoperative transient ischemic symptoms, three (1%) had intraoperative strokes, 1 (0.3%) had transient ischemic symptoms after operation, and 10 (3.3%) had postoperative strokes. Four (1.3%) patients died. Microemboli (> 10) noticed during dissection were related to both intraoperative (p < 0.002) and postoperative (p < 0.02) cerebral complications. Microemboli that occurred during shunting were also related to intraoperative complications (p < 0.007). Microembolism never resulted in new morphologic changes on postoperative computed tomography scans. On the contrary, the phenomenon of more than 10 microemboli during dissection was significantly (p < 0.005) related to new hyperintense lesions on postoperative T2-weighted magnetic resonance images., Conclusions: During CEA the presence of microembolism (> 10 microemboli) during dissection shows a statistically significant relationship with perioperative cerebral complications and with new ischemic lesions on magnetic resonance images of the brain. Moreover, microembolism during shunting is also related to intraoperative complications. Surgeons can be guided by the audio Doppler and emboli signals by changing their technique. This change may result in a decrease of microembolism and consequently in a decline of the intraoperative stroke rate.

Thirty-six patients with pathology in the area of the craniocervical junction and the cervical spine have been studied with Magnetic Resonance Imaging (MRI), using the Inversion Recovery and Spin-Echo technique. The value of MRI for diagnosis and management is compared, in retrospect, to X-ray Computer Tomography and Myelography. The conclusion is that MRI can replace CT and myelography in the clinical evaluation of many patients with pathology of the craniocervical junction and the cervical spine.

The authors describe a case of panmedullary ependymoma presenting with multiple cysts complicated by fatty deposits in the spinal cord from C6 to D2 as demonstrated by CT-scanning. To the authors' best knowledge the combination of these features have not been described previously. The radiological, operative and histological findings are discussed and compared with those of other panmedullary spinal cord tumours such as astrocytomas.

The case reports of 102 patients with subdural empyema, diagnosed in the years 1935-83, were reviewed to determine the factors affecting the outcome. Statistical analysis (likelihood ratio tests with chi square approximation and logistic regression) showed that year of diagnosis (p less than 0.01) and level of consciousness at the moment of diagnosis (p less than 0.01) had a significant bearing on the chance to survive and that these same two factors (each factor p less than 0.01) and extent of subdural pus accumulation at the moment of diagnosis (p less than 0.05) had a significant bearing on the chance of survival without severe disability. Among others the duration of the disease up to the moment of diagnosis and the mode of the first surgical procedure had no significant bearing on the outcome. These results together with those in the literature are discussed and it is concluded that diagnosis and treatment before the patient lapses into stupor or coma, increases the chance of survival and that with adequate management a mortality rate of 10% or lower is to be expected.

A case history of a patient with a Migrant sensory neuritis of Wartenberg is presented. In this syndrome several isolated cutaneous nerves are affected, apparently due to traction lesions. This benign disease should be differentiated from other, more serious neurological diseases.

The data of 48 patients with a subdural empyema, treated in the period 1946-1980, have been reviewed in order to evaluate factors that influenced the outcome. A delay in diagnosis and surgical treatment, plus a severe disturbance of consciousness at the moment of surgery, all had a negative bearing on the subsequent outcome. The mode of operation also had an influence on the outcome in this series. In those patients with a severely disturbed level of consciousness at the time of surgery, the outcome was more favourable if multiple burr-holes were performed rather than a craniotomy. In patients with a minor disturbance of consciousness, however, this difference was not apparent.

The authors discuss the value of intravenous contrast enhancement in CT scanning in acute head injury. In a series of seventy consecutive patients they conclude that no incremental information was obtained by performing contrast-enhanced CT scans in the acute phase of the head injury.

After the introduction of CT-scanning the management of focal cerebral infections has been modified. Based on the data of two patients and on the literature the authors discuss the choice between fully conservative, immediately neurosurgical or delayed neurosurgical treatment. It is the author's opinion that by closely following the infectious process too early neurosurgical intervention can be avoided and thus unnecessary sacrifice of viable neural tissue.

We present two patients with an astrocytoma, involving the whole spinal cord. Operation was performed in both cases: one patient died because of complications after the operation, the condition of the other patient improved greatly. In the literature we could find three other cases of astrocytoma, extending into more than ten segments of the spinal cord. The clinical picture and the differential diagnosis with ependymomas of the same length are discussed.

The EEG findings in 9 patients with a subdural empyema are reported. In all cases the EEG, recorded before the diagnosis had been established, contained focal zeta waves, extensive unilateral depression of cortical activity and, in all but one, a diffuse slowing of the background activity. This combination has not been reported before in the literature and it is concluded that in its presence the existence of a subdural empyema should be seriously considered. Comparison with CT scan findings in 3 cases indicated that sometimes EEG may be more sensitive than CT scanning in the diagnosis of subdural empyema. The value of EEG and CT scan in the diagnosis of patients presenting with an acute or subacute bacterial meningo-encephalitis is briefly discussed.