Treatment of intracerebellar haemorrhage: Poor outcome and high long-term mortality.

BACKGROUND: Intracerebellar haemorrhage constitutes around 10% of all spontaneous, non-aneurysmal intracerebral haemorrhages (ICHs) and often carries a grim prognosis. In symptomatic patients, surgical evacuation is usually regarded the standard treatment. Our objective was to compare the in-hospital mortality and functional outcome at hospital discharge in either medically or surgically treated patients, and the impact of either treatment on long-term mortality after a cerebellar ICH. METHODS: An observational, retrospective, single-centre consecutive series of 114 patients with cerebellar ICH. We assessed the effect of different demographic factors on functional outcome and in-hospital mortality using logistic regression. We also divided the patients in medical and surgical treatment groups based on how they had been treated and compared the clinical and radiological parameters, in-hospital, and long-term mortality in the different groups. RESULTS: In our series, 38 patients (33.3%) underwent haematoma evacuation and 76 (66.7%) received medical treatment. Glasgow coma scale <8, blocked quadrigeminal cistern, and severe hydrocephalus were associated with in-hospital death or poor functional outcome at discharge (modified Rankin scale 4-6). Surgically treated patients were younger, had larger haematomas both in volume and diameter, were in a worse clinical condition, and suffered more from hydrocephalus and brainstem compression. There were no statistically significant differences in in-hospital or long-term mortality. However, the surgically treated patients remained in a poor clinical condition. CONCLUSIONS: Surgical treatment of cerebellar ICH can be life-saving but often leads to a poor functional outcome. New studies are needed on long-term functional outcome after a cerebellar ICH.

Visualization of luminal thrombosis and mural Iron accumulation in giant aneurysms with Ex vivo 4.7T magnetic resonance imaging.

BACKGROUND: Better diagnostic tools to identify rupture-prone saccular intracranial aneurysms (sIA) are needed. Inflammation and luminal thrombus associate with degeneration and rupture of the sIA wall. Iron-uptake has been detected in the inflammatory cells of the sIA wall and thrombus is the likely source of this iron. We investigated ex vivo the use of magnetic resonance imaging (MRI) to detect iron accumulation and luminal thrombus in giant sIAs. METHODS: Giant sIAs (n = 3) were acquired from microsurgical operations, fixed with formalin, embedded in agar and imaged at 4.7T. Samples were sectioned maintaining the orientation of the axial plane of MRI scans, and stained (hematoxylin-eosin and Prussian blue). RESULTS: All three giant sIAs showed a degenerated hypocellular wall with both mural and adventitial iron accumulation and displayed different degrees of luminal thrombus formation and thrombus organization. Signal intensity varied within the same sIA wall and associated with iron accumulation in all tested sequences. Wall areas with iron accumulation had significantly lower signal to noise ratio (SNR) compared with areas without iron accumulation (P = 0.002). Fresh and organizing thrombus differed in their MRI presentation and differed in signal intensity of the aneurysm wall (P = 0.027). CONCLUSION: MRI can detect ex vivo the accumulation of iron in giant sIA wall, as well as fresh and organizing luminal thrombus. These features have been previously associated with fragile, rupture-prone aneurysm wall. Further studies of iron accumulation as a marker of rupture-prone aneurysm wall are needed.

High-resolution TOF MR angiography at 4.7 Tesla for volumetric and morphologic evaluation of coiled aneurysm neck remnants in a rat model.

BACKGROUND: Detection of morphologic and volumetric changes in aneurysm necks is important when evaluating the effects of endovascular devices for aneurysm occlusion. PURPOSE: To optimize high-resolution 3D-TOF MRA at 4.7 T in order to achieve the best aneurysm-to-background contrast in experimental rat aneurysms, and to quantify the volume of the aneurysm neck by imaging. MATERIAL AND METHODS: Saccular aneurysms in the abdominal aorta of rats were coiled with platinum coils. Tissue relaxation times were measured, and used in a mathematical simulation. To optimize 3D-TOF angiography, imaging parameters were varied within the range obtained from the simulations. Tissue contrast and contrast-to-noise ratio were measured from MR images. TOF images were compared to conventional spin echo and gradient echo images and to endoscopic and histological analyses. RESULTS: Parameters yielding the best aneurysm-to-background contrast and contrast-to-noise ratio were determined. The agreement between the results from in vivo imaging and simulation was good. The optimized 3D-TOF MRA sequence (TR/TE/FA = 60 ms/6.6 ms/20°) had an isotropic voxel size of 117 µm, which enabled measurement of the aneurysm neck volume. CONCLUSION: High-resolution 3D-TOF angiography enables non-invasive quantification of changes in neck remnants of endovascularly coiled experimental aneurysms. In this model innovations like bioactive coils can be accurately tested for their efficacy for aneurysm occlusion.

Optimization of high-resolution USPIO magnetic resonance imaging at 4.7 T using novel phantom with minimal structural interference.

PURPOSE: To characterize the effect of ultrasmall superparamagnetic iron oxides (USPIOs) on magnetic resonance imaging (MRI) signal at 4.7 T, and to find the highest sensitivity pulse sequence for high-resolution USPIO MRI. MATERIALS AND METHODS: A novel phantom was constructed for optimization of sequence parameters for neuroradiological MR applications, and a wide range of dilutions of the USPIO ferumoxtran-10 was imaged using T(2)/T(1)-, T(1)-, T(2)-, T* (2)-, and PD-weighted sequences. The effect of varying sequence parameters was investigated using phantom measurements and simulations. RESULTS: The relaxivities r(1), r(2), and r*(2) of ferumoxtran-10 at 4.7 T (21°C) were 5.1, 82.2, and 148.4 mmol(-1) L s(-1), respectively. Gradient echo sequences produced superior susceptibility artifacts at high concentrations; susceptibility artifacts were seen down to a concentration of 137 nmol Fe/mL. A concentration of 17.5 µmol Fe/mL caused a signal void independently of sequence and parameters, and at concentrations ≤273 nmol Fe/mL no signal void was caused. Signal enhancement on T(1)-weighted imaging was seen only at concentrations 137-547 nmol Fe/mL. For the same effective echo time T(2)-weighted rapid acquisition with relaxation enhancement (RARE) yielded significantly higher contrast-to-noise ratio with RARE factor 16 than with RARE factor 8. CONCLUSION: At nanomolar concentrations of USPIO, steady-state free precession offers an alternative to T(2)- and T*(2)-weighted sequences. Optimum parameters depend highly on USPIO concentration.

Occlusion of neck remnant in experimental rat aneurysms after treatment with platinum- or polyglycolic-polylactic acid-coated coils.

BACKGROUND: Neck remnants and aneurysm recurrences are marked limitations of endovascular treatment of cerebral artery aneurysms. We compared the evolution of neck remnants of experimental arterial rat aneurysms after treatment with either platinum- or PGLA-coated coils. METHODS: We created 20 standard-size aneurysms in the abdominal aortas of male Wistar rats. Aneurysms were embolized with either PGLA-coated coils or platinum coils, with care taken to leave a neck remnant. Neck remnant size and shape was closely monitored to detect progressive enlargement or occlusion. Using a 4.7 T MR scanner, we acquired high-resolution MR images 6 times during the 4-week follow-up. For quantitative measurements, we used a high-resolution 3D-TOF angiography sequence. Results were verified by endoscopy and histology. RESULTS: Aneurysms treated with PGLA coils showed, on average, a 12.9% reduction of neck remnant size (P = .044) and significant disappearance of dog ears, the blood-filled spaces between coils and aneurysm wall. The aneurysms treated with platinum coils lacked these changes. In endoscopy, neointima was found to cover both PGLA and platinum coils but was more often incomplete or translucent in the platinum group. In histology, thrombus organization and inflammatory cell infiltration were higher with PGLA. CONCLUSION: Use of PGLA-coated coils was followed by a moderate progressive reduction of the neck remnant size and a better angiographic outcome, seen as disappearance of dog ears during follow-up. The rat model proved to be suitable for comparison of different coil types.

Outcome of a comprehensive neurorehabilitation program for patients with traumatic brain injury.

OBJECTIVE: To evaluate the outcome of a comprehensive neurorehabilitation program compared with that of conventional clinical care and rehabilitation for patients with traumatic brain injury (TBI). DESIGN: Nonrandomized, controlled trial with a 2-year follow-up. SETTING: Nationwide rehabilitation center and level I trauma center, both in Finland. PARTICIPANTS: We studied 19 consecutive adults with a significant TBI who underwent a comprehensive neurorehabilitation program and 20 control patients who received conventional rehabilitation referred by physicians in the general health care system. The outcome of the control patients was not known before the selection. The groups were similar in age, sex, education, injury severity (assessed on the Glasgow Coma Scale, radiologic and neuropsychologic findings, neurosurgical interventions), time from the injury, and preinjury employment status. INTERVENTIONS: A postacute, intensive, interdisciplinary, 6-week rehabilitation program for TBI patients who are considered to have adequate potential to achieve productivity by this means; focus on neuropsychologic rehabilitation and psychotherapy with vocational interventions and follow-up support. MAIN OUTCOME MEASURE: Status of productivity, judged as productive (defined as working, studying, or participating in volunteer activities) or nonproductive, evaluated on questionnaires filled in by patients and their significant others at the time of follow-up evaluation. RESULTS: At follow-up, 89% of the treated patients were productive compared with 55% of the controls. The rehabilitation program was significantly predictive of the productive status at follow-up (odds ratio=6.96; 95% confidence interval, 1.26-38.44; P=.017). Other factors did not explain the better productivity of the treatment group. Two neuropsychologist-evaluators, who were blind to the rehabilitation history of patients and to each other's evaluations, were perfectly consistent in their classification of patients' productivity statuses. CONCLUSIONS: The findings support the proposition that comprehensive neuropsychologically oriented rehabilitation programs can improve psychosocial functioning in terms of productivity in postacute patients with moderate to severe TBI. Additional larger controlled studies are needed to establish the efficacy of TBI rehabilitation interventions.