Health-related quality of life in patients with untreated cavernous malformations of the central nervous system.

BACKGROUND AND PURPOSE: To estimate health-related quality of life (HRQOL) in patients with untreated cavernous malformation of the CNS [cavernous cerebral malformations (CCMs)]. METHODS: We performed a cross-sectional observational study on patients with CCMs admitted to our department from 1 November 2017 to 10 January 2020 using standardized interviews [short-form-36 questionnaire, hospital anxiety and depression score (HADS-A/D), CCM perception questionnaire]. Included criteria were diagnosis of an untreated CCM and information about the diagnosis in a specialized CCM consultation. Health-related quality of life (HRQOL) data were analyzed and compared to the German normal population. Uni- and multivariate analyses were carried out to identify variables with impact on outcome. RESULTS: Two hundred nineteen (93%) of 229 eligible patients were included. Mean age was 46.3 ± 14.7 (18-86) years; 136 (62%) were female. Ninety-eight (45%) patients presented with symptomatic hemorrhage (SH), and 17 (8%) with repetitive SH. Ninety-two (42%) patients were asymptomatic. Thirty-seven patients (17%) suffered from cavernoma-related epilepsy. Twenty-eight patients (13%) suffered from familial CCMs. Patients showed significantly decreased component scores and subdomain scores compared to the normal population, with effects ranging from small to large. This accounted largely also for asymptomatic patients (except for physical component score and main physical subdomains). Multivariate regression analysis confirmed impact of functional impairment on physical component score. HADS-A was significantly increased. HADS-A/D strongly correlated with mental component score and individual perception of the CCM. CONCLUSIONS: Patients with the diagnosis of a CCM showed decreased HRQOL compared to the normal population even when not suffering functional impairment or neurological symptoms. Our data may function as benchmarks in evaluation of different (future) management strategies.

Wall Contrast Enhancement of Thrombosed Intracranial Aneurysms at 7T MRI.

BACKGROUND AND PURPOSE: The pathophysiology of wall contrast enhancement in thrombosed intracranial aneurysms is incompletely understood. This in vivo study aimed to investigate wall microstructures with gadolinium-enhanced 7T MR imaging. MATERIALS AND METHODS: Thirteen patients with 14 thrombosed intracranial aneurysms were evaluated using a 7T whole-body MR imaging system with nonenhanced and gadolinium-enhanced high-resolution MPRAGE. Tissue samples were available in 5 cases, and histopathologic findings were correlated with 7T MR imaging to identify the gadolinium-enhancing microstructures. RESULTS: Partial or complete inner wall enhancement correlated with neovascularization of the inner wall layer and the adjacent thrombus. Additional partial or complete outer wall enhancement can be explained by formation of vasa vasorum in the outer aneurysm wall layer. The double-rim enhancement correlated with perifocal edema and wall histologic findings suggestive of instability. CONCLUSIONS: Two distinct aneurysm wall microstructures responsible for gadolinium enhancement not depictable at lower spatial resolutions can be visualized in vivo using high-resolution gadolinium-enhanced 7T MR imaging.

Automatic and efficient MRI-US segmentations for improving intraoperative image fusion in image-guided neurosurgery.

Knowledge of the exact tumor location and structures at risk in its vicinity are crucial for neurosurgical interventions. Neuronavigation systems support navigation within the patient's brain, based on preoperative MRI (preMRI). However, increasing tissue deformation during the course of tumor resection reduces navigation accuracy based on preMRI. Intraoperative ultrasound (iUS) is therefore used as real-time intraoperative imaging. Registration of preMRI and iUS remains a challenge due to different or varying contrasts in iUS and preMRI. Here, we present an automatic and efficient segmentation of B-mode US images to support the registration process. The falx cerebri and the tentorium cerebelli were identified as examples for central cerebral structures and their segmentations can serve as guiding frame for multi-modal image registration. Segmentations of the falx and tentorium were performed with an average Dice coefficient of 0.74 and an average Hausdorff distance of 12.2 mm. The subsequent registration incorporates these segmentations and increases accuracy, robustness and speed of the overall registration process compared to purely intensity-based registration. For validation an expert manually located corresponding landmarks. Our approach reduces the initial mean Target Registration Error from 16.9 mm to 3.8 mm using our intensity-based registration and to 2.2 mm with our combined segmentation and registration approach. The intensity-based registration reduced the maximum initial TRE from 19.4 mm to 5.6 mm, with the approach incorporating segmentations this is reduced to 3.0 mm. Mean volumetric intensity-based registration of preMRI and iUS took 40.5 s, including segmentations 12.0 s.

Visualization and Classification of Deeply Seated Collateral Networks in Moyamoya Angiopathy with 7T MRI.

BACKGROUND AND PURPOSE: Collateral networks in Moyamoya angiopathy have a complex angioarchitecture difficult to comprehend on conventional examinations. This study aimed to evaluate morphologic patterns and the delineation of deeply seated collateral networks using ultra-high-field MRA in comparison with conventional DSA. MATERIALS AND METHODS: Fifteen white patients with Moyamoya angiopathy were investigated in this prospective trial. Sequences acquired at 7T were TOF-MRA with 0.22 × 0.22 × 0.41 mm3 resolution and MPRAGE with 0.7 × 0.7 × 0.7 mm3 resolution. Four raters evaluated the presence of deeply seated collateral networks and image quality in a consensus reading of DSA, TOF-MRA, and MPRAGE using a 5-point scale in axial source images and maximum intensity projections. Delineation of deeply seated collateral networks by different imaging modalities was compared by means of the McNemar test, whereas image quality was compared using the Wilcoxon signed-rank test. RESULTS: The relevant deeply seated collateral networks were classified into 2 categories and 6 pathways. A total of 100 collateral networks were detected on DSA; 106, on TOF-MRA; and 73, on MPRAGE. Delineation of deeply seated collateral networks was comparable between TOF-MRA and DSA (P = .25); however, both were better than MPRAGE (P < .001). CONCLUSIONS: This study demonstrates excellent delineation of 6 distinct deeply seated collateral network pathways in Moyamoya angiopathy in white adults using 7T TOF-MRA, comparable to DSA.

Ventricular Microaneurysms in Moyamoya Angiopathy Visualized with 7T MR Angiography.

The pathophysiologic role of hemodynamic alteration to peripheral vessels in Moyamoya angiopathy and the formation of microaneurysms remains unclear. The purpose of this study was to investigate microaneurysms in collateral Moyamoya vessels by using 7T ultra-high-field MR imaging. Ten patients with Moyamoya disease were evaluated with TOF-MRA at 7T acquired with 0.22 × 0.22 × 0.41 mm(3) resolution. In 10 patients, 4 microaneuryms located in the ventricles were delineated. The mean diameters of collateral vessels and microaneurysms arising from those vessels were 0.87 mm (range, 0.79-1.07 mm) and 0.80 mm (range, 0.56-0.96 mm), respectively. In 1 case with follow-up scans 6 months after a direct extracranial-intracranial bypass operation, the microaneurysm disappeared. Ventricular microaneurysms in Moyamoya angiopathy collateral vessels, inaccessible by conventional imaging techniques, can be detected by 7T TOF-MRA.

The CHESS score: a simple tool for early prediction of shunt dependency after aneurysmal subarachnoid hemorrhage.

BACKGROUND AND PURPOSE: Acute hydrocephalus is an early and common complication of aneurysmal subarachnoid hemorrhage (SAH). However, considerably fewer patients develop chronic hydrocephalus requiring shunt placement. Our aim was to develop a risk score for early identification of patients with shunt dependency after SAH. METHODS: Two hundred and forty-two SAH individuals who were treated in our institution between January 2008 and December 2013 and survived the initial impact were retrospectively analyzed. Clinical parameters within 72 h after the ictus were correlated with shunt dependency. Independent predictors were summarized into a new risk score which was validated in a subsequent SAH cohort treated between January and December 2014. RESULTS: Seventy-five patients (31%) underwent shunt placement. Of 23 evaluated variables, only the following five showed independent associations with shunt dependency and were subsequently used to establish the Chronic Hydrocephalus Ensuing from SAH Score (CHESS, 0-8 points): Hunt and Hess grade ≥IV (1 point), location of the ruptured aneurysm in the posterior circulation (1 point), acute hydrocephalus (4 points), the presence of intraventricular hemorrhage (1 point) and early cerebral infarction on follow-up computed tomography scan (1 point). The CHESS showed strong correlation with shunt dependency (P = 0.0007) and could be successfully validated in both internal SAH cohorts tested. Patients scoring ≥6 CHESS points had significantly higher risk of shunt dependency (P < 0.0001) than other patients. CONCLUSION: The CHESS may become a valuable diagnostic tool for early estimation of shunt dependency after SAH. Further evaluation and external validation will be required in prospective studies.

Giant Intracranial Aneurysms at 7T MRI.

Giant intracranial aneurysms are rare vascular pathologies associated with high morbidity and mortality. The purpose of this in vivo study was to assess giant intracranial aneurysms and their wall microstructure by 7T MR imaging, previously only visualized in histopathologic examinations. Seven giant intracranial aneurysms were evaluated, and 2 aneurysms were available for histopathologic examination. Six of 7 (85.7%) showed intraluminal thrombus of various sizes. Aneurysm walls were depicted as hypointense in TOF-MRA and SWI sequences with excellent contrast ratios to adjacent brain parenchyma (range, 0.01-0.60 and 0.58-0.96, respectively). The triple-layered microstructure of the aneurysm walls was visualized in all aneurysms in TOF-MRA and SWI. This could be related to iron deposition in the wall, similar to the findings in 2 available histopathologic specimens. In vivo 7T TOF-MRA and SWI can delineate the aneurysm wall and the triple-layered wall microstructure in giant intracranial aneurysms.

First-pass contrast-enhanced renal MRA at 7 Tesla: initial results.

OBJECTIVE: The aim of this study was to assess the feasibility of first-pass contrast-enhanced renal MR angiography (MRA) at 7 T. METHODS: In vivo first-pass contrast-enhanced high-field examinations were obtained in eight healthy subjects on a 7-T whole-body MRI. A custom-built body transmit/receive radiofrequency (RF) coil and RF system suitable for RF shimming were used for image acquisition. For dynamic imaging, gadobutrol was injected intravenously and coronal unenhanced, arterial and venous data sets using a T1-weighted spoiled gradient-echo sequence were obtained. Qualitative image analysis and assessment of artefact impairment were performed by two senior radiologists using a five-point scale (5 = excellent, 1 = non-diagnostic). SNR and CNR of the perirenal abdominal aorta and both main renal arteries were assessed. RESULTS: Qualitative image evaluation revealed overall high-quality delineation of all assessed segments of the unenhanced arterial vasculature (meanunenhanced 4.13). Nevertheless, the application of contrast agent revealed an improvement in vessel delineation of all the vessel segments assessed, confirmed by qualitative (meanunenhanced 4.13 to meancontrast-enhanced 4.85) and quantitative analysis (SNR meanunenhanced 64.3 to meancontrast-enhanced 98.4). CONCLUSION: This study demonstrates the feasibility and current constraints of ultra-high-field contrast-enhanced renal MRA relative to unenhanced MRA.

New look at renal vasculature: 7 tesla nonenhanced T1-weighted FLASH imaging.

PURPOSE: To investigate the feasibility of 7 Tesla (T) nonenhanced high field MR imaging of the renal vasculature and to evaluate the diagnostic potential of various nonenhanced T1-weighted (T1w) sequences. MATERIALS AND METHODS: Twelve healthy volunteers were examined on a 7T whole-body MR system (Magnetom 7T, Siemens Healthcare Sector) using a custom-built eight-channel radiofrequency (RF) transmit/receive body coil. Subsequent to RF shimming, the following sequences were acquired (i) fat-saturated two-dimensional (2D) FLASH, (ii) fat-saturated 3D FLASH, and a (iii) fat-saturated 2D time-of-flight MR angiography (TOF MRA). SNR and CNR were measured in the aorta and both renal arteries. Qualitative analysis was performed with regard to vessel delineation (5-point scale: 5 = excellent to 1 = nondiagnostic) and presence of artifacts (5-point scale: 5 = no artifact present to 1 = strong impairment). RESULTS: The inherently high signal intensity of the renal arterial vasculature in T1w imaging enabled moderate to excellent vessel delineation in all sequences. Qualitative (mean, 4.7) and quantitative analysis (SNR(mean) : 53.9; CNR(mean) : 28.0) demonstrated the superiority of TOF MRA, whereas 2D FLASH imaging provided poorest vessel delineation and was most strongly impaired by artifacts (overall impairment 3.7). The 3D FLASH MRI demonstrated its potential for fast high quality imaging of the nonenhanced arterial vasculature, providing homogeneous hyperintense vessel signal. CONCLUSION: Nonenhanced T1w imaging in general and, TOF MRA in particular, appear to be promising techniques for good quality nonenhanced renal artery assessment at 7 Tesla.

[The "AMDP scale for dissociation and conversion (AMDP-DK)": development of an observer-rated scale and first psychometric properties]. / Das AMDP-Modul zu Dissoziation und Konversion (AMDP-DK): Entwicklung einer Checkliste und erste Befunde zu ihren psychometrischen Charakteristika.

The AMDP scale for dissociation and conversion (AMDP-DK) represents an observer-rated scale for the assessment of dissociative and conversive phenomena, which closes the gap between available self-report questionnaires and time-consuming structured interviews with their respective disadvantages. The instrument comprises 30 operationalized items, which are rated according to the AMDP rules, and which are theoretically-driven divided into the subscales dissociation (15 items), conversion (9 items) and a "formal" dimension (6 items) to cover associated phenomena. In a sample of psychiatric inpatients (n = 73) the covered symptoms showed a great variety of frequency and intensity. The AMDP-DK and its subscales had good internal consistency (Cronbachs alpha between 0.76 and 0.85). A factor-analysis mostly replicated the theoretically constructed subscales. The convergent and divergent validity of the scale was good, as well as its ability to discriminate between high- and low-dissociating patients. The findings are discussed with regard to the psychometric properties and the relevance for the theories of dissociation and conversion.

[Temporary implantation of a metal stent in Vater's ampulla. Evaluation of early changes of the bile ducts in an animal study]. / Passagere Implantation eines Metallstents in der Papilla Vateri. Beurteilung von Frühveränderungen an der Gallengangswand im Tiermodell.

PURPOSE: Evaluation of temporary stent implantation in the papilla of vater and the subsequent alterations of the bile ducts in a controlled animal study. MATERIAL AND METHODS: In seven domestic pigs the papilla of vater was stented with a nitinolelastalloy-strecker stent over a period of three days. The microscopic and macroscopic changes of the biliary tract and the serologic parameters were judged. RESULTS: In three cases a slight widening of the peripheric bile ducts was found. With the exception of a mild elevation of lactate dehydrogenase the serological parameters remained normal. The explantation of the stent two possible in six cases. A thickening of the outer layers of the bile ducts and a low to middle grade injury of the mucosa were found histologically. CONCLUSION: A temporary stent implantation in the papilla of vater is feasible. The mucosal injuries caused by the temporary stent placement may be fully repairable. The method seems to be suitable for prolonged dilatation of benign stenoses.