Endovascular stroke therapy in Austria: a nationwide 1-year experience.

BACKGROUND AND PURPOSE: Based on a tight network of stroke units (SUs) and interventional centres, endovascular treatment of acute major intracranial vessel occlusion has been widely implemented in Austria. Documentation of all patients in the nationwide SU registry has thereby become mandatory. METHODS: Demographic, clinical and interventional characteristics of patients who underwent endovascular treatment for acute ischaemic stroke in 11 Austrian interventional centres between 1 October 2013 and 30 September 2014 were analysed. RESULTS: In total, 301 patients (50.5% women; median age 70.5 years; median National Institutes of Health Stroke Scale score 17) were identified.193 patients (64.1%) additionally received intravenous thrombolysis. The most frequent vessel occlusion sites were the M1 segment of the middle cerebral artery (n = 161, 53.5%), the intracranial internal carotid artery (n = 60, 19.9%) and the basilar artery (n = 40, 13.3%). Stent retrievers were used in 235 patients (78.1%) and adequate reperfusion (modified Thrombolysis in Cerebral Infarction scores 2b and 3, median onset to reperfusion time 254 min) was achieved in 242 patients (81.4%). Symptomatic intracranial haemorrhage occurred in 7%. 43.8% of patients (n = 132) had good functional outcome (modified Rankin Scale score 0-2) and the mortality rate was 20.9% (n = 63) after 3 months. Compared to the anterior circulation, vertebrobasilar stroke patients had higher mortality. Patients with secondary hospital transportation had better outcomes after 3 months than in-house treated patients. CONCLUSION: Our results document nationwide favourable outcome and safety rates of endovascular stroke treatment comparable to recent randomized trials. The ability to provide such data and the need to further optimize such an approach also underscore the contribution of respective registries.

[Periradicular infiltration therapy : Clinical indications, technique and results]. / Periradikuläre Infiltrationstherapie : Klinische Indikationen, Technik und Ergebnisse.

BACKGROUND: Minimally invasive procedures have played an emerging role in pain management during recent years. OBJECTIVES: Evaluation of the different types of periradicular infiltration as fundamental procedures in the progressive stepwise concept of pain management. Comparison of the different therapeutic substances. RESULTS: In the mid-term and long-term periradicular infiltration is effective in 60-80 % of patients regarding analgesic and functional aspects. Compliance with the guidelines should help to minimize potentially fatal complications. CONCLUSION: Periradicular infiltration is of significant importance concerning the treatment of spinal nerve root irritation. Periradicular infiltration is regarded as a safe procedure, especially when supported by computed tomography (CT) scans.

Noncontrast and contrast enhanced MR imaging in the evaluation of partial ureteral obstruction: an experimental study in the micropig.

Twelve Yucatan micropigs (3 controls; 3 sham-operated; 6 with unilateral obstruction) were studied to assess the value of noncontrast and contrast-enhanced (Gadolinium-DTPA) magnetic resonance (MR) imaging in the evaluation of partial ureteral obstruction. MR findings were correlated with findings of quantitative (Tc-99m-DMSA) scintigraphy, and histology. On noncontrast T1-weighted images, the normal porcine kidney demonstrated good corticomedullary contrast (CMC = 16.8% +/- 5.0). Five minutes after administration of Gd-DTPA, there was enhancement of the renal cortex (+24.4% and medulla (+46.2%), and CMC was no longer discernible. Enhancement of the urine within the collecting system (+119.1%) was also observed. The obstructed kidneys demonstrated marked thinning of the renal parenchyma and decreased signal intensity on noncontrast T1- and T2-weighted images (P less than 0.01). Urine in the dilated collecting system did not differ significantly from urine in controls except in the three animals with urinary tract infection (P less than 0.05). Five minutes following injection of Gd-DTPA, there was enhancement of the renal parenchyma in all kidneys. Excretion was seen in three pigs and no excretion in two. Thus, useful information can be obtained in partial ureteral obstruction from both pre-contrast and Gd-DTPA-enhanced MR images of the kidney.

Rapid, contrast-enhanced, diuretic magnetic resonance imaging of unilateral partial ureteral obstruction. An experimental study in micropigs.

The value of rapid, contrast-enhanced, diuretic magnetic resonance (MR) imaging (using ferrioxamine B and furosemide) in demonstrating partial unilateral ureteral obstruction and the potential of such MR imaging in differentiating obstructive from nonobstructive hydronephrosis was assessed in six micropigs. MR imaging (0.35 Tesla, partial-flip technique with repetition time [TR] of 125 milliseconds, echo-delay time [TE] of 20 milliseconds, and flip angle of 70 degrees) was performed before, and at 5, 12, and 19 days after partial ureteral obstruction. Additionally, MR images were acquired 5, 12, and 19 days after release of obstruction. The diuretic was injected 10 minutes after the contrast medium. MR findings were correlated with results from nuclear scintigraphy (99mTc-DMSA uptake). MR images provided good morphologic detail from which renal size, parenchymal thickness, and degree of hydronephrosis could be determined. Contrast medium allowed assessment of cortical uptake and urinary excretion. The course of cortical signal enhancement best characterized the difference between obstructive and nonobstructive hydronephrosis. Normal kidneys and kidneys with nonobstructive hydronephrosis showed progressive decrease in cortical signal enhancement (-11.7% within 40 minutes) after furosemide injection. The kidneys with obstructive hydronephrosis demonstrated a plateau of signal enhancement without decrease (-0.7% within 40 minutes). These results demonstrate the utility of rapid contrast-enhancing, diuretic MR imaging in differentiating obstructive from nonobstructive hydronephrosis.

Thoracic aortic aneurysms: treatment with endovascular self-expandable stent grafts.

BACKGROUND: This study was performed to evaluate the safety and feasibility of endovascular stent graft placement in the treatment of descending thoracic aortic aneurysms. METHODS: Between November 1996 and February 1999, endovascular stent graft repair was used in 21 patients. There were 5 women and 16 men with a mean age of 67 years (range, 41 to 87 years). An atherosclerotic aneurysm with a diameter of more than 6 cm was the indication for intervention in 19 patients (90.5%). In 2 patients (9.5%), a localized aortic dissection with a diameter of more than 6 cm was treated. In 71.4% (15 of 21) of patients, multiple stents were necessary for aneurysm exclusion. To allow safe deployment of the stent graft, preliminary subclavian-carotid artery transposition was performed in 9 patients (42.9%). Vascular access was achieved through a small incision in the abdominal aorta (n = 6), an iliac artery (n = 8), or a femoral artery (n = 7). Talent and Prograft stent grafts were used. RESULTS: Successful deployment of the endovascular stent grafts was achieved in all patients. Two patients died postoperatively (mortality rate, 9.5%), 1 of aneurysmal rupture and the other of impaired perfusion of the celiac axis. Repeat stenting was done in 3 patients because of intraoperative leakage. CONCLUSIONS: Endovascular stent graft repair is a promising and less invasive alternative to exclude the aneurysm from blood flow. This technique allows treatment of patients who are unsuitable for conventional surgical procedures. An exact definition of inclusion criteria and technical development of stent grafts should contribute to further improvements in clinical results.

Endovascular stent graft repair for aneurysms on the descending thoracic aorta.

BACKGROUND: The traditional treatment of aneurysms of the descending thoracic aorta includes posterolateral thoracotomy and aortic replacement with a prosthetic graft. In this study, we report our experiences and results in endovascular stent graft placement as an alternative to surgical repair. METHODS: Between January 1989 and July 1997, a total of 68 patients (24 women) underwent replacement of the thoracic aorta. Mean age at operation was 51 years. Fifty-eight patients underwent conventional surgical treatment. All of these patients were suitable candidates for endovascular stenting; however, no stent graft material was available at the time of operation. Ten patients (1 chronic dissection, 9 atherosclerotic aneurysm) received in the past 8 months the first commercially manufactured endovascular stent graft. The mean diameter of the aneurysms in this group was 7 cm (range, 6 to 8 cm). Two stent patients were operated on using only spinal cord analgesia. All stent grafts were custom designed for each of the 10 patients. RESULTS: The 30-day mortality in the conventional group was 31% versus 10% in the stent group. Mean length of intervention was 320 minutes in the conventional group versus 150 minutes in the endovascular group. Spinal cord injury occurred in 5 patients (12%) in the surgical group, whereas none of the stented patients developed any neurologic sequelae. Mean intensive care unit stay was 13 days, followed by a mean of 10 days on a ward in the first group compared to 4 days in the intensive care unit and 6 days on the ward in the stent group. One stent was required in 2 patients, two stents were required in 3 patients, and four stents were deployed in 5 patients of our series. Five patients required transposition of the left subclavian artery to achieve a sufficient neck for the proximal placement of the stent. There was complete thrombosis of the thoracic aortic aneurysm surrounding the stent graft in 8 patients (80%). Two patients required restenting as a result of leakage (20%). Stent graft placing was performed through the femoral artery in 8 patients, whereas access was only achieved through the abdominal aorta in 2 patients. CONCLUSIONS: These preliminary results demonstrate that endovascular stent graft replacement might be a promising, cheaper, and safe alternative method in selected patients with descending thoracic aneurysms.

Highly active antiretroviral therapy for patients with AIDS dementia complex: effect on MR imaging findings and clinical course.

BACKGROUND AND PURPOSE: Recent studies have reported the clinical improvement in patients with AIDS treated with a combination of antiretroviral regimens. The purpose of our study was to describe the effects of highly active antiretroviral therapy on MR images in patients with HIV encephalopathy and to compare the clinical course with follow-up neuroimaging studies. METHODS: Initial and follow-up MR imaging findings are described in four patients with AIDS dementia complex at baseline and after antiretroviral therapy, and correlated with clinical and immunologic findings. RESULTS: Initial MR imaging revealed white matter signal abnormalities on long-TR images without mass effect and without enhancement on postcontrast images, consistent with HIV encephalopathy. Lesions were located in the basal ganglia and posterior fossa in two patients. All four patients showed progression of white matter disease on the first follow-up MR scan (mean, 6 months). On subsequent scans, regression was seen in three patients and stabilization of white matter disease was observed in one patient. Increases in CD4+ count and decreases in viral load below the limit of quantification were present in all patients. CONCLUSION: Although our patient population was small, the results suggest that disease regression in patients with AIDS dementia complex after treatment with highly active antiretroviral therapy can be characterized and monitored by MR imaging.

Comparison of T2-weighted and fluid-attenuated inversion-recovery fast spin-echo MR sequences in intracerebral AIDS-associated disease.

PURPOSE: To compare the value of fast fluid-attenuated inversion-recovery (FLAIR) with T2-weighted fast spin-echo MR imaging in the detection of acquired immunodeficiency virus (AIDS)-related lesions of the brain. METHODS: Forty-four human immunodeficiency virus (HIV)-positive patients were examined with both sequences on either a 1.0-T or a 1.5-T MR system. The number, size, location, and conspicuity of the lesions were evaluated by two independent observers. Contrast ratios between lesions and normal brain/cerebrospinal fluid were determined, and contrast-to-noise ratios were calculated. RESULTS: FLAIR was found to be superior to T2-weighted fast spin-echo in detection of small lesions and of lesions located in cortical/subcortical regions and deep white matter. The two techniques were equal in delineation of lesions larger than 2 cm and for lesions located in the basal ganglia and posterior fossa. In 24 patients, more lesions were detected with the FLAIR fast spin-echo technique. Lesion/cerebrospinal fluid contrast ratios and contrast-to-noise ratios were significantly higher for the FLAIR fast spin-echo sequences than for the T2-weighted fast spin-echo sequences. CONCLUSION: FLAIR allows early detection of small lesions in subcortical and cortical locations, especially in HIV encephalitis. Because of its improved lesion detection rate and greater overall lesion conspicuity, we believe FLAIR is useful in the evaluation of subtle changes in the brains of AIDS patients with central nervous system disease, and could even replace the T2-weighted fast spin-echo technique.

MR imaging of the uterus: low-signal-intensity abnormalities of the endometrium and endometrial cavity.

T2-weighted magnetic resonance (MR) images showing focal areas of low signal intensity involving the endometrium or endometrial cavity were analyzed retrospectively in 28 women. The causes of the hypointense foci were disclosed histologically in 25 patients and by follow-up MR examinations in the other 3. The low signal intensity foci were due to submucosal leiomyoma (11 patients), blood clot (7 patients), endometrial carcinoma (4 patients), early intrauterine pregnancy (3 patients), retained products of conception (2 patients), and endometrial hamartoma (1 patient). The correct diagnosis was made on the basis of MR findings alone in 9 of the 11 submucosal leiomyomas. MR findings were nonspecific in the remainder of the cases. The results indicate that, on MR images, hypointense foci within the endometrium or endometrial cavity can arise from a variety of causes. Often, a specific diagnosis is not possible, and correlation with clinical history is essential.

Magnetic resonance imaging of splenic iron overload.

The value of magnetic resonance (MR) imaging in assessing iron overload in the spleen was retrospectively investigated in 40 consecutive patients. MR appearance, measure of signal intensity and T1- and T2-relaxation times were correlated with the histologically determined level of iron in the spleen in each patient. Histologic examination revealed no iron overload in 19 patients, mild iron overload in seven, moderate iron overload in six, and severe iron overload in eight. All 19 patients with no splenic iron overload and 11 of the other 21 patients with splenic iron overload were correctly identified by MR imaging (sensitivity 52%, specificity 100%, accuracy 75%). Splenic iron overload was diagnosed when a decrease of signal intensity of the spleen compared with those of adipose tissue and renal cortex was demonstrated. MR images demonstrated all eight cases of severe, three of the six cases of moderate, and none of the seven cases of mild iron overload. Only spleens with severe iron overload had a significant mean decrease in signal intensity and T1- and T2-relaxation times. Although specific, MR imaging is poorly sensitive to splenic iron overload.

[Simon nitinol vena cava filters: effectiveness and complications]. / Simon Nitinol-Vena-cava-Filter: Wirksamkeit und Komplikationen.

UNLABELLED: Simon nitinol vena cava filters: effectiveness and complications. PURPOSE: The aim of this retrospective analysis was to evaluate the clinical safety and effectiveness of the Simon Nitinol inferior vena cava filter (SNF) for prevention of pulmonary embolism. PATIENTS AND METHODS: 117 patients (63 male, 54 female; aged 58.38 +/- 14.59 years) underwent percutaneous implantation of an SNF from 1993 through 1999. Patient reports were retrospectively analysed for complications during and after implantation and deep venous thrombosis (DVT) and pulmonary embolism before and after implantation. Helical-CT with contrast media and plain abdominal radiography were performed on 35 patients, helical-CT alone on two patients. We checked the position and configuration of the SNF and looked for a perforation of the filter legs through the wall of the inferior vena cava (IVC). The IVC and deep pelvic veins were analysed for patency. RESULTS: During implantation 10 of 117 (9 %) patients had minor complications, major complications were reported in 0.9 % (1/117). There was no significant increase in thrombosis of the deep pelvic veins and the IVC after implantation. Pulmonary re-embolism (PE) was documented in 9 out of 117 patients (7.7 %). One out of the 35 examined patients (2.9 %) showed a single strut fracture of the SNF. Tilting more than 15 degrees was seen in 7 out of 37 patients (19 %). Dislocation of the SNF more than 10 mm occurred in one out of 35 patients (2.9 %), perforation through the wall of the IVC in all 37 patients. We found no occlusion of the IVC. CONCLUSION: The SNF is easy and safe to implant and successfully prevents pulmonary embolism. In our study the rate of well documented pulmonary re-embolism (7.7 %) is satisfactory. Except for the high perforation rate through the wall of the IVC (100 %, but without clinical relevance), complication rates during and after implantation of the SNF are low compared with other filter types.

[Cervical carcinoma staging with magnetic resonance tomography: the use of gadolinium-DOTA with 31 patients]. / Staging des Zervixkarzinoms mit der magnetischen Resonanztomographie: Anwendung von Gadolinium-DOTA bei 31 Patientinnen.

Thirty-one patients with histologically proven carcinoma of the cervix were studied by contrast-enhanced MRI. T2-weighted sequences in a spin-echo mode and T1-weighted sequences were carried out before and after the application of Gd-DOTA. This resulted in improved staging. Contrast-enhanced MRI provided valuable additional information concerning tumour extension into the parametrium. In the presence of motion artifacts and ill-defined infiltration into the parametrium on the T2 sequences, the use of contrast-enhanced T1 images provided a valuable addition to the investigation of carcinoma of the cervix.

[Treatment of arterial aneurysms of the pelvic leg vessels using dacron covered nitinol stents]. / Behandlung arterieller Aneurysmen der Becken-Bein-Gefässe mittels Dacron-ummantelter Nitinol-Stents.

PURPOSE: To evaluate the success rates of the implantation of stent grafts in the treatment of peripheral aneurysms. MATERIALS AND METHODS: In 13 patients with 15 aneurysms at the common iliac artery (n = 6), external iliac artery (n = 1), hypogastric artery (n = 2), femoral artery (n = 2) or popliteal artery (n = 4), implantation of dacron-covered nitinol stents was performed. The patients were followed up for three to 20 months (mean, 8.8 months) with intravenous digital subtraction angiography, CT or colour-coded Doppler sonography. RESULTS: In all cases, the aneurysm was successfully occluded after stent implantation. In one case with a popliteal aneurysm, kinking of the vessel caused thrombosis of the stent. The stent was successfully reopened. The aneurysm however, had to be surgically treated 9 months later. The primary and secondary patency rates at 6 months were 93% and 100%, respectively. CONCLUSION: The method described might be an alternative therapy to surgery. There are some limitations in respect of treatment of popliteal aneurysms.

[Contrast media in peripheral angiography: does cost reduction mean loss of quality and safety? A reevaluation based on a randomized double-blind comparative study of ioxaglate versus iopromide]. / Kontrastmittel in der peripheren Angiographie: Bedeutet Kostenreduktion Verlust an Qualität und Sicherheit? Eine Reevaluierung anhand einer randomisierten Doppelblind-Vergleichsstudie von Ioxaglat versus Iopromid.

PURPOSE: To evaluate whether meglumine-sodium-ioxaglate (Hexabrix) and iopromide (Ultravist) are identically appropriate for peripheral angiography. Outcome variables were pain, image quality and adverse events. METHODS: Sixty patients were included in a randomised double-blind study. In all patients an intraarterial digital subtraction angiography (i.a. DSA) of iliac and peripheral arteries was performed. RESULTS: Analysis of the study revealed no significant difference between both contrast media in terms of the main and additional outcome variables. In comparison to iopromide, ioxaglate caused milder pain sensations (VAS 4.70 vs. 7.76, p = 0.25). Mild adverse events were observed more frequently in ioxaglate angiography (11% vs. 0%, p = 0.1). CONCLUSION: Both contrast media seem to be appropriate for peripheral angiography using DSA technique. Ioxaglate causes a cost reduction of about 20-35%. However, an increase of mild adverse reactions up to 11% to 15% has to be accepted.

[Gd-DOTA in musculoskeletal diseases]. / Gd-DOTA bei muskuloskelettalen Erkrankungen.

T1-weighted images after the injection of Gd-DOTA, a new paramagnetic contrast medium, were compared with non-enhanced T2-weighted images in 42 consecutive cases of musculoskeletal pathology. In addition we evaluated the incidence of side effects. Enhanced T1-weighted images were superior in depicting the various parts of a lesion and the borders between the lesion and normal tissue or perifocal reaction. On the other hand the non-enhanced T2-weighted images better depicted the border between the perifocal reaction and normal tissue. In aggressive lesions, especially in malignant tumours, the two sequences are complementary. Enhanced T1-weighted images did not contribute significantly to assessing benign lesions. The incidence of side effects was acceptable and no severe reactions occurred.

[Carotid stenosis: the technic for PTA and stent implantation]. / Karotisstenose: Technik der PTA und Stentimplantation.

Percutaneous transluminal angioplasty and stenting of carotid artery stenosis represents an innovative experimental modality which has been increasingly employed in high-risk patients. Currently, results from prospective randomized trials are not available; thus, guidelines with regard to indications and technique are preliminary. Numerous technical innovations to avoid associated complications have evolved in neurointerventional procedures. Dedicated guiding catheters and stents using a transfemoral approach have been introduced for treatment of carotid artery disease. Low-profile stent delivery systems may decrease risk of releasing embolic load when crossing high-grade stenosis or kinking of the vessel. The introduction of a cerebral protection with the use of temporary occlusion balloons or filter systems has resulted in a reduction of procedure-related neurological complications, and is strongly recommended by leading experts in the field.

MR imaging of pelvic masses in women: contrast-enhanced vs unenhanced images.

OBJECTIVE: We compared the value of contrast-enhanced MR images with that of T2-weighted MR images in the diagnosis and staging of pelvic masses in women. MATERIALS AND METHODS: The findings on preoperative MR studies of 97 patients with a total of 124 surgically proved lesions were retrospectively analyzed. Unenhanced T1- and T2-weighted spin-echo images were compared with contrast-enhanced T1-weighted images. The final diagnosis included benign (36 patients), borderline (six patients), and malignant (15 patients) ovarian masses, fallopian tube masses (15 patients), endometrial tumors (seven patients), cervical carcinomas (32 patients), subserous leiomyomas (11 patients), and two masses of extragenital origin. RESULTS: In the depiction of pelvic lesions, the sensitivity of contrast-enhanced MR imaging (96%) was equal to that of unenhanced T2-weighted imaging (97%). Contrast-enhanced images were useful in the definition of intratumoral architecture and tumor borders of 72 adnexal masses, resulting in better determination of malignancy (accuracy, 95%) than on T2-weighted images (85%). Size of viable tumor, differentiation of tumor from retained fluid, and depth of myometrial invasion of six endometrial carcinomas were most reliably shown on contrast-enhanced images. In the evaluation of cervical carcinoma, overall staging accuracy of contrast-enhanced imaging (80%) was slightly inferior to that of T2-weighted imaging (83%). However, contrast-enhanced images improved assessment of parametrial and organ invasion in seven cases in which findings on T2-weighted MR images were equivocal. Administration of contrast material was not helpful in the evaluation of subserous leiomyomas or masses of extragenital origin. CONCLUSIONS: The findings suggest that when results of unenhanced T1- and T2-weighted MR imaging of pelvic masses are equivocal, contrast-enhanced MR images should be used as supportive and complementary pulse sequences to (1) improve definition of intratumoral architecture and prediction of malignancy in adnexal tumors, (2) stage endometrial carcinoma, and (3) determine tumor extension in cervical carcinoma.

Retrovesical leiomyoma: CT and contrast-enhanced MR imaging findings.

The computed tomographic (CT) and magnetic resonance (MR) appearance of a retrovesical leiomyoma in a male patient is presented. Although leiomyomas are common lesions, the location within the retrovesical pouch is very unusual.

[Management of abdominal aortic and peripheral aneurysm using stent grafts]. / Behandlung von Aneurysmen der Aorta abdominalis und der Becken-/Beingefässe mittels Stentgrafts.

The implantation of stent grafts is a relatively new method for the treatment of aneurysms of the aorta or peripheral aneurysms. Before the implantation precise measurements are mandatory to obtain the necessary information about the aneurysm. The numerous contraindications must be observed strictly to successfully exclude the aneurysmal sac. The stent graft is inserted via a percutaneous puncture or, in the case of an aortic graft, through a surgical arteriotomy. After the implantation rigorous follow-up is mandatory to detect complications such as leaks or thrombi: Spiral CT angiography is the method of choice. Some of the complications require secondary interventions such as the implantation of additional stent grafts. The results are encouraging, with a secondary exclusion rate of the aneurysm of up to more than 95%; however, long-term results are not available.