Recurrent reversible in-stent-stenosis after flow diverter treatment.

Flow diverter stents (FDS) are well established in the treatment of intracranial aneurysms which are difficult to treat with conventional endovascular techniques. However, they carry a relatively high risk of specific complications compared to conventional stents. A minor but frequent finding is the occurrence of reversible in-stent-stenosis (ISS) that tend to resolve spontaneously over time. Here, we report the case of a patient in their 30s who was treated with FDS for bilateral paraophthalmic internal carotid artery (ICA) aneurysms. ISS were found at the respective early follow-up examinations on both sides and had resolved at the 1-year follow-up examinations. Surprisingly ISS reoccurred at both sides in later follow-up examinations and again resolved spontaneously. The recurrence of ISS after resolution is a finding that has not been described previously. Its incidence and further development should be investigated systematically. This might contribute to our understanding of the mechanisms underlying the effect of FDS.

[Unusual forms of inflammatory diseases of the central nervous system]. / Seltene Formen der entzündlichen Erkrankungen des Zentralnervensystems.

BACKGROUND: White matter lesions of the central nervous system (CNS) are frequently encountered on magnetic resonance imaging (MRI) exams. If the morphologic findings, clinical symptoms and laboratory results are not typical for one of the more common inflammatory CNS diseases, the diagnosis may become challenging, which also means that interesting and sometime emotional discussions may arise. OBJECTIVE: While frequent causes of inflammatory CNS diseases were already discussed in a previous article, we now focus on more seldom forms and place attention on morphologic characteristics which may help to find the correct diagnosis.

[Cervical fractures and disc lesions]. / Frakturen der Halswirbelsäule und Bandscheibenläsionen.

CLINICAL ISSUE: The head accounts for about 8% of the total body weight, and only modest ligaments stabilize the cervical spine. In children, the ratio head weight/body mass is even worse, so not surprisingly injuries to the cervical spine are common. This article reviews the most common classifications of different cervical fractures. In addition, ruptures of the ligaments and lesions to the intervertebral discs and the vertebral arteries are discussed. PRACTICAL RECOMMENDATIONS: In high velocity trauma, it is vital to exclude lesions to the vertebral arteries and the cervical ligaments to prevent/minimize further harm and to accurately assess the stability of the cervical spine.

[Inflammatory diseases of the central nervous system]. / Entzündliche Erkrankungen des zentralen Nervensystems.

Autoimmune inflammatory diseases of the central nervous system (CNS) can be a diagnostic challenge despite advanced imaging techniques. Diagnostic errors can have fatal consequences (e. g. tumefactive lesions) as inappropriate treatment can exacerbate the symptoms of the patients. The aim of this article is to provide help in decision making for selected autoimmune inflammatory diseases of the CNS, in order not to fall into diagnostic traps. The primary focus is on lesions in the neurocranium as inflammatory diseases of the spinal cord were already extensively discussed in a previous article.

[Embryonic development and congenital diseases of the orbit]. / Embryologische Entwicklung und angeborene Erkrankungen des Auges.

Many neuroradiologists focus primarily on the central nervous system and give little attention to other regions like the eye/orbit. It is easy to be deceived by the pitfall called satisfaction of search (also abbreviated SOS), despite most congenital eye diseases being easily recognized if one is aware of them. In this article, the most common congenital orbital abnormalities are described, and their basic prenatal causes are summarized.

[Imaging in headache]. / Bildgebung bei Kopfschmerzen.

Headache is worldwide one of the leading reasons to consult a general practitioner or a neurologist. In addition to the medical history and results of laboratory parameters, imaging represents one of the most important diagnostic steps. As there is a myriad of possible causes, it is nearly impossible to cover the whole spectrum of this topic. This article summarizes the most important morphological imaging findings and their pitfalls.

[Diagnostic work-up, findings, and documentation of multiple sclerosis]. / Diagnostik, Befunde und Dokumentation bei multipler Sklerose.

BACKGROUND: Although multiple sclerosis is the most common chronic inflammatory demyelinating disease of the central nervous system, the rate of misdiagnosis in clinical practice is high. This is usually due to the inadequate application of the McDonald criteria and misinterpretation of images. OBJECTIVE: This review focuses on typical clinical symptoms, choice of magnetic resonance imaging (MRI) sequences, correct application of the McDonald criteria, and finally interpretation of the images.

[Diagnosis of germ cell tumors]. / Diagnostik der Keimzelltumoren.

CLINICAL/METHODICAL ISSUE: Intracranial germ cell tumors are rare central nervous system (CNS) diseases in Europa and America. Because of their low frequency and lack of typical imaging features, they represent a difficult diagnosis for any radiologist. STANDARD RADIOLOGICAL METHODS: Magnetic resonance imaging (MRI) is a sensible diagnostic tool for the initial diagnosis of germ cell tumors, although it has limitations. METHODOLOGICAL INNOVATIONS: So far, no typical morphologic pattern as a red flag for germ cell tumors has been identified. Correlation with clinical symptoms and laboratory results is mandatory. PERFORMANCE: In certain cases, combining the location of the tumor and clinical findings may allow a diagnosis to be made even without histologic confirmation. PRACTICAL RECOMMENDATIONS: In addition to imaging, the radiologist needs the age, background, and laboratory findings to be able to make an accurate diagnosis.

Endovascular Treatment Strategies for Aneurysms of the Origin of the Posterior Inferior Cerebellar Artery.

BACKGROUND: Treatment of aneurysms at the origin of the posterior inferior cerebellar artery (PICA) is challenging. Surgery is difficult due to the deep location and proximity to cranial nerves and endovascular treatment is complicated due to the often tortuous anatomy of the PICA and its small diameter. The purpose of this study is to report our experience with the endovascular treatment of aneurysms at the origin of the PICA. METHODS: Consecutive patients with aneurysms at the origin of the PICA who were endovascularly treated at our department were identified from our registry of neuro-angiographies. Clinical, angiographic, and treatment data were analyzed. Endpoints included successful occlusion and recurrence. RESULTS: Twenty-nine patients were included. 79.3% of the aneurysms were wide-neck with a dome-to-neck ratio <2.65.5% of all endovascular procedures were performed by coiling alone. The procedural rupture rate was 18.75% for endovascularly treated aneurysms presenting with subarachnoid hemorrhage (SAH). Successful embolization was achieved non-significantly more often in the coiling-only group (94.7% vs. 70%, P = 0.066). Aneurysm recurrence after successful occlusion was observed in one case. CONCLUSIONS: Though aneurysm and parent vessel characteristics were challenging successful occlusion was achieved in a high rate of treatments, often with standalone coiling. Adjunctive techniques like retrograde stenting seem promising to further enhance endovascular results. Interestingly aneurysms arising solely from the origin of the PICA without the V4-segment involved presented with SAH significantly more often and wide-neck aneurysms presenting with SAH had a significantly higher periinterventional rupture rate.

Comparison of Antiepileptic Approaches in Treatment of Benzodiazepine Nonresponsive Status Epilepticus.

AIMS: Status epilepticus and seizure clusters are common neurological emergencies. The purpose of this monocentric, retrospective cohort study was to comparatively assess different antiepileptic approaches in the treatment of status epilepticus and seizure clusters, which were nonresponsive to benzodiazepines. METHODS: We reviewed medical records of 66 patients, who were treated for status epilepticus or seizure clusters in the Department of Neurology at the University of the Saarland between January 2007 and July 2012, and failed to respond to benzodiazepines with the equivalent dosage of at least 20 mg of diazepam. As endpoints, we analyzed both the effectiveness of lacosamide, levetiracetam, valproic acid, and phenytoin used as second- and third-line therapy, and the Glasgow Outcome Scale at day 7. RESULTS: Sixty-one (92.4%) of the patients had status epilepticus, and 5 (7.6%) had seizure clusters. The compared drugs were equally effective in terminating seizures. There was also no significant difference in the Glasgow Outcome Scale (P = 0.60) after 7 days. CONCLUSION: Our data support the use of the modern antiepileptic treatment strategies, such as levetiracetam, valproic acid, and lacosamide in the treatment of status epilepticus and seizure clusters.

Response of Toll-like receptors in experimental Guillain-Barré syndrome: a kinetic analysis.

Guillain-Barré syndrome (GBS) is an autoimmune disorder caused by the interaction between cellular and humoral immune responses in the peripheral nervous system. Toll-like receptors (TLRs) are key players in innate and have regulatory functions in adaptive immunity. In this study, we systematically examined expression patterns of TLRs in sciatic nerve and lymphoid organs during the disease course of murine experimental autoimmune neuritis and in blood from Guillain-Barré patients. A kinetic response pattern was identified, characterized by a pronounced up-regulation of TLR2, 6 and 11 on T cells and TLR4 and 6 on APCs, while TLR1 expression was decreased. Moreover, an enhanced expression of the disease promoting cytokine Interleukin-(IL)17A was detected. Additional analysis of GBS patients revealed an up-regulation of TLR2, TLR4 and TLR6 mRNA, negatively correlated with disease severity. This first systematic analysis of TLR expression pattern may contribute to elucidating the role of TLRs in GBS pathophysiology.