A Network-Wide Stroke Team Program Reduces Time to Treatment for Endovascular Stroke Therapy in a Regional Stroke-Network.

BACKGROUND AND PURPOSE: Driven by the positive results of randomized, controlled trials of endovascular stroke therapies (EVT) in stroke patients with large vessel occlusion, different approaches to speed up the workflow for EVT candidates are currently being implemented worldwide. We aimed to assess the effect of a simple stroke network-wide workflow improvement project, primarily focusing on i.v. thrombolysis, on process times for patients undergoing EVT. METHODS: In 2015, we conducted a network-wide, peer-to-peer acute stroke workflow improvement program for i.v. thrombolysis with the main components of implementing a binding team-based algorithm at every stroke unit of the regional network, educating all stroke teams about non-technical skills and providing a stroke-specific simulation training. Before and after the intervention we recorded periprocedural process times, including patients undergoing EVT at the 3 EVT-capable centers (January - June 2015, n = 80 vs. July 2015 - June 2016, n = 184). RESULTS: In this multi-centric evaluation of 268 patients receiving EVT, we observed a relevant shortening of the median time from symptom onset to EVT specifically in patients requiring secondary transfer by almost an hour (300 min, 25-75% interquartile range [IQR] 231-381 min to 254 min, IQR 215.25-341 min; p = 0.117), including a reduction of the median door-to-groin time at the EVT-capable center in this patient group by 15.5 min (59 min, IQR 35-102 min to 43.5 min, IQR 27.75-81.25 min; p = 0.063). In patients directly admitted to an EVT-capable center, the median door-to-groin interval was reduced by 10.5 min (125 min, IQR 83.5-170.5 min to 114.5 min, IQR 66.5-151 min; p = 0.167), but a considerable heterogeneity between the centers was observed (p < 0.001). CONCLUSIONS: We show that a simple network-wide workflow improvement program primarily directed at fast i.v. thrombolysis also accelerates process times for EVT candidates and is a promising measure to improve the performance of an entire stroke network.

Peripheral markers of Alzheimer's disease: surveillance of white blood cells.

Inflammation is part of the complex biological response of vascular tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. This is a mechanism of innate immunity, which may cause an increase in the number of monocytes and neutrophils circulating in the blood. Literature indicated that chronic inflammation might be a factor in developing neurological problems, including Alzheimer's, Parkinson's and other similar illnesses. Our main objective is to identify peripheral markers of Alzheimer's disease and for that purpose; we are looking at the profile of white blood cells focusing on monocytes, neutrophils, lymphocytes and basophils. Twenty-seven patients of Alzheimer's disease (AD), diagnosed by magnetic resonance imaging and neuropsychological tests were observed for their blood profile. Key observations during this study were that the levels of monocytes in the blood of the diagnosed AD patients were high irrespective of their age and sex. For those patients whose monocytes were in normal range their neutrophil levels were significantly high. Whereas blood levels of lymphocytes and basophils were found to be constantly low. Escalated levels of monocytes and neutrophils are hallmarks of chronic inflammation and may be precursor to Alzheimer's disease. A low lymphocyte count specifies that the body's resistance to fight infection is substantially reduced, whereas low basophil levels indicates their over utilization due to chronic allergic inflammatory condition. Future studies involved closer look at the cytokines produced by these white blood cells especially TNF IL-1, and IL-12, which are products of monocytes. Likewise, blood glucose and creatinine levels were high whereas calcium ions were low. Our studies indicated that white blood cells along with other inflammatory byproducts may act as peripheral markers for early diagnosis of Alzheimer's disease.

Validity of temporomandibular disorder examination procedures for assessment of temporomandibular joint status.

INTRODUCTION: This hypothesis-generating study was performed to determine which items in the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) and additional diagnostic tests have the best predictive accuracy for joint-related diagnoses. METHODS: One hundred forty-nine TMD patients and 43 symptom-free subjects were examined in clinical examinations and with magnetic resonance imaging (MRI). The importance of each variable of the clinical examination for correct joint-related diagnosis was assessed by using MRI diagnoses. For this purpose, "random forest" statistical software (based on classification trees) was used. RESULTS: Maximum unassisted jaw opening, maximum assisted jaw opening, history of locked jaw, joint sound with and without compression, joint pain, facial pain, pain on palpation of the lateral pterygoid area, and overjet proved suitable for distinguishing between subtypes of joint-related TMD. Measurement of excursion, protrusion, and midline deviation were less important. CONCLUSIONS: The validity of clinical TMD examination procedures can be enhanced by using the 16 variables of greatest importance identified in this study. In addition to other variables, maximum unassisted and assisted opening and a history of locked jaw were important when assessing the status of the TMJ.

Prolonged low-dose intravenous thrombolysis in a stroke patient with distal basilar thrombus.

BACKGROUND AND PURPOSE: Patients with high-grade basilar artery stenosis secondary to thromboembolism are at high risk of developing subsequent vessel occlusion. Optimal medical management of this condition is unclear. SUMMARY OF CASE: We present a patient with a small subacute brain stem infarction and filiform distal basilar residual lumen attributable to arterioarterial or cardiogenic embolism. Beginning 3 days after symptom onset, low-dose intravenous thrombolysis with 0.125 mg/kg recombinant tissue plasminogen activator was continuously infused for 48 hours. Follow-up magnetic resonance angiography revealed complete resolution of the embolus. No further cerebral ischemic episodes occurred during 3-month follow-up, and the basilar artery remained patent. CONCLUSIONS: Our observation suggests a potential for prolonged low-dose intravenous thrombolysis in basilar artery embolism, but further data are needed to judge the effectiveness and risk of this intervention.

Psychosocial behaviour and health care utilization in patients suffering from temporomandibular disorders diagnosed on the basis of clinical findings and MRI examination.

UNLABELLED: The aim of this study was to evaluate psychosocial behaviour and differences in health care utilization between subgroups of patients suffering from temporomandibular disorders, using both clinical examination and magnetic resonance imaging (MRI). MATERIALS AND METHODS: 70 patients were examined according to the research diagnostic criteria for temporomandibular disorders (RDC/TMD), and were divided into groups according to their clinical diagnoses. MRIs were acquired and joint-related RDC/TMD diagnoses were modified on the basis of MRI findings. Group I suffered from joint pathology, group II from myofascial pain and group III from a combination. Non-parametric statistics were used to reveal group-related differences in psychosocial and behavioural aspects. Differences in group assignment based on clinical and MRI examination were assessed (kappa statistics). RESULTS: MRI findings led to group assignments that were different from clinical assignments (k = 0.3). For both types of assignment, patients with myofascial pain displayed higher somatization scores, used more splints and consulted more physicians. For clinical assignment only, depression scores were higher in the myofascial pain group. For MRI based assignment, sex differences were significant between groups I and III. CONCLUSION: Somatization-specific behaviour is more widespread in patients suffering from exclusively myofascial pain than in patients presenting joint pathology. Inconsistencies in differences of other psychosocial variables between groups of TMD patients seem to be related to differences in group assignment either with or without objective information on joint pathology.

Time-efficient localization of the human secondary somatosensory cortex by functional magnetic resonance imaging.

Standardized, robust and time-efficient localization of the human secondary somatosensory cortex (S2) is a challenge in clinical blood oxygen level dependent (BOLD) functional magnetic resonance imaging (fMRI). A fully automated tactile stimulation was optimized in seven right-handed volunteers at 1.5 T for minimum scan time, high BOLD signals and robust localization of S2 by systematically varying the applied block-design. All volunteers had six different fMRI measurements of five stimulation-baseline-cycles (sbc) each with equal block duration that was changed between the measurements from 6 s to 30 s. Additional data sets of 4, 3 and 2 cycles were generated post hoc resulting in a total of 168 data sets that were evaluated individually for BOLD-signal intensity (dS%), correlation to the hemodynamic reference function (r) and Euclidean coordinates (x, y, z). Using different block-designs the S2 activation was highly variable regarding the localization rate (lr), the hemispheric symmetry and the BOLD-signals. The protocol with 3 cycles, a block duration (dp) of 15 s and a total scan time (dt) of 105 s most robustly localized S2 (contralateral: lr=71.4%, r=0.65, dS=1.01%; ipsilateral: lr=100%, r=0.6, dS=1.14%) whereas the most time-efficient protocol to localize SI (sbc=5, dp=6 s, dt=66 s) provided no robust localization of S2. Compared to other published fMRI protocols a scan time reduction up to 86% was achieved.

MR imaging-based volumetry in patients with early-treated phenylketonuria.

BACKGROUND AND PURPOSE: Our purpose was to specify the most severely affected brain structures in early treated phenylketonuria regarding volume loss and establish possible correlations between volume loss and plasma levels of phenylalanine (Phe). METHODS: In 31 patients with early treated phenylketonuria and in 27 healthy volunteers, we acquired volumetric MR imaging data. Serum Phe concentrations at different times were measured as well. Semiautomatic volumetric postprocessing of the cerebellum, cerebrum (supratentorial brain tissue), hippocampus, intracranial volume, lateral ventricles, nucleus caudatus, nucleus lentiformis, pons, and thalamus, as well as the two-dimensional extension of the corpus callosum, was performed using the software BRAINS2. For each separate brain structure, the relative differences between the normal and the phenylketonuria group (delta(rel)) were calculated. RESULTS: The cerebrum, corpus callosum, hippocampus, intracranial volume, and pons were significantly smaller in patients with phenylketonuria than in healthy patients. The volume of the lateral ventricles was significantly larger in patients with phenylketonuria than in healthy ones. The most severely affected structures were the pons (delta(rel) = 16%), hippocampus (delta(rel) = 14.5%), cerebrum (delta(rel) = 13%), and corpus callosum (delta(rel) = 10%). No significant differences were found for the basal ganglia, cerebellum, and thalamus. There were no significant correlations found between the volume of any of the different brain structures and the metabolic parameters. CONCLUSION: The most severely affected brain structures in early-treated patients with phenylketonuria regarding volume loss are the cerebrum, corpus callosum, hippocampus, and pons.

Fully automated localization of the human primary somatosensory cortex in one minute by functional magnetic resonance imaging.

A clinical functional magnetic resonance imaging (fMRI) protocol based on a fully automated tactile stimulation was optimized in 10 right-handed volunteers at 1.5 T for minimum scan time, high BOLD-signals and robust localization of the primary somatosensory cortex (S1) by systematically varying the applied block design. All volunteers had six different fMRI measurements of 5 stimulation/baseline cycles each with equal block duration that was changed between the measurements from 6 to 30 s. Data sets of 4, 3 and 2 cycles were generated post hoc resulting in a total of 240 data sets that were evaluated individually for BOLD-signal intensity (dS%), correlation to the hemodynamic reference function (r) and Euclidean coordinates (x, y, z). The protocol with 5 cycles, a block duration of 6 s and a total scan time of 66 s provided the best BOLD-signal characteristics (dS% = 1.15, r = 0.78). Compared to the mean scan time of other clinical fMRI protocols (174 s) a reduction of 62% was achieved.

Robust localization and lateralization of human language function: an optimized clinical functional magnetic resonance imaging protocol.

An optimized clinical functional magnetic resonance imaging (fMRI) protocol with a total scanning time of 8 min is presented that localizes Broca's and Wernicke's areas robustly and determines hemispheric dominance. Language function was visualized using two different sentence generation (SG) and word generation (WG) tasks. Block designed blood oxygenation level dependent (BOLD) fMRI was applied in 14 right-handed volunteers at 1.5 T during visual stimulation. BOLD-clusters were assessed individually for anatomical localization. Reference data are provided for the maximum correlation of the measured BOLD-signal time course to the applied reference function (r(max)), for the maximum relative signal change (dS%), cluster size and Euklidian coordinates of Broca and Wernicke activation and of the anatomical homologues in the right hemispheres. Statistical means and a lateralization index (LI) were calculated. Broca activation focussed on the inferior frontal gyrus, and Wernicke activation on the superior temporal, supramarginal or middle temporal gyri. Mean BOLD-signals for Broca ranged from 1.53% (SG) to 2.56% (WG), and for Wernicke from 1.47% (SG) to 1.80% (WG). LI indicated left language dominance. The data provided further evidence for the high anatomical variability of language areas, which underlined the relevance of an individual language localization and lateralization prior to brain surgery.

Temporomandibular joint pathosis in patients with myofascial pain: a comparative analysis of magnetic resonance imaging and a clinical examination based on a specific set of criteria.

OBJECTIVE: We sought to determine the prevalence of joint diseases in patients with either of 2 forms of myofascial pain (with and without limited mouth opening) and to verify the accuracy of temporomandibular joint-related clinical diagnoses through the use of magnetic resonance imaging (MRI). STUDY DESIGN: On the basis of the results of a clinical examination carried out according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD), 61 patients were divided into 2 subgroups. The first group consisted of 36 patients who had myofascial pain with limited mouth opening (MPLO), whereas the other 25 patients were diagnosed with myofascial pain without limited mouth opening. MRI was carried out on all patients. The clinical joint-related diagnoses from RDC/TMD were compared with MRI results. RESULTS: Patients with MPLO often had joint diseases that were not detected by means of a clinical examination alone. The kappa statistic was used to compare MRI and clinical diagnoses, confirming poor agreement in patients with MPLO (kappa=0.13) and acceptable agreement in patients with myofascial pain without limited mouth opening (kappa=0.72). CONCLUSION: Restricted mandibular mobility is frequently associated with temporomandibular joint diseases that were not identified during a clinical examination. Therefore, an adaptation of the classification scheme used for the RDC/TMDs may result in the improvement of the sensitivity of clinical joint-related diagnoses, especially in patients with MPLO.

Absence of the fourth cranial nerve in congenital Brown syndrome.

PURPOSE: To elucidate the aetiology of congenital Brown syndrome. METHODS: Four consecutive patients diagnosed with unilateral congenital Brown syndrome had a comprehensive standardized ocular motility examination. Any compensatory head posture was measured. Brain magnetic resonance imaging (MRI) with regard for the IV cranial nerve (CN) was performed in all patients. Orbital MRI was performed in 2/4 patients, with images acquired in eight directions of gaze and superior oblique (SO) muscle areas compared. RESULTS: CN IV could not be identified bilaterally in two patients, but was absent only on the side of the Brown syndrome in the two other patients. On the normal side, orbital MRI revealed a smaller SO muscle area in upgaze than in downgaze, demonstrating normal actions of this muscle. On the side of the Brown syndrome, the SO area remained the same in upgaze and in downgaze and approximately symmetric to the area of SO in downgaze on the normal side. CONCLUSIONS: These cases add further anatomical support to the theory of paradoxical innervation in congenital Brown syndrome. CN IV was absent in two patients on the side of the Brown syndrome, but without muscle hypoplasia. SO muscle size did not vary in up- and downgaze, which we interpreted as a sign of constant innervation through branches of CN III.

Preliminary longitudinal report on symptom outcomes in symptomatic and asymptomatic women with imaging evidence of temporomandibular joint arthritic changes.

PURPOSE: The objectives of this preliminary, longitudinal, and explorative cohort study were to assess changes in and the onset of osteoarthrosis (OA)-related pain in the temporomandibular joint (TMJ) and to address factors that might impact the development or reduction of associated pain symptoms. MATERIALS AND METHODS: In this sex-matched study, 60 women were recruited (30 asymptomatic with a magnetic resonance imaging [MRI] diagnosis of OA-related TMJ changes, 30 symptomatic with accompanying MRI evidence of OA of the TMJ). All subjects underwent a baseline clinical examination and MRI assessment and were subsequently referred to a dental practitioner, who was informed of the diagnosis and further treatment where required. Not all subjects underwent dental treatment interventions. Following a mean 4-year period, subjects were reexamined clinically. Spearman rank correlation and Mann-Whitney U tests were used to evaluate possible correlations in reported pain level changes with the number of posterior occlusal contacts and new dental restorations placed between baseline and recall appointments. RESULTS: The dropout rate was 28% (6.7% for symptomatic, 50% for asymptomatic). OA-related TMJ pain in symptomatic subjects decreased with time (pain reduction: ?3.6 ± 3.4 on a 0 to 10 numeric rating scale); asymptomatic patients rarely developed pain. CONCLUSION: These preliminary results suggest that factors other than dental occlusion might play a role in the reduction of pain.

Localizing and lateralizing language in patients with brain tumors: feasibility of routine preoperative functional MR imaging in 81 consecutive patients.

PURPOSE: To prospectively assess the feasibility of standardized presurgical functional magnetic resonance (MR) imaging for localizing the Broca and Wernicke areas and for lateralizing language function. MATERIALS AND METHODS: The study was approved by the responsible ethics commission, and patients gave written informed consent. Eighty-one patients (36 female and 45 male patients; age range, 7-75 years) with different brain tumors underwent blood oxygen level-dependent functional MR imaging at 1.5 T with two paradigms: sentence generation (SG) and word generation (WG). Functional MR imaging measurements, data processing, and evaluation were fully standardized by using dedicated software. Four regions of interest were evaluated in each patient: the Broca and Wernicke areas and their anatomic homologues in the right hemisphere. Statistics were calculated. RESULTS: The SG and WG paradigms were successfully completed by all (100%) and 70 (86%) patients, respectively. Success rates in localizing and lateralizing language were 96% for the Broca and Wernicke areas with the SG paradigm, 81% for the Broca area and 80% for the Wernicke area with the WG paradigm, and 98% for both areas when the SG and WG paradigms were used in combination. Functional localizations were consistent for SG and WG paradigms in the inferior frontal gyrus (Broca area) and the superior temporal, supramarginal, and angular gyri (Wernicke area). Surgery was not performed in seven patients (9%) and was modified in two patients (2%) because of functional MR imaging findings. CONCLUSION: Functional MR imaging proved to be feasible during routine diagnostic neuroimaging for localizing and lateralizing language function preoperatively.

Age- and tooth-related pulp cavity signal intensity changes in healthy teeth: a comparative magnetic resonance imaging analysis.

OBJECTIVE: To determine if it is possible to measure age-related pulp cavity signal intensity changes by using magnetic resonance imaging (MRI). STUDY DESIGN: Dental pulp cavity signal intensities were assessed in 92 test subjects on the basis of MRI signal intensity measurements at freely defined regions of interest by using T1 gradient echo sequences before and after contrast-agent administration. Relative signal intensity differences were calculated and provided the basis for age- and tooth-related comparisons. RESULTS: Significant signal intensity differences were noted between the oldest (born between 1930 and 1959) and the youngest (born after 1980) test subjects and the other groups (P < .05). In addition, the first molars showed significantly lower signal intensity differences than the second molars (P < .05). CONCLUSION: Magnetic resonance imaging can be used to determine pulp cavity signal-intensity changes with age.

Assessment of the reliability and validity of panoramic imaging for assessment of mandibular condyle morphology using both MRI and clinical examination as the gold standard.

OBJECTIVES: The purpose of this study was to evaluate both reliability and validity of the assessment of the shape of the mandibular condyle in panoramic images of the TMJ. STUDY DESIGN: Forty subjects were included and were examined according to the Research Diagnostic Criteria for Temporomandibular Disorders. Panoramic radiographs (PRs) and magnetic resonance images (MRIs) were completed for all subjects. Both MRIs and PRs were rated by raters blinded to the clinical diagnosis. Kappa statistics were used to compare the results of the raters of the PRs. Additionally, the specificity and the sensitivity of the PRs were calculated for 2 scenarios: one with MRI and the other with clinical findings as the gold standard. RESULTS: The sensitivity was 0.94 (specificity = 0.45) for the assumption that MRI is the gold standard and 0.86 (specificity = 0.49) for the assumption that the clinical examination is the gold standard. For reliability, the results for kappa ranged from 0.06 to 0.327. CONCLUSION: It can be concluded that PRs are not a reliable method of accurately judging the shape of the mandibular condyle.

Prediction of TMJ arthralgia according to clinical diagnosis and MRI findings.

PURPOSE: The aim of this study was to investigate the ability of clinical and magnetic resonance imaging (MRI) diagnoses to predict pain in the temporomandibular joint (TMJ). MATERIALS AND METHODS: One hundred forty-nine patients were examined by 2 calibrated examiners in strict accordance with the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD). All patients who presented with a defined clinical RDC/TMD diagnosis were included and underwent bilateral coronal and sagittal MRI of the TMJ. Two raters blinded to the clinical diagnosis interpreted the MRI scans for TMJ pathology. The results were tested against the clinical diagnosis according to the RDC/TMD, including pain-related disability and psychosocial status, for associations to TMJ arthralgia using logistic regression analysis (GENMOD procedure, P < .05). RESULTS: MRI-depicted anatomic changes, such as joint effusions, disc displacement, and osteoarthrosis, were not significantly correlated with the presence of pain in the TMJ. However, a significant relationship between pain on palpation of the masseter muscle origin (P = .0050) and psychosocial factors (P = .0452) and pain in the TMJ was demonstrated. CONCLUSIONS: Pain in the TMJ caused by the anatomic proximity of the muscle masseter origin and the lateral TMJ pole and the possible existence of trigger points in the musculature may lead to a false-positive or a false-negative diagnosis of arthralgia. Additionally, clinicians must consider the psychosocial aspects of pain in ideal treatment planning.