Interdisciplinary management of acute ischaemic stroke: Current evidence training requirements for endovascular stroke treatment. Position Paper from the ESC Council on Stroke and the European Association for Percutaneous Cardiovascular Interventions with the support of the European Board of Neurointervention.

This ESC Council on Stroke/EAPCI/EBNI position paper summarizes recommendations for training of cardiologists in endovascular treatment of acute ischaemic stroke. Interventional cardiologists adequately trained to perform endovascular stroke interventions could complement stroke teams to provide the 24/7 on call duty and thus to increase timely access of stroke patients to endovascular treatment. The training requirements for interventional cardiologists to perform endovascular therapy are described in details and should be based on two main principles: (i) patient safety cannot be compromised, (ii) proper training of interventional cardiologists should be under supervision of and guaranteed by a qualified neurointerventionist and within the setting of a stroke team. Interdisciplinary cooperation based on common standards and professional consensus is the key to the quality improvement in stroke treatment.

Cognitive function following head CT in childhood: a randomized controlled follow-up trial.

Background The question has been raised whether low dose radiation toward the brain in childhood can affect cognitive functions. Purpose To examine if a head computed tomography (CT) examination in childhood affect later cognitive functions. Material and Methods A total of 147 participants (67 girls/women, 80 boys/men) from a previous randomized controlled trial on management strategies after mild head injury (head CT examination or in-hospital observation) were followed up. Participants were aged 6-16 years (mean age = 11.2 ± 2.8) at first inclusion and 11-24 years (mean age = 17.8 ± 2.9) at follow-up. Computerized neuropsychological measures used for the assessment were motor speed and coordination, reaction time, selective attention, visuospatial ability, verbal and non-verbal short-term and long-term memory, and executive function tests from the neurocognitive test battery EuroCog and the Wechsler Memory Scale III. Results were analyzed with Student's t-tests and multivariate analyses adjusting for sex, age at time of injury/exposure, and age at assessment were performed with Factorial ANOVAs. Results The exposed and unexposed groups did not differ in any of the neuropsychological measures and results did not change when sex, age at time of injury/exposure, and age at assessment were included in the analyses. Conclusion A head CT examination at the age of 6-16 years does not seem to affect later cognitive functions.

Risk of Meningioma after CT of the Head.

Purpose To investigate the association between exposure to head computed tomography (CT) and subsequent risk of meningioma. Materials and Methods The study was approved by the local ethics committee. A cohort of 26 370 subjects was retrospectively collected from a radiology archive of CT examinations of the head performed from 1973 through 1992. For comparison, an age- and sex-matched cohort of 96 940 subjects who were not exposed to CT (unexposed cohort) was gathered. The risk of meningioma was assessed by using data from the Swedish Cancer Registry; however, one-third of patients with meningioma had to be excluded because they either had a prevalent meningioma or other brain tumor at the first CT examination or had undergone radiation treatment to the head. Hazard ratios (HRs) were calculated from time of exposure to the occurrence of meningioma or death or until December 31, 2010, with logistic regression. Results Comparison of exposed and unexposed cohorts showed that there was no statistically significant increase in the risk of meningioma after exposure to CT of the head (HR: 1.49; 95% confidence interval: 0.97, 2.30; P = .07). If incident cases at the time of the first CT examination were not excluded, the risk of meningioma would have been falsely increased (HR: 2.28; 95% confidence interval: 1.56, 3.33; P = .0001). Conclusion When prevalent cases of meningioma at first exposure to CT of the head are excluded, no statistically significant increase in risk of meningioma was found among exposed subjects compared with unexposed control subjects. © RSNA, 2017.

Grey matter brain injuries are common in Ugandan children with cerebral palsy suggesting a perinatal aetiology in full-term infants.

AIM: There is limited literature on brain imaging studies of children with cerebral palsy (CP) in low and middle income countries. We investigated neuroimaging patterns of children with CP attending a tertiary referral centre in Uganda to determine how they differed from studies reported from high income countries and their relationship with prenatal and postnatal factors. METHODS: Precontrast and postcontrast computed tomography (CT) scans of 78 CP children aged 2-12 years were conducted using a Philips MX 16-slice CT scanner. Two radiologists, blinded to the patient's clinical status, independently reviewed the scans. RESULTS: Abnormal CT scans were detected in 69% of the children sampled, with very few having primary white matter injuries (4%). Primary grey matter injuries (PGMI) (44%) and normal scans (31%) were most frequent. Children with a history of hospital admission following birth were three times more likely to have PGMI (odds ratio [OR] 2.8; 95% CI 1.1-7.1), suggesting a perinatal period with medical complications. CONCLUSION: Brain imaging patterns in this group of CP children differed markedly from imaging studies reported from high income countries, suggesting a perinatal aetiology in full-term infants and reduced survival in preterm infants.

Association between adolescents' self-perceived oral health and self-reported experiences of abuse.

This study investigated the association between self-perceived oral health and self-reported exposure to different types of child abuse. It was hypothesized that self-perceived oral health is compromised in exposed adolescents. All Grade-9 compulsory school and second-year high-school pupils in Södermanland County, Sweden (n = 7,262) were invited to take part in a population-based survey; 5,940 adolescents responded. Survey items on health and social wellbeing included self-perceived oral health and exposure to abuse. The results showed that poor self-perceived oral health was associated with self-reported experience of physical abuse, intimate partner violence, forced sex, and bullying (adjusted OR = 2.3-14.7). The likelihood of reporting poor oral health increased from an adjusted OR of 2.1 for a single incident of abuse to an adjusted OR of 23.3 for multiple abuses. In conclusion, poor self-perceived oral health and previous exposure to child physical abuse, intimate partner violence, bullying, and forced sex is associated. It is important that dental professionals recognize adolescents with poor subjective oral health and take into consideration child abuse as a possible cause in order to prevent these adolescents from further victimization. These results further strengthen that dental professionals are an important resource in child protection.

Academic achievement after a CT examination toward the head in childhood: Follow up of a randomized controlled trial.

INTRODUCTION: Increasing use of CT examinations has led to concerns of possible negative cognitive effects for children. The objective of this study is to examine if the ionizing radiation dose from a CT head scan at the age of 6-16 years affects academic performance and high school eligibility at the end of compulsory school. MATERIALS AND METHODS: A total of 832 children, 535 boys and 297 girls, from a previous trial where CT head scan was randomized on patients presenting with mild traumatic brain injury, were followed. Age at inclusion was 6-16 years (mean of 12.1), age at follow up 15-18 years (mean of 16.0), and time between injury and follow up one week up to 10 years (mean of 3.9). Participants' radiation exposure status was linked with the total grade score, grades in mathematics and the Swedish language, eligibility for high school at the end of compulsory school, previously measured GOSE-score, and their mothers' education level. The Chi-Square Test, Student's t-Test and factorial logistics were used to analyze data. RESULTS: Although estimates of school grades and high school eligibility were generally higher for the unexposed, the results showed no statistically significant differences between the exposed and unexposed participants in any of the aforementioned variables. CONCLUSIONS: Any effect on high school eligibility and school grades from a CT head scan at the age of 6-16 years is too small to be detected in a study of more than 800 patients, half of whom were randomly assigned to CT head scan exposure.

Location of gliomas in relation to mobile telephone use: a case-case and case-specular analysis.

The energy absorbed from the radio-frequency fields of mobile telephones depends strongly on distance from the source. The authors' objective in this study was to evaluate whether gliomas occur preferentially in the areas of the brain having the highest radio-frequency exposure. The authors used 2 approaches: In a case-case analysis, tumor locations were compared with varying exposure levels; in a case-specular analysis, a hypothetical reference location was assigned for each glioma, and the distances from the actual and specular locations to the handset were compared. The study included 888 gliomas from 7 European countries (2000-2004), with tumor midpoints defined on a 3-dimensional grid based on radiologic images. The case-case analyses were carried out using unconditional logistic regression, whereas in the case-specular analysis, conditional logistic regression was used. In the case-case analyses, tumors were located closest to the source of exposure among never-regular and contralateral users, but not statistically significantly. In the case-specular analysis, the mean distances between exposure source and location were similar for cases and speculars. These results do not suggest that gliomas in mobile phone users are preferentially located in the parts of the brain with the highest radio-frequency fields from mobile phones.

A longitudinal observational study of brain atrophy rate reflecting four decades of multiple sclerosis: a comparison of serial 1D, 2D, and volumetric measurements from MRI images.

INTRODUCTION: Multiple sclerosis (MS) has a variable progression with an early onset of atrophy. Individual longitudinal radiological evaluations (over decades) are difficult to perform due to the limited availability of magnetic resonance imaging (MRI) in the past, patients lost in follow-up, and the continuous updating of scanners. We studied a cohort with widespread disease duration at baseline. The observed individual atrophy rates over time of 10 years represented four decades of disease span. METHODS: Thirty-seven MS patients (age range 24-65 years with disease duration 1-33 years) were consecutively selected and evaluated with MRI at baseline 1995 and in 1996. They were followed up for a decade (mean of 9.25 years, range 7.3-10 years) up to 2003-2005. Brain parenchymal volume and volumes of the supratentorial ventricles were analyzed with semi-automated volumetric measurements at three time points (1995, 1996, and 2003-2005). RESULTS: Volumetric differences were found over shorter periods of time (1-7 months); however, differences vanished by the end of follow-up. A uniform longitudinal decrease in brain volume and increase in ventricle volumes were found. Frontal horn width (1D) correlated strongest to 3D measures. No statistical differences of atrophy rates between MS courses were found. Supratentorial ventricular volumes were associated with disability and this association persisted during follow-up. CONCLUSION: Despite variable clinical courses, the degenerative effects of MS progression expressed in brain atrophy seem to uniformly progress over longer periods of time. These volumetric changes can be detected using 1D and 2D measurements performed on a routine PACS workstation.

Visual field function in school-aged children with spastic unilateral cerebral palsy related to different patterns of brain damage.

AIM: To relate visual field function to brain morphology in children with unilateral cerebral palsy (CP). METHOD: Visual field function was assessed using the confrontation technique and Goldmann perimetry in 29 children (15 males, 14 females; age range 7-17y, median age 11y) with unilateral CP classified at Gross Motor Function Classification System (GMFCS) level I and Manual Ability Classification System levels I to III. The type and extent of brain lesions were determined using cerebral imaging. RESULTS: Eighteen children had subnormal visual field function. The visual fields were severely restricted in six. The underlying brain lesions were malformation (n=7), white matter damage of immaturity (WMDI; n=13), and cortical-subcortical lesions (n=9). Visual field function could be correlated with the pattern of brain damage in children with cortical-subcortical lesions or extensive lesions caused by malformation or WMDI. Total homonymous hemianopia was common in the cortical-subcortical group but rare in children with malformation or WMDI. Five children had normal visual field function despite having malformation or WMDI involving parts of the brain usually encompassing the visual system. INTERPRETATION: Visual field function may be preserved by plasticity of the immature brain in children with malformation and WMDI. Severely restricted visual fields were more often associated with lesions occurring later in the developing brain. All children with severely restricted visual fields were identified by the confrontation technique. Goldmann perimetry was a suitable method to identify relative visual field defects.

Evaluation of documentation in potential abusive head injury of infants in a Paediatric Emergency Department.

AIM: The aim is to evaluate medical record documentation regarding potential abusive head injury (AHI) in infants presenting to a Paediatric Emergency Department (ED) with certain primary complaints known to be associated with AHI. METHODS: A database search was performed to find all medical records over a period of one year relating to those children who had one AHI-related primary complaint and who had had a CT head-scan performed in conjunction with admission. Each medical record was reviewed, in order to assess whether potential abuse had been investigated and documented. Each CT-scan image was re-evaluated for missed indications of potential injuries attributable to AHI. RESULTS: Forty-seven such medical records were found. Of these, 87% showed the diagnosis to be head injuries. The largest group of children was in the age group 0-3 months (38%). Of the children admitted to the Paediatric ED due to a head injury, 54% had a history deemed to raise suspicions of abuse but only five of them had had a documented investigation of child abuse. The re-evaluation of the CT-scans showed no missed cases. CONCLUSION: In this study we found that among children with known risk factors for AHI, only a few had documentation regarding potential child abuse. The use of a standardized protocol could be helpful in the important work to help staff discover potential AHI.

Injuries to the Immature Optic Radiation Show Correlated Thinning of the Macular Ganglion Cell Layer.

Injuries to the immature optic radiation (OR) are associated with thinning of the retinal nerve fiber layer and corresponding visual field (VF) defects. The aim of the current study was to seek evidence for causal retrograde trans-synaptic degeneration by exploring the correspondence between the localization and extension of the injury to the OR and the structure of the macular ganglion cell complex, and the relation to VF function. Seven adults (age range 18-35) with visual dysfunction secondary to white-matter damage of immaturity and six healthy adults (age range 22-33) underwent magnetic resonance imaging (MRI). Fiber tractography was used to generate the geniculate projections to the dorsal and ventral striate cortex, delineated by retinotopic functional MRI mapping. The structure of the macular ganglion cell complex was measured with optical coherence tomography. The tractography showed overlaps between the dorsal and ventral geniculo-striate projections. However, in four patients with inferior VF defects, the dorsal projections were to a large extent traversing the space normally solely occupied by ventral projections. This is consistent with structural changes to the OR and suggests of re-organization upon injury. Diffusion parameters were significantly different between patients and controls, and most pronounced in the dorsal geniculo-striate projections, with a pattern indicating primary injury. The macular ganglion cell complex was significantly thinner in the patients and most pronounced in the superior sectors; a pattern particularly evident in the four patients with inferior VF defects. The ratio of the mean thickness of the macular ganglion cell complex in the superior and inferior sectors significantly correlated with the axial and mean diffusivities in the contra- and ipsilateral dorsal striate projections. The results suggest a causal link between injuries to the superior portion of the immature OR and secondary thinning in the macular ganglion cell complex, resulting in inferior VF defects.

Progression of non-age-related callosal brain atrophy in multiple sclerosis: a 9-year longitudinal MRI study representing four decades of disease development.

BACKGROUND: In multiple sclerosis (MS), multiple periventricular lesions are commonly the first findings on MRI. However, most of these MS lesions are clinically silent. The brain atrophy rate has shown better correlation to physical disability, but it is not clear how atrophy develops over decades. Corpus callosum forms the roof of the third and lateral ventricles. The corpus callosum area (CCA) in a midsagittal image is age independent in a normal adult population up to the seventh decade; therefore it can be used as a marker for non-age-related, pathological brain atrophy. OBJECTIVES: To investigate whether and how CCA decreases in size over time in patients with MS. METHODS: In a clinical observational study, 37 patients with MS with a wide range of disease duration at baseline (1-33 years) were followed. Three different MS courses were represented. The mean of individual MRI follow-up was 9 years. Multiple sclerosis severity score (MSSS) was also applied to evaluate disability at baseline and after 9 years of follow-up. RESULTS: A significant decrease in CCA over 9 years (p<0.001) and a persisting association between CCA and the disability status were found. The atrophy rate was similar ever four decades of MS for all MS courses. The mean annual CCA decrease was 9.25 mm2 (1.8%). Surprisingly, atrophy rate did not correlate with sex, disease duration, age at MS onset or MS course. CONCLUSIONS: Serial evaluations of CCA might be a robust method in monitoring a non-age-related decrease in CCA, reflecting progression of irreversible destructive changes in MS.

Clinical and MRI correlates of cerebral palsy: the European Cerebral Palsy Study.

CONTEXT: Magnetic resonance imaging (MRI) findings have been reported for specific clinical cerebral palsy (CP) subgroups or lesion types but not in a large population of children with all CP subtypes. Further information about the causes of CP could help identify preventive strategies. OBJECTIVE: To investigate the correlates of CP in a population sample and compare clinical findings with information available from MRI brain studies. DESIGN AND SETTING: Cross-sectional, population-based investigative study conducted in 8 European study centers (North West London and North East London, England; Edinburgh, Scotland; Lisbon, Portugal; Dublin, Ireland; Stockholm, Sweden; Tübingen, Germany; and Helsinki, Finland). PARTICIPANTS: Five hundred eighty-five children with CP were identified who had been born between 1996 and 1999; 431 children were clinically assessed and 351 had a brain MRI scan. MAIN OUTCOME MEASURES: Standardized clinical examination results, parental questionnaire responses, MRI results, and obstetric, genetic, and metabolic data from medical records. RESULTS: Important findings include the high rate of infections reported by mothers during pregnancy (n = 158 [39.5%]). In addition, 235 children (54%) were born at term while 47 children (10.9%) were very preterm (<28 weeks). A high rate of twins was found, with 51 children (12%) known to be from a multiple pregnancy. Clinically, 26.2% of children had hemiplegia, 34.4% had diplegia, 18.6% had quadriplegia, 14.4% had dyskinesia, 3.9% had ataxia, and 2.6% had other types of CP. Brain MRI scans showed that white-matter damage of immaturity, including periventricular leukomalacia (PVL), was the most common finding (42.5%), followed by basal ganglia lesions (12.8%), cortical/subcortical lesions (9.4%), malformations (9.1%), focal infarcts (7.4%), and miscellaneous lesions (7.1%). Only 11.7% of these children had normal MRI findings. There were good correlations between the MRI and clinical findings. CONCLUSIONS: These MRI findings suggest that obstetric mishaps might have occurred in a small proportion of children with CP. A systematic approach to identifying and treating maternal infections needs to be developed. Multiple pregnancies should be monitored closely, and the causes of infant stroke need to be investigated further so preventive strategies can be formulated. All children with CP should have an MRI scan to provide information on the timing and extent of the lesion.

Damage to the immature optic radiation causes severe reduction of the retinal nerve fiber layer, resulting in predictable visual field defects.

PURPOSE: The aim of the present study was to seek evidence of a relationship between damage to the optic radiation (OR) in the immature brain and subsequent development of the retinal nerve fiber layer (RNFL) and associated visual manifestations. METHODS: Seven cases (2 males and 5 females ranging in age from 18 to 35 years old) were selected from a large cohort of individuals with known white matter damage of immaturity (WMDI), who had presented with visual dysfunction. They underwent magnetic resonance imaging (MRI), including diffusion-weighted MRI. Visual function was evaluated by best-corrected visual acuity and visual field (VF) testing using Goldmann perimetry and Humphrey field analyzer (HFA). RNFL thickness was measured by optical coherence tomography. RESULTS: A homogeneous lesion pattern with bilateral WMDI predominantly in the superior posterior periventricular white matter was seen in all subjects. However, as shown by white matter fiber tractography, only cases with injuries to the superior portion of the OR had corresponding inferior VF defects. In the individuals showing structural abnormalities in the OR, a commensurate reduction in the peripapillary RNFL was seen. The RNFL loss was most pronounced in the subjects suffering from the more extensive lesions, and it followed the pattern of OR damage in the sense that damage in the superior portion of the OR gave a reduced RNFL thickness in the superior part of the peripapillary RNFL. CONCLUSIONS: Primary injuries in the immature OR are associated with reduced RNFL thickness, and examination of the RNFL may be a helpful predictor of VF defects.