Ageing shows a pattern of cerebellar degeneration analogous, but not equal, to that in patients suffering from cerebellar degenerative disease.

Ageing generally leads to impairments in cognitive function and the ability to execute and learn new movements. While the causes of these impairments are often multi-factorial, integrity of the cerebellum in an elderly population is an important predictive factor of both motor function and cognitive function. A similar association between cerebellar integrity and function is true for cerebellar patients. We set out to investigate the analogies between the pattern of cerebellar degeneration of a healthy ageing population and cerebellar patients. We quantified cerebellar regional volumes by applying voxel-based morphometry (VBM) to a publicly available dataset of MR images obtained in 313 healthy subjects aged between 18 and 96 years and a dataset of MR images of 21 cerebellar patients. We observed considerable overlap in regions with the strongest loss of cerebellar volume in the two datasets. In both datasets, the anterior lobe of the cerebellum (lobules I-V) and parts of the superior cerebellum (primarily lobule VI) showed the strongest degeneration of cerebellar volume. However, the most significant voxels in cerebellar patients were shifted posteriorly (lobule VII) compared to the voxels that degenerate most with age in the healthy population. The results showed a pattern of significant degeneration of the posterior motor region (lobule VIIIb) in both groups, and significant degeneration of lobule IX and X in the healthy population, but not in cerebellar patients. Furthermore, we saw strong volumetric degeneration of functionally defined cerebellar regions associated with cerebral somatomotor function in both groups. Predominance of degeneration in the anterior lobe and lobule VI suggests impairment of motor function in both groups, while we suggest that the posterior shift of degeneration in cerebellar patients would be associated with relatively stronger impairment of higher motor function and cognitive function. Thus, these results may explain the specific symptomology associated with cerebellar degeneration in ageing and in cerebellar patients.

Current concepts for diagnosis and treatment of retinoblastoma in Germany: aiming for safe tumor control and vision preservation.

Retinoblastoma affects approximately 40 children in Germany per year. Most children are diagnosed early with localized intraocular disease, and the overall survival rate exceeds 95%. However, the prognosis of metastasized retinoblastoma remains poor. In 40% of the patients, retinoblastoma occurs bilaterally and, especially for these children, the salvage of the eye and visual function is of major importance. The variety of conservative treatment options for localized retinoblastoma includes laser coagulation, thermotherapy, cryotherapy, brachytherapy and chemotherapy. While systemic chemotherapy has nearly completely replaced external beam radiotherapy in the primary treatment of intraocular retinoblastoma, intra-arterial, intravitreal and periocular application of chemotherapy was also shown to be effective in treating intraocular retinoblastoma in case series. Genetic testing is an integral part of the routine diagnostics of all patients. Available tumor material should be analyzed to detect mutational mosaicism, that affects >10% of children with unilateral retinoblastoma. Genetic testing also identifies children with heritable (50% of patients) retinoblastoma. These children have a genetic predisposition for second malignancies. For this reason, late effects are an increasing concern and the care of patients with retinoblastoma requires a multidisciplinary approach to tailor therapy and long-term follow-up. Multicenter clinical trials are being developed to evaluate evidence-based treatment concepts for localized and metastasized retinoblastoma to improve survival rates and quality of life of children with retinoblastoma.

[Blunt force injuries due to martial arts in children--a diagnostic problem? Delayed diagnosis of an infected hematoma]. / Stumpfe Verletzungen im Kampfsport bei Kindern--ein diagnostisches Problem? Verzögerte Diagnose eines infizierten Hämatoms.

INTRODUCTION: Blunt force injuries in martial arts occur frequently but isolated hematoma of muscles in the extremities is rare. Even minor trauma of the lower extremities due to throwing techniques in judo and other forms of Asian martial arts can lead to major pathologies. METHODS: A 9-year-old girl presented with an unclear swelling and soreness of the calf muscle. The patient could not remember an obvious traumatic event. She was admitted 4 days later because of increased swelling, pain and erythema. The parents reported a minor trauma at judo training 1 week ago. Further investigation was performed with MRI and confirmed a massive hematoma much greater than previously shown by sonography. RESULTS: Histologic and microbiologic evaluation demonstrated florid inflammation and proof of Staphylococcus aureus was found intra-operatively. DISCUSSION: The diagnosis of blunt force injuries due to martial arts is difficult in childhood because often children do not remember a traumatic event. Therefore, it is important to obtain a thorough history from caregivers. Because sonography depends highly on the experience of the investigator MRI is considered to be a better diagnostic modality to diagnose and guide treatment in this age group.

Cerebral venous thrombosis after epidural blood patch: coincidence or causal relation? A case report and review of the literature.

We report on a female patient who developed post-dural puncture headache (PDPH) after epidural analgesia for delivery. Treatment with epidural blood patch led to complete headache remission and the patient was discharged. Two days later the patient was readmitted with hemihypaesthesia and mild hemiparesis of the right side. Magnetic resonance imaging showed a small left parietal cortical haemorrhage probably following cerebral venous thrombosis (CVT). Coagulation screening detected heterozygous Factor V mutation. Headache is a common symptom of PDPH and CVT. Review of the literature revealed five patients in puerperal state, who developed CVT in close temporal relationship after blood patch treatment for PDPH. Change of headache character with loss of postural influence was reported frequently before diagnosis of CVT was confirmed. These findings may indicate a causal relationship.

[Cerebral MRI in neurological asymptomatic patients with malignant melanoma]. / Zerebrales MRT bei neurologisch asymptomatischen Patienten mit malignem Melanom.

PURPOSE: Detection of metastasis in the whole body is important for sufficient the staging of malignant melanoma. Sufficient imaging of the brain is particularly important. Although there is evidence that clinical examination is not sufficient for prediction of cerebral metastasis, MRI scan is not always regarded as reasonable in neurological asymptomatic patients. Therefore, we explored the incidence of cerebral metastasis in our patient population in relation to the stage of disease to estimate the reasonability of this examination. MATERIALS AND METHODS: 120 consecutive patients with malignant melanoma were retrospectively evaluated. All patients were neurologically without pathological findings and received routine staging by cranial MRI. The incidence of brain metastasis was evaluated. The examination protocol consisted of an axial orientated flair and a T 1 sequence. Ten minutes after administration of contrast agent, a T 1 sequence in axial and coronal orientation was performed using the magnetization transfer technique. The type of melanoma, the thickness of the tumor, the Clark level, the location of the primary tumor, and the clinical stage were recorded from the clinical records. RESULTS: 15 (12.5 %) of the 120 patients (clinical stage I: 27 patients, stage II: 29 patients, stage III: 25 patients, stage IV: 39 patients) had cerebral metastasis in MRI. 14 patients were in stage III or IV at this time. Consequently 21.8 % of the patients in stage III and IV had cerebral metastasis. Only one patient in stage IIc had cerebral metastasis. CONCLUSION: Cranial MRI of neurologically asymptomatic patients seems to be an important factor in the staging of melanoma especially in the advanced stage of this disease and in patients with a thick primary tumor.

Endovascular treatment of middle cerebral artery aneurysms with electrolytically detachable coils.

BACKGROUND AND PURPOSE: Middle cerebral artery (MCA) aneurysms often have an unfavorable aneurysm geometry that might limit endovascular therapy. Our purpose was to analyze the feasibility, safety, and efficacy of coil embolization in a consecutive series of MCA aneurysms chosen for endovascular treatment. PATIENTS AND TECHNIQUES: Of 235 MCA aneurysms seen at our institution during the past 5 years, 36 patients harboring 38 MCA aneurysms were primarily selected for coil embolization: 18 patients had an acute subarachnoid hemorrhage (SAH), 16 of which were due to a ruptured MCA aneurysm. SAH was classified according to Hunt and Hess grade: I (5), II (7), III (5), IV (0), and V (1). RESULTS: Complete occlusion could be achieved in 33 of 38 aneurysms. In 5 aneurysms, coil embolization was not performed because of an unfavorable aneurysm geometry with a wide neck or incorporation of adjacent branches (3) or failed because of insecure coil placement (1) or severe vasospasm (1). Procedural complications included coil protrusion into the parent artery (1), and thromboembolic M2 occlusion (5), with recanalization in 4 of 5 cases. Of 8 aneurysms with initial subtotal occlusion, 3 progressed to total occlusion during follow-up. Three aneurysms had to be retreated, and no patient rebled. Glasgow Outcome Scale at 6 months for the patients with SAH (17/18) was good recovery (12), moderate disability (4), severe disability (0), persistent vegetative state (0), and death (1); outcomes for patients with an incidental aneurysm (17/18) were good recovery (16) and moderate disability (1). CONCLUSION: Endovascular coil embolization can be performed safely and effectively in selected MCA aneurysms. Initial subtotal aneurysm occlusion might progress to total occlusion.

Posterior Reversible Encephalopathy Syndrome: The Spectrum of MR Imaging Patterns.

AIM: The aim of this study was to describe lesion patterns, distribution, and evolution in posterior reversible encephalopathy syndrome (PRES) in a larger single-center population. METHODS: Scans and follow-up, if available, of 50 patients with PRES between 2002 and 2011 were reviewed retrospectively. Lesion patterns, extent, and signal intensity changes were identified and graded on fluid-attenuated inversion recovery (FLAIR) and diffusion-weighted images. Hemorrhagic changes were identified on T2* or susceptibility-weighted images, and gadolinium enhancement on T1-weighted images was identified if available. RESULTS: The most frequently affected regions on FLAIR were the frontal lobes in 54 %, occipital lobes in 34.3 %, and parietal lobes in 31.0 % of cases, thus 65.3 % in the posterior regions. Temporal lobes were affected in 10.6 %, the cerebellum in 6.5 %, and basal ganglia in 1.6 %. Division into vascular supply showed involvement in the anterior circulation in 66.5 % and in the posterior circulation in 33.5 % of cases. On diffusion-weighted imaging (DWI), vasogenic edema was observed in 6.9 %, cytotoxic edema in 9.1 %, and both in 2 % of cases. In 31.9 %, there was shine through, and in 15.9 %, there was shine through as well as cytotoxic or vasogenic edema. Topologic distribution on DWI showed affection of the frontal lobes in 43.5 %, occipital lobes in 25.8 %, parietal lobes in 17.7 %, temporal lobes in 11.3 %, and cerebellum in 1.6 %. T2* or susceptibility-weighted images showed spot-like hemosiderin accumulation in 17.2 % of cases. In 23.1 %, enhancement was seen. Follow-up magnetic resonance imaging showed complete resolution in 66.6 % of patients. CONCLUSION: The spectrum of imaging findings in PRES is wide. Almost always subcortical and cortical structures are involved. Although posterior changes are prominent in this syndrome, frontal involvement is more frequent than posterior on FLAIR imaging and DWI. On DWI, mixed patterns are not uncommon. Reversibility generally takes place independent of DWI pathology. Hypertension was not a prognostic factor.

Benefit of second catheter angiography in patients with nontraumatic subarachnoidal hemorrhage.

PURPOSE: This study aimed to determine the yield of repetitive catheter angiography (digital subtraction angiography (DSA)) for the detection of causative vascular lesions in patients with nontraumatic subarachnoidal hemorrhage (SAH) and negative initial DSA. We hypothesize that a second DSA might be helpful to detect an initially occult bleeding source. METHODS: We retrospectively evaluated 649 patients with acute SAH and invasive catheter angiographies between 2004 and 2012. In 90 SAH patients initial imaging was negative concerning a causative bleeding source. A total of 113 repetitive DSA were performed. Two neuroradiologists reanalyzed the initial imaging and the result of the reangiography independently. RESULTS: In 4/90 patients (4.5 %) bleeding source was first detected in the second or third DSA. In all other patients, no causative vascular lesion was found. Reasons for the initially false negative diagnostics were one dissecting aneurysm and thrombosis of three aneurysms within the acute phase of SAH. CONCLUSIONS: Repetitive DSA revealed the cause of SAH in 4.5 % of the cases. These findings have a therapeutic and prognostic impact. We think that at least a second DSA should be part of diagnostic work-up in patients with SAH and missing bleeding source, even considering the risk of an additional invasive angiography itself.

Multimodal imaging in the elastase-induced aneurysm model in rabbits: a comparative study using serial DSA, MRA and CTA.

BACKGROUND AND PURPOSE: The elastase-induced aneurysm model in rabbits has proved to be suitable for testing new endovascular occlusion devices. The purpose of this study was to evaluate different imaging modalities for the depiction of anatomy and size of elastase-induced aneurysms and for serial follow-up imaging. MATERIALS AND METHODS: Elastase-induced aneurysms were created in eight Chinchilla bastard rabbits by endoluminal incubation of porcine elastase. Serial imaging was performed using intravenous DSA (IVDSA), contrast-enhanced MRA (CEMRA), and time-of-flight MRA (TOF) 14 days, 4 weeks and 3 months after aneurysm creation. Intraarterial DSA (IADSA) and CT angiography (CTA) were performed after 3 months. Aneurysm size and geometry (height H, width W, neck width N) were compared. RESULTS: On IVDSA after two weeks mean aneurysm height was 6.2 mm (range 2.8 - 11.0 mm), mean aneurysm width was 2.8 mm (range 2.0 - 4.2 mm) and mean aneurysm neck width was 2.7 mm (range 2.0 - 4.2 mm). We did not observed any statistically significant change in aneurysm dimensions during follow-up at 4 weeks (CEMRA: H: 5.4, W: 2.4, N: 2.4; TOF: H: 5.7, W: 2.4, N: 2.7) and 3 months (CEMRA: H: 5.8, W: 2.6, N: 2.6; TOF: H: 6.9, W: 2.8, N: 3.0). Aneurysm dimensions could be best seen on IADSA (H: 6.2, W: 3.0, N: 2.7) with good correlation to CTA (r = 0.94; H: 6.1, W: 2.8, N: 2.6), CE-MRA (r = 0.92), and TOF (r = 0.97). TOF was superior to CEMRA in delineating the aneurysm wall. CONCLUSIONS: Serial imaging using MRA, CTA or intravenous and intraarterial angiography is feasible in the elastase-induced aneurysm model. Contrast-enhanced MRA, TOF-MRA and CTA showed good correlation to IADSA and are all suitable for non-invasive pretherapeutic measurement of aneurysm size.

Silent embolism after stent-assisted coiling of cerebral aneurysms: diffusion-weighted MRI study of 75 cases.

PURPOSE: New ischemic brain lesions are common findings after cerebral diagnostic angiography and endovascular therapy. Diffusion-weighted MRI (DWI) can be used for detection of these lesions. The aim of the present study was to investigate the incidence of DWI lesions after stent-assisted coiling and the evaluation of possible risk factors. METHODS: The study included a total of 75 consecutive patients treated with stent-assisted coiling. Post-procedural DWI of the brain was performed to detect ischemic lesions. Demographic data, aneurysm characteristics and angiographic parameters were correlated with properties of DWI lesions. RESULTS: In post-procedural DWI, 48 of the 75 patients (64%) had 163 DWI lesions in a pattern consistent with embolic events. The number of patients with DWI lesions was significantly increased in older patients (≥55 years) and longer intervention times (≥120 min). The ischemic brain volume was significantly increased in older patients (≥55 years) as well as in patients who were implanted with a shorter stent (<20 mm). CONCLUSIONS: Thromboembolic events are common after stent-assisted coiling with an incidence comparable to DWI studies after coiling alone. Despite several devices and low operator experience, stent-assisted coiling for intracranial aneurysms has a very low risk of permanent neurologic disability. Further studies are necessary to improve the safety of stent-assisted coiling for patients in conditions with increased risk potential (age, procedure time, stent length).

[3-year follow-up after endovascular aneurysm treatment with Silk® flow diverter]. / 3-Jahres-Follow nach Aneurysmabehandlung mit dem Silk® Flow Diverter.

PURPOSE: Flow diverters may occlude aneurysms by endoluminal reconstruction of the parent artery and by reducing the blood flow into the aneurysm. The purpose of this study was to assess the rate of intervention-associated complications and a 3-year-follow-up. MATERIALS AND METHODS: We retrospectively analyzed 18 patients treated with Silk® FD. Only patients with unruptured aneurysms were included. Treatment indications were fusiform, giant or recurrent aneurysms. We considered all aneurysms to have a high likelihood of failure and/or recurrence when treated with conventional endovascular techniques. RESULTS: Silk FD could directly be placed in a proper position across the whole length of the aneurysm in 16/18 patients. In one case an additional PTA was necessary. In another case the first FD could not be properly deployed. 17 of 18 aneurysms (95 %) were occluded immediately, in the mid-term follow-up after 6 months or 3 years after treatment. The overall complication rate including technical (11.1 %), acute or delayed thromboembolic complication without (11.1 %) or with (16.6 %) severe complications was documented. CONCLUSION: FD treatment is effective with a high occlusion rate of aneurysms also in long-term follow-up. In these complex aneurysms the complication rate is higher than in conventional stent-assisted coiling.

Neuroimaging in a Three-Year-Old Girl - MRI without Anesthesia: Easier than One Thinks. A Case Report.

Magnetic resonance imaging (MRI) is the imaging modality of choice in the diagnosis of structural brain abnormalities in children. Routine scans are usually not reliable in pediatric neuroimaging without sedation before the age of seven. Before this age sedation or general anesthesia with procedural risks and additional costs might be needed. We report on MRI in a 3.1-year-old patient referred after a first seizure performed with a combination of role model and self-experience. MRI with high imaging quality was performed without the need for anesthesia in our daily routine. The imaging procedure was performed without previous preparation needed and within target date.Our reported technique of a combination of role model and self-experience, avoiding anesthesia in a 3.1-year-old girl is suitable for children and it is applicable in the daily routine.

A High CSF Signal on FLAIR: It Is Not Always Blood.

We describe a patient with progressive neurologic deficit due to middle cerebral branch occlusion. Temporary partial balloon occlusion of the abdominal aorta led to an increased signal in the subarachnoid space on fluid-attenuated inversion recovery images with no evidence of subarachnoid hemorrhage. After spontaneous recanalization, the increased signal of the subarachnoid space returned to normal. We assume that signal changes in the subarachnoid space were due to a temporary increase in blood volume in the superficial brain vessels.

Elastase-induced aneurysm in Swine: proof of feasibility in a first case. A technical note.

SUMMARY: This is the first description of a modified endovascular elastase-induced aneurysm model in swine. The advantage of this model is the combination of an aneurysm of true vessel continuation with arterial wall and the possibility of using large femoral access devices. Imaging revealed a successful aneurysm creation at the origin of the right CCA. High personal and financial expense and partial thrombus formation might limit the routine use and this model might be reserved for exclusive issues.

Percutaneous embolization of carotid paragangliomas using solely Onyx.

BACKGROUND AND PURPOSE: Paragangliomas are highly vascularized usually benign neoplasms arising from nerve tissue. Endovascular preoperative embolization is used to facilitate surgery but is often not complete, due to tiny feeding arteries not feasible for selective catheterization. Our purpose was to evaluate angiographic and clinical outcome using Onyx for percutaneous glomus tumor embolization. MATERIALS AND METHODS: A consecutive series of 4 patients with 6 paragangliomas located at the bifurcation of the common carotid artery were treated with percutaneous embolization using Onyx as the sole embolic material. RESULTS: Complete devascularization of the 6 paragangliomas was achieved using a percutaneous embolization technique with Onyx as a sole agent, combined with an endovascular microballoon that offered protection of the internal carotid artery. CONCLUSIONS: Further documentation is necessary to prove the higher grade of devascularization of paragangliomas with Onyx compared with other embolic material and the associated potential to facilitate surgery. Nevertheless, Onyx seems to be safe when used percutaneously due to its lavalike pattern flow and its controllable properties, allowing slow tumor bed penetration.

Treatment of wide-necked intracranial aneurysms with a self-expanding stent: mid-term results.

PURPOSE: To evaluate mid-term clinical and angiographic results after using a self-expanding neurovascular stent and coils for the management of broad-based intracranial aneurysms. METHODS: During the period from August 2001 to October 2004 we treated a total of 42 patients with 44 aneurysms using a self-expandable stent. To date we have data on more than 6 months of follow-up in 25 patients with 26 aneurysms. Aneurysm occlusion was divided into the following categories: 100 % (complete), 95-99 % (subtotal), and < 95 % (incomplete). RESULTS: In 15 aneurysms complete occlusion, in 11 aneurysms subtotal occlusion was initially achieved. Control DSA showed progressive thrombosis in seven aneurysms leading to total occlusion in another 4 aneurysms. Three recanalizations were observed in one large and two giant ICA aneurysms. No vessel occlusion occurred. One vessel stenosis of the stented segment was noted, but it was not clinically relevant. One patient experienced a small embolic infarction after stopping antiplatelet medication. No persistent deterioration of the clinical status occurred. CONCLUSION: Combining a stent with coils seems to be an acceptable treatment option for broad-based intracranial aneurysms. As this special subgroup of treated aneurysms includes only those with an unfavourable geometry, the results are extremely promising.

Flow-directed microcatheters for cerebral embolizations using Ethibloc--an in vitro study.

We conducted an in vitro performance study to test the flow-directed Spinnaker microcatheter for potential endovascular embolizations with Ethibloc as embolic agent. We performed in vitro testing using 50 Spinnaker 1.8F hydrophilic infusion microcatheters of three different types. As embolic agent, different mixtures of Ethibloc and Lipiodol (E/L 1:1, 1:2, 1:3) were used. In an in vitro setting, each catheter was injected to a maximum of ten times (E/L 1:1, n = 20 catheters; E/L 1:2, n = 20; E/L 1:3, n = 10). In addition, we evaluated the thinner Spinnaker 1.5F microcatheter (165/20, n = 10). Five Spinnaker 1.5F catheters were each injected with a mixture of Ethibloc and Lipiodol (E/L 1:2 and 1:3). When a mixture of E/L 1:1 was used, 9 of 20 (45%) Spinnaker 1.8F microcatheters ruptured distally near the tip of the microcatheter, each during injection nos. 5-9. One Spinnaker 1.8F was distally occluded after the fifth injection. With a mixture of E/L 1:2, 4 of 20 (20%) Spinnaker 1.8F microcatheters ruptured distally, during injection no. 6 (n = 2), 7 (n = 1), and 8 (n = 1). With a mixture of E/L 1:3, all ten Spinnaker 1.8F microcatheters could be injected without any problems. All ten microcatheters of the thinner Spinnaker 1.5F ruptured (10-18 cm proximally to the catheter tip). This in vitro study using the flow-directed Spinnaker microcatheter revealed that microcatheters can rupture. The Spinnaker 1.8F can rupture when a mixture of Ethibloc and Lipiodol 1:1 or 1:2 and more than four injections are used. The Spinnaker 1.8F does not rupture when a mixture of E/L 1:3 is used, or with a mixture of E/L 1:1 or 1:2 and injecting to a maximum of four times. The Spinnaker 1.5F microcatheter is not suitable for embolizations using Ethibloc. For embolizations with Ethibloc we therefore recommend the use of a guidewire-directed microcatheter.