Brain iron accumulation in Wilson disease: a post mortem 7 Tesla MRI - histopathological study.

AIMS: In Wilson disease (WD), T2/T2*-weighted (T2*w) MRI frequently shows hypointensity in the basal ganglia that is suggestive of paramagnetic deposits. It is currently unknown whether this hypointensity is related to copper or iron deposition. We examined the neuropathological correlates of this MRI pattern, particularly in relation to iron and copper concentrations. METHODS: Brain slices from nine WD and six control cases were investigated using a 7T-MRI system. High-resolution T2*w images were acquired and R2* parametric maps were reconstructed using a multigradient recalled echo sequence. R2* was measured in the globus pallidus (GP) and the putamen. Corresponding histopathological sections containing the lentiform nucleus were examined using Turnbull iron staining, and double staining combining Turnbull with immunohistochemistry for macrophages or astrocytes. Quantitative densitometry of the iron staining as well as copper and iron concentrations were measured in the GP and putamen and correlated with R2* values. RESULTS: T2*w hypointensity in the GP and/or putamen was apparent in WD cases and R2* values correlated with quantitative densitometry of iron staining. In WD, iron and copper concentrations were increased in the putamen compared to controls. R2* was correlated with the iron concentration in the GP and putamen, whereas no correlation was observed for the copper concentration. Patients with more pronounced pathological severity in the putamen displayed increased iron concentration, which correlated with an elevated number of iron-containing macrophages. CONCLUSIONS: T2/T2*w hypointensity observed in vivo in the basal ganglia of WD patients is related to iron rather than copper deposits.

Glioma infiltration of the corpus callosum: early signs detected by DTI.

The most frequent primary brain tumors, anaplastic astrocytomas (AA) and glioblastomas (GBM): tend to invasion of the surrounding brain. Histopathological studies found malignant cells in macroscopically unsuspicious brain parenchyma remote from the primary tumor, even affecting the contralateral hemisphere. In early stages, diffuse interneural infiltration with changes of the apparent diffusion coefficient (ADC) and fractional anisotropy (FA) is suspected. The purpose of this study was to investigate the value of DTI as a possible instrument of depicting evidence of tumor invasion into the corpus callosum (CC). Preoperatively, 31 patients with high-grade brain tumors (8 AA and 23 GBM) were examined by MRI at 3 T, applying a high-resolution diffusion tensor imaging (DTI) sequence. ADC- and FA-values were analyzed in the tumor-associated area of the CC as identified by fiber tracking, and were compared to matched healthy controls. In (MR-)morphologically normal appearing CC the ADC values were elevated in the tumor patients (n = 22; 0.978 × 10(-3) mm²/s) compared to matched controls (0.917 × 10(-3) mm²/s, p < 0.05), and the corresponding relative FA was reduced (rFA: 88 %, p < 0.01). The effect was pronounced in case of affection of the CC visible on MRI (n = 9; 0.978 × 10(-3) mm²/s, p < 0.05; rFA: 72 %, p < 0.01). Changes in diffusivity and anisotropy in the CC can be interpreted as an indicator of tumor spread into the contralateral hemisphere not visible on conventional MRI.

Recombinant human erythropoietin delays loss of gray matter in chronic schizophrenia.

Neurodevelopmental abnormalities together with neurodegenerative processes contribute to schizophrenia, an etiologically heterogeneous, complex disease phenotype that has been difficult to model in animals. The neurodegenerative component of schizophrenia is best documented by magnetic resonance imaging (MRI), demonstrating progressive cortical gray matter loss over time. No treatment exists to counteract this slowly proceeding atrophy. The hematopoietic growth factor erythropoietin (EPO) is neuroprotective in animals. Here, we show by voxel-based morphometry in 32 human subjects in a placebo-controlled study that weekly high-dose EPO for as little as 3 months halts the progressive atrophy in brain areas typically affected in schizophrenia, including hippocampus, amygdala, nucleus accumbens, and several neocortical areas. Specifically, gray matter protection is highly associated with improvement in attention and memory functions. These findings suggest that a neuroprotective strategy is effective against common pathophysiological features of schizophrenic patients, and strongly encourage follow-up studies to optimize EPO treatment dose and duration.

Cetacean brain evolution: Dwarf sperm whale (Kogia sima) and common dolphin (Delphinus delphis) - An investigation with high-resolution 3D MRI.

This study compares a whole brain of the dwarf sperm whale (Kogia sima) with that of a common dolphin (Delphinus delphis) using high-resolution magnetic resonance imaging (MRI). The Kogia brain was scanned with a Siemens Trio Magnetic Resonance scanner in the three main planes. As in the common dolphin and other marine odontocetes, the brain of the dwarf sperm whale is large, with the telencephalic hemispheres remarkably dominating the brain stem. The neocortex is voluminous and the cortical grey matter thin but expansive and densely convoluted. The corpus callosum is thin and the anterior commissure hard to detect whereas the posterior commissure is well-developed. There is consistency as to the lack of telencephalic structures (olfactory bulb and peduncle, olfactory ventricular recess) and neither an occipital lobe of the telencephalic hemisphere nor the posterior horn of the lateral ventricle are present. A pineal organ could not be detected in Kogia. Both species show a tiny hippocampus and thin fornix and the mammillary body is very small whereas other structures of the limbic system are well-developed. The brain stem is thick and underlies a large cerebellum, both of which, however, are smaller in Kogia. The vestibular system is markedly reduced with the exception of the lateral (Deiters') nucleus. The visual system, although well-developed in both species, is exceeded by the impressive absolute and relative size of the auditory system. The brainstem and cerebellum comprise a series of structures (elliptic nucleus, medial accessory inferior olive, paraflocculus and posterior interpositus nucleus) showing characteristic odontocete dimensions and size correlations. All these structures seem to serve the auditory system with respect to echolocation, communication, and navigation.

Coil migration after endovascular coil occlusion of internal carotid artery pseudoaneurysms within the sphenoid sinus.

INTRODUCTION: We report two cases of coil migration after endovascular treatment of pseudoaneurysm of the internal carotid artery within the sphenoid sinus with coils and noncovered stents. CASE REPORTS: Two patients underwent sphenoid sinus exposure for pituitary adenoma and chronic infection, respectively. As a complication pseudoaneurysms of the internal carotid artery within the sphenoid sinus developed. One patient was treated with stent and coils, the second with coils alone. Both patients experienced coil migration after 9 and 26 months, respectively, with the necessity for further treatment. Imaging was performed using flat detector computed tomography (FD-CT). Literature review revealed two additional cases of coil migration and four patients with the same treatment in stable condition. CONCLUSION: Pseudoaneurysms of the internal carotid artery are a special entity and the environment of the aneurysm within the sphenoid sinus may change over a long time. Coil embolization may lead to the late onset complication of coil migration with the possible risk of acute epistaxis. As a consequence, these patients need a careful and prolonged follow up. FD-CT is an appropriate technique to visualize the implanted coils and if present the migration of coil material.

The problem of strict image-based inclusion criteria for mechanical thrombectomy - an analysis of stroke patients with an initial low CBV-ASPECTS score.

INTRODUCTION: Endovascular treatment for acute ischaemic stroke with large artery occlusion has become the standard of care. However, the question if a subgroup of patients, with a low cerebral blood volume Alberta Stroke Program Early CT score (CBV-ASPECTS) ≤ 7 should be excluded from endovascular treatment remains open. Therefore; we investigated the difference of outcome between patients who were treated by endovascular treatment vs patients who did not receive endovascular treatment. METHODS: We retrospectively analysed our stroke database for all patients who presented within six hours of onset with unfavourable imaging findings and who received endovascular treatment or best medical treatment alone. Unfavourable imaging was defined as a CBV-ASPECTS ≤ 7, which was an exclusion criterion for endovascular treatment at our institution before 2015. RESULTS: From 60 patients with an initial CBV-ASPECTS ≤ 7, 40 received best medical treatment and 20 were treated with endovascular treatment. Arterial hypertension and atrial fibrillation was more present in patients without endovascular treatment, the other baseline characteristics and percentage of patients treated with intravenous recombinant tissue plasminogen activator were not significantly different in both groups. At discharge, 40% of the interventional treated patients had a favourable outcome (eight of 20 (40%) vs six of 40 (15%; p = 0.031). The median values of the National Institute of Health Stroke Score and modified Rankin Scale at discharge were significantly lower in the treated cohort (6.5 (2.5-10.5) vs 16 (9.5-22.5); p = 0.006; 3 (0-5.5) vs 5 (4.5-5.5); p = 0.003). CONCLUSION: Patients with a CBV-ASPECTS ≤ 7 are likely to benefit from therapy and therefore may not be excluded from endovascular treatment. Further randomised trials are warranted to validate the data.

Early treatment after a symptomatic event is not associated with an increased risk of stroke in patients undergoing carotid stenting.

A recently symptomatic carotid artery stenosis carries a high risk of subsequent ischaemic events and thus requires rapid treatment. We investigated the influence of the time delay between the last symptomatic event of a carotid stenosis and subsequent carotid artery stenting (CAS) with respect to the combined 30-day outcome of stroke and death. In a group of 320 patients undergoing CAS the median delay before the intervention was 19 days (interquartile range 10-36) and the combined 30-day complication rate was 8.4%. Time delay was not significantly associated with peri-procedural complications, regardless of whether this variable was dichotomized (<14 days and > or =14 days), separated into interquartile ranges or analysed as a continuous variable. Our results indicate that early CAS is not associated with an increased complication rate in patients with a recently symptomatic carotid stenosis. Thus, if CAS has been selected as the treatment modality for a patient, it should be performed as soon as possible to maximize the benefit of the intervention in reducing the risk of stroke.

Aortic calcification on plain chest radiography predicts embolic complications during carotid artery stenting.

BACKGROUND AND PURPOSE: Aortic arch calcification (AC) on conventional angiograms has recently been shown to be associated with embolic complications during carotid artery stenting (CAS). Because conventional angiography is not routinely carried out in patients prior to CAS, a less invasive, commonly available diagnostic modality is warranted to identify AC. METHODS: We investigated the occurrence of AC on routinely acquired chest radiographs and its influence on diffusion-weighted imaging (DWI) lesions as surrogate markers for stroke. RESULTS: A total of 152 patients (mean age: 67.5 +/- 8.9 years, 112 men) underwent CAS and completed pre- and post-procedural DWI. AC larger than 1 cm in length was classified as relevant and could be detected in 63 patients (41.4%) on plain chest radiographs. In patients with AC, significantly more new DWI-lesions were found than in patients without AC [median 2; interquartile range (IQR): 0-7 vs. median 1, IQR: 0-2; P < 0.05]. After multivariate regression analysis, AC was independently associated with new post-procedural DWI lesions. DISCUSSION: AC is a common finding in patients with a high-grade carotid stenosis and predicts embolic complications during CAS. Since AC can be detected on plain chest radiography, this diagnostic tool is useful to identify high-risk patients for CAS.

Morphology and evolutionary biology of the dolphin (Delphinus sp.) brain--MR imaging and conventional histology.

Whole brains of the common dolphin (Delphinus delphis) were studied using magnetic resonance imaging (MRI) in parallel with conventional histology. One formalin-fixed brain was documented with a Siemens Trio Magnetic Resonance scanner and compared to three other brains which were embedded in celloidin, sectioned in the three main planes and stained for cells and fibers. The brain of the common dolphin is large, with the telencephalic hemispheres dominating the brain stem. The neocortex is voluminous and the cortical grey matter thin but extremely extended and densely convoluted. There is no olfactory ventricular recess due to the lack of an anterior olfactory system (olfactory bulb and peduncle). No occipital lobe of the telencephalic hemisphere and no posterior horn of the lateral ventricle are present. A pineal organ could not be detected. The brain stem is thick and underlies a very large cerebellum. The hippocampus and mammillary body are small and the fornix is thin; in contrast, the amygdaloid complex is large and the cortex of the limbic lobe is extended. The visual system is well developed but exceeded by the robust auditory system; for example, the inferior colliculus is several times larger than the superior colliculus. Other impressive structures in the brainstem are the peculiar elliptic nucleus, inferior olive, and in the cerebellum the huge paraflocculus and the very large posterior interpositus nucleus. There is good correspondence between MR scans and histological sections. Most of the brain characteristics can be interpreted as morphological correlates to the successful expansion of this species in the marine environment, which was characterized by the development of a powerful sonar system for localization, communication, and acousticomotor navigation.

Diagnosing Early Ischemic Changes with the Latest-Generation Flat Detector CT: A Comparative Study with Multidetector CT.

BACKGROUND AND PURPOSE: One-stop management of mechanical thrombectomy-eligible patients with large-vessel occlusion represents an innovative approach in acute stroke treatment. This approach reduces door-to-reperfusion times by omitting multidetector CT, using flat detector CT as pre-mechanical thrombectomy imaging. The purpose of this study was to compare the diagnostic performance of the latest-generation flat detector CT with multidetector CT. MATERIALS AND METHODS: Prospectively derived data from patients with ischemic stroke with large-vessel occlusion and mechanical thrombectomy were analyzed in this monocentric study. All included patients underwent multidetector CT before referral to our comprehensive stroke center and flat detector CT in the angiography suite before mechanical thrombectomy. Diagnosis of early ischemic signs, quantified by the ASPECTS, was compared between modalities using cross tables, the Pearson correlation, and Bland-Altman plots. The predictive value of multidetector CT- and flat detector CT-derived ASPECTS for functional outcome was investigated using area under the receiver operating characteristic curve analysis. RESULTS: Of 25 patients, 24 (96%) had flat detector CT with sufficient diagnostic quality. Median multidetector CT and flat detector CT ASPECTSs were 7 (interquartile range, 5.5-9 and 4.25-8, respectively) with a mean period of 143.6 ± 49.5 minutes between both modalities. The overall sensitivity was 85.1% and specificity was 83.1% for flat detector CT ASPECTS compared with multidetector CT ASPECTS as the reference technique. Multidetector CT and flat detector CT ASPECTS were strongly correlated (r = 0.849, P < .001) and moderately predicted functional outcome (area under the receiver operating characteristic curve, 0.738; P = .007 and .715; P = .069, respectively). CONCLUSIONS: Determination of ASPECTS on flat detector CT is feasible, showing no significant difference compared with multidetector CT ASPECTS and a similar predictive value for functional outcome. Our findings support the use of flat detector CT for emergency stroke imaging before mechanical thrombectomy to reduce door-to-groin time.

Improved visibility of the subthalamic nucleus on high-resolution stereotactic MR imaging by added susceptibility (T2*) contrast using multiple gradient echoes.

Reliable identification of the subthalamic nucleus (STN) is a critical step in deep brain stimulation for Parkinson disease but difficult on T1-weighted stereotactic MR imaging. By simultaneous imaging of multiple gradient echoes, susceptibility contrast is added to conventional T1-weighted high-resolution MR image. Thus, the visibility of the STN is enhanced on a second co-localized dataset by exploiting the sensitivity of the T2*-relaxation to local iron deposits. The feasibility is underpinned by quantitative measurements on healthy adults.

Preprocedural C-reactive protein levels predict stroke and death in patients undergoing carotid stenting.

BACKGROUND AND PURPOSE: Elevated baseline levels of C-reactive protein (CRP) are associated with an adverse outcome during coronary stent placement. The aim of this study was to evaluate whether preprocedural CRP levels also are predictive of stroke and death in patients undergoing carotid stent placement (CAS). MATERIALS AND METHODS: We reviewed data prospectively collected from 130 patients (97 men, 33 women; mean age, 68.5 +/- 10.1 years; range, 43-89 years) who underwent CAS for symptomatic carotid stenosis and from whom preprocedural CRP values had been obtained. A CRP value of >5 mg/L was considered to be elevated. The frequency of stroke and death within 30 days was compared between patients with and without elevated baseline CRP levels using chi(2) and multivariate logistic regression analysis. RESULTS: Baseline CRP values were normal in 94 (72.3%) patients but were elevated in 36 (27.7%) patients. The demographic and clinical characteristics were similar in both treatment groups. The 30-day stroke and death rate was significantly higher in patients with elevated CRP values (8/36; 22.2%) than in those without (3/94; 3.2%; P < .01). After adjusting for demographic characteristics, degree of carotid stenosis, and use of cerebral protection devices and/or statin therapy, an elevated CRP value before CAS remained a significant and independent predictor of stroke and death within 30 days after CAS (odds ratio, 7.7; 95% confidence interval: 1.8-32.8, P = .006). CONCLUSIONS: Baseline CRP is a powerful predictor of outcome in patients undergoing CAS, which underscores the role of inflammation in the pathogenesis of embolic complications during this procedure.

Pattern of cortical changes in sporadic Creutzfeldt-Jakob disease.

BACKGROUND AND PURPOSE: High cortical signal intensity on diffusion-weighted (DW) or fluid-attenuated inversion recovery (FLAIR) images is increasingly described in sporadic Creutzfeldt-Jakob disease (sCJD). The aim of this study was to assess the extent and location of high cortical signal intensity, to investigate whether DW or FLAIR is superior in showing changes in cortical signal intensity, and to find out whether the distribution of the signal intensity changes is random or follows a common pattern. MATERIALS AND METHODS: We analyzed FLAIR and DW MR imaging scans of 39 patients with sCJD for hyperintense cortical signal intensity. We compared the sensitivity of the DW and FLAIR scans. We correlated the extent and location of the cortical signal intensity changes with concomitant changes in deep gray matter and the genotype of codon 129 of the prion protein gene. RESULTS: There was high signal intensity in the insula, the cingulate gyrus, and the superior frontal gyrus in 95%. The cortical areas near the midline also frequently showed the abnormal signal intensity (precuneus 87%, paracentral lobe 77%). The precentral and postcentral gyri were affected less frequently (41% and 28%, respectively). The DW MR imaging showed the cortical changes more effectively than FLAIR. There was no correlation between the distribution of changes and additional signal alterations in deep gray matter or the genotype of codon 129. CONCLUSION: The distribution of cortical signal intensity abnormalities in patients with sCJD follows a common pattern, affecting mainly the cortical areas near the midline, the insula, cingulum, and the superior frontal cortex. DW imaging is superior to FLAIR in the detection of cortical high signal intensity.

Hyperacute intracerebral hemorrhage complicating carotid stenting should be distinguished from hyperperfusion syndrome.

We describe a patient who experienced a fatal ipsilateral basal ganglia hemorrhage within an hour after carotid angioplasty and stent placement. In the few similar cases published there were no prodromata, but hyperacute onset of severe neurologic deterioration corresponding to intracerebral hemorrhage (ICH). Our findings suggest that besides the delayed ICH that is associated with hyperperfusion syndrome (HPS), a second type of hyperacute and usually fatal ICH exists that resembles hypertensive hemorrhage.

Creutzfeldt-Jakob disease: comparative analysis of MR imaging sequences.

BACKGROUND AND PURPOSE: MR imaging has played an increasingly important role in the diagnosis of Creutzfeldt-Jakob disease (CJD) since basal ganglia abnormalities on T2-weighted images have been described; thus, the aim of our study was to compare the value of different MR images in the diagnosis of CJD. METHODS: One hundred fifty-seven patients with CJD underwent MR imaging examinations. Ninety-two patients were neuropathologically confirmed, and 65 were clinically classified as having CJD through the CJD Surveillance Unit (probability of 95%). There was no standardized MR imaging protocol; thus, the examinations included 143 T2-weighted, 43 proton attenuation (PD)-weighted, 84 fluid-attenuated inversion recovery (FLAIR), and 44 diffusion-weighted images (DWI). The MR images were reviewed for pathologic changes of the basal ganglia, thalamus, and cerebral cortex. RESULTS: Cortical abnormalities were present in 70 patients (45%) and were visible in 80% (35/44) of all available DWI examinations. The basal ganglia were affected in 94 patients (60%), in particular in the caudate nucleus; the most sensitive sequences were DWI (64%) and PD-weighted (63%). A thalamic involvement was more frequently diagnosed on PD-weighted images (19%) and DWI (14%) than on FLAIR or T2-weighted images. CONCLUSION: PD-weighted images and DWI showed better results in the diagnosis of signal intensity changes in the basal ganglia compared with T2-weighted or FLAIR images; however, in the diagnosis of cortical changes, DWI was clearly superior. Our data suggest that DWI is the most sensitive MR imaging technique in the diagnosis of CJD.

[Transcranial color-coded duplex ultrasonography of arteriovenous malformations]. / Möglichkeiten und Grenzen der transkraniellen Farbduplexsonographie bei der Darstellung intrakranieller arteriovenöser Malformationen.

PURPOSE: Using transcranial color coded duplex sonography (TCCS) it is possible to visualize intracranial arteriovenous malformations (AVMs). The purpose of this study is to describe their typical ultrasonographic features and to define sensitivity for diagnosis with regard to the localization of an AVM. MATERIALS AND METHODS: Over a period of six years we prospectively examined 54 intracranial AVMs confirmed by angiography. Using TCCS the vessels of the circle of Willis were identified by location, course and direction of flow on color flow images. The examination was performed during the first three years of the study using the Acuson 128 XP 10 system, equipped with a sector transducer with a 2.0/2.5 - MHz imaging frequency for the transcranial examination, and with a 7.0 MHz linear transducer fot the extracranial examination. During the second three years of the study, transcranial examination was performed with an Acuson Seqouia 512 ultrasound system equipped with a 2 - 4 MHz phased array transducer. RESULTS: In accordance with digital subtraction angiography, the intracranial AVMs could be visualized in 42 cases (77.8 %). The major feeding vessels of the AVMs could be easily identified due to typical hemodynamic parameters showing increased systolic and diastolic flow velocities and decreased pulsatility index. We failed to visualize AVMs localized near the cortex, i. e. in the parietal, frontal, occipital and cerebellar regions of the brain. In contrast, 88.9 % of AVMs localized in the basal regions were very easy to image. Additionally, TCCS was useful for postoperative or postinterventional follow-up, although only a limited number of patients could be examined by TCCS in the post-treatment period. CONCLUSION: TCCS is a noninvasive method for the diagnosis and possibly valuable in the long-term follow-up of intracranial AVMs. However, further research is needed to establish TCCS as an imaging modality in the follow-up after treatment of AVMs. The method can be regarded as a useful supplement to the palette of established, noninvasive diagnostic techniques such as MRI and MRA. However, since TCCS cannot rule out an AVM, angiography is still the method of choice for the definitive diagnosis.

Unenhanced Time-of-Flight MR Angiography versus Gadolinium-Enhanced Time-of-Flight MR Angiography in the Follow-Up of Coil-Embolized Aneurysms.

Background and Purpose Coil embolization of ruptured and unruptured aneurysms has emerged as a widely accepted alternative to clipping. Unfortunately, coil-embolized aneurysms need a long-term imaging follow-up to confirm the stability of the occlusion status. We investigated whether contrast-enhanced time-of-flight (ToF) magnetic resonance angiography (MRA) (gadolinium [Gd]-ToF) provides any diagnostic benefit over conventional ToF MRA (nonenhanced [NE]-ToF) in this context. Material and Methods From October 2013 to January 2015, all patients who were regularly scheduled for their follow-up after coil embolization were examined with Gd-ToF and NE-ToF angiography. The general visibility of the occlusion result was compared between the two MRAs as well as with the last digital subtraction angiography (DSA) available. Subgroups of interest (follow-up after stent-assisted coil embolization, cases with already known aneurysm remnants) were also analyzed. Results A total of 70 patients (44 female) harboring 74 treated aneurysms were examined. The reproducibility of the DSA result in terms of therapeutic relevance was 100%. In 10 of 74 cases (14%), the aneurysm status was more difficult to judge in the NE-ToF images (p = 0.02), and the visualization of small vessels was significantly better in the Gd-ToF (p = 0.003). NE-ToF did not fail to show any aneurysm remnants but were more difficult to depict in 35% of the cases (p = 0.09). Regarding the aneurysms that were coiled with stent assistance, there was no significant difference in terms of the visualization (p = 0.1). Conclusion Gd-ToF angiography is in general not superior to NE- ToF for the follow-up of coil-embolized aneurysms.

Emergency Stenting of the Extracranial Internal Carotid Artery in Combination with Anterior Circulation Thrombectomy in Acute Ischemic Stroke: A Retrospective Multicenter Study.

BACKGROUND AND PURPOSE: Several small case series reported a favorable clinical outcome for emergency stent placement in the extracranial internal carotid artery combined with mechanical thrombectomy in acute stroke. The rate of postinterventional symptomatic intracranial hemorrhages was reported to be as high as 20%. Therefore, we investigated the safety and efficacy of this technique in a large multicentric cohort. MATERIALS AND METHODS: The data bases of 4 German stroke centers were screened for all patients who received emergency stent placement of the extracranial internal carotid artery in combination with mechanical thrombectomy of the anterior circulation between 2007 and 2014. The primary outcome measure was the rate of symptomatic intracranial hemorrhage according to the European Cooperative Acute Stroke Study III criteria; secondary outcome measures included the angiographic revascularization results and clinical outcome. RESULTS: One hundred seventy patients with a median age of 64 years (range, 25-88 years) were treated. They presented after a median of 98 minutes (range, 52-160 minutes) with a median NIHSS score of 15 (range, 12-19). Symptomatic intracranial hemorrhages occurred in 15/170 (9%) patients; there was no statistically significant difference among groups pertaining to age, sex, intravenous rtPA, procedural timings, and the rate of successful recanalization. In 130/170 (77%) patients, a TICI score of ≥ 2b could be achieved. The in-hospital mortality rate was 19%, and 36% of patients had a favorable outcome at follow-up. CONCLUSIONS: Emergency stent placement in the extracranial internal carotid artery in combination with anterior circulation thrombectomy is effective and safe. It is not associated with a significantly higher risk of symptomatic intracranial hemorrhage compared with published series for mechanical thrombectomy alone.

CT and diffusion-weighted MR imaging in randomized order: diffusion-weighted imaging results in higher accuracy and lower interrater variability in the diagnosis of hyperacute ischemic stroke.

BACKGROUND AND PURPOSE: Diffusion-weighted MRI (DWI) has become a commonly used imaging modality in stroke centers. The value of this method as a routine procedure is still being discussed. In previous studies, CT was always performed before DWI. Therefore, infarct progression could be a reason for the better result in DWI. METHODS: All hyperacute (<6 hours) stroke patients admitted to our emergency department with a National Institutes of Health Stroke Scale (NIHSS) score >3 were prospectively randomized for the order in which CT and MRI were performed. Five stroke experts and 4 residents blinded to clinical data judged stroke signs and lesion size on the images. To determine the interrater variability, we calculated kappa values for both rating groups. RESULTS: A total of 50 patients with ischemic stroke and 4 patients with transient symptoms of acute stroke (median NIHSS score, 11; range, 3 to 27) were analyzed. Of the 50 patients, 55% were examined with DWI first. The mean delay from symptom onset until CT was 180 minutes; that from symptom onset until DWI was 189 minutes. The mean delay between DWI and CT was 30 minutes. The sensitivity of infarct detection by the experts was significantly better when based on DWI (CT/DWI, 61/91%). Accuracy was 91% when based on DWI (CT, 61%). Interrater variability of lesion detection was also significantly better for DWI (CT/DWI, kappa=0.51/0.84). The assessment of lesion extent was less homogeneous on CT (CT/DWI, kappa=0.38/0.62). The differences between the 2 modalities were stronger in the residents' ratings (CT/DWI: sensitivity, 46/81%; kappa=0.38/0.76). CONCLUSIONS: CT and DWI performed with the same delay after onset of ischemic stroke resulted in significant differences in diagnostic accuracy. DWI gives good interrater homogeneity and has a substantially better sensitivity and accuracy than CT even if the raters have limited experience.

Acute disseminated encephalomyelitis: a follow-up study of 40 adult patients.

OBJECTIVES: To describe the clinical, CSF, and radiologic findings and long-term follow-up in a cohort of patients with acute disseminated encephalomyelitis (ADEM), and to determine possible prognostic factors for progression to MS. METHODS: Forty adults (28 women, mean age 33.5 years) diagnosed with ADEM were analyzed. Clinical symptoms, cranial MRI and CSF findings, and the response to a standardized treatment during the acute phase of the disease were analyzed by chart review. The final diagnosis of ADEM or clinically definite MS was established upon follow-up examination after 8 to 137 months. The patients with ADEM and MS were compared to detect differences between the two groups. RESULTS: Fifteen patients had a preceding infection (n = 14) or immunization (n = 1). The most frequent clinical signs were motor deficit (80%), followed by sensory deficits, brainstem signs, and ataxia. CSF findings were highly variable; normal results were present in 20% of patients. Oligoclonal bands were positive in 65% of patients. Ninety-five percent of all patients improved during the acute phase of the disease. Upon follow-up, 14 patients had developed clinically definite MS. Of the 26 patients with the final diagnosis of ADEM, two patients had died, nine had minor deficits, three had moderate deficits, and 12 patients had no remaining symptoms. Patients with the final diagnosis of ADEM were older, and more often had a preceding infection, clinical signs of brainstem involvement, a higher CSF albumin fraction, and infratentorial lesions. CONCLUSIONS: Many patients initially diagnosed with ADEM develop clinically definite MS upon long-term follow-up. The authors found no useful diagnostic criteria for the differentiation of a first episode of MS from monophasic ADEM. The term ADEM may still be employed as a description of a clinical syndrome, but should not be used as a distinct entity until reliable diagnostic criteria have been developed.