Peak Edema Extension Distance: An Edema Measure Independent from Hematoma Volume Associated with Functional Outcome in Intracerebral Hemorrhage.

BACKGROUND: Our objective was to test the association between hematoma volume and long-term (> 72 h) edema extension distance (EED) evolution and the association between peak EED and early EED increase with functional outcome at 3 months in patients with intracerebral hemorrhage (ICH). METHODS: This retrospective cohort study included patients with spontaneous supratentorial ICH between January 2006 and January 2014. EED, an edema measure defined as the distance between the hematoma border and the outer edema border, was calculated by using absolute hematoma and edema volumes. We used multivariable logistic regression accounting for age, ICH volume, and location and receiver operating characteristic analysis for assessing measures associated with functional outcome and EED evolution. Functional outcome after 3 months was assessed by using the modified Rankin Scale (0-3 = favorable, 4-6 = unfavorable). To identify properties associated with peak EED multivariable linear and logistic regression analyses were conducted. RESULTS: A total of 292 patients were included. Median age was 70 years (interquartile range [IQR] 62-78), median ICH volume on admission 17.7 mL (IQR 7.9-40.2), median peak perihemorrhagic edema (PHE) volume was 37.5 mL (IQR 19.1-60.6), median peak EED was 0.67 cm (IQR 0.51-0.84) with an early EED increase up to 72 h (EED72-0) of 0.06 cm (- 0.02 to 0.15). Peak EED was found to be independent of ICH volume (R2 = 0.001, p = 0.6). In multivariable analyses, peak EED (odds ratio 0.224, 95% confidence interval [CI] [0.071-0.705]) and peak PHE volume (odds ratio 0.984 [95% CI 0.973-0.994]) were inversely associated with favorable functional outcome at 3 months. Receiver operating characteristic analysis identified a peak PHE volume of 26.8 mL (area under the curve 0.695 [95% CI 0.632-0.759]; p ≤ 0.001) and a peak EED of 0.58 cm (area under the curve 0.608 [95% CI 0.540-0.676]; p = 0.002) as best predictive values for outcome discrimination. CONCLUSIONS: Compared with absolute peak PHE volume, peak EED represents a promising edema measure in patients with ICH that is largely hematoma volume-independent and nevertheless associated with functional outcome.

What is the hemodynamic effect of the Woven EndoBridge? An in vivo quantification using time-density curve analysis.

PURPOSE: Using the Woven EndoBridge (WEB) for aneurysm treatment has emerged as endovascular approach aiming for flow disruption in aneurysm sac. Since quantifiable data confirming the hemodynamic effect are lacking, we investigated in vivo aneurysmal flow alterations using time-density curve (TDC) analysis. Additionally, we evaluated whether flow parameters could be identified as independent factor to predict aneurysm occlusion. METHODS: Forty cerebral aneurysm patients treated with WEB were enrolled. Pre- and postinterventional digital subtraction angiography series were postprocessed and TDCs generated. TDCs were quantified calculating the parameters aneurysmal inflow velocity, outflow velocity, mean flow velocity, and relative time-to-peak (rTTP) of aneurysm filling. Pre- and postinterventional values were compared and related to occlusion rate. RESULTS: WEB implanting induced highly significant rTTP prolongation by 52% (p = 0.001) and highly significant decrease of aneurysmal inflow, outflow, and mean flow velocity (p < 0.001). While outflow velocity was reduced by 49%, inflow velocity was reduced by 33% only. No statistically significant difference between the occluded and the non-occluded group was observed. No flow parameter reached significance level concerning predicting aneurysm occlusion. CONCLUSION: Flow quantification confirms a significant flow-disrupting effect of WEB reducing more the outflow than the inflow velocity. In our small cohort, no flow parameter reached statistical significance to show predictive value regarding complete aneurysm occlusion. The hemodynamic effect of WEB is on comparable level to flow-diverting stents meaning that aneurysm closure can be delayed. In case of only slight inflow changes and high aneurysmal hemodynamic stress, some aneurysms might not be adequately protected in the short term.

Microcatheters with extra-long detachable tip: A promising treatment option in dural arteriovenous fistulas.

PURPOSE: Treating cerebral dural arteriovenous fistulas (dAVFs) by transarterial embolization is an established endovascular approach but no data exist regarding the utility of using the newly introduced microcatheters with extra-long detachable tip. Aim of our study was to evaluate the value of these microcatheters and, additionally, of combining them with the simplified pressure cooker technique. METHODS: Twenty-nine patients treated for dAVF with transarterial embolization were enrolled. In a subgroup of fifteen patients the simplified pressure cooker technique was additionally applied. Demographics and characteristics were collected for patients and dAVFs and procedural details reviewed. The association between covariates and binary-coded occlusion status was evaluated. RESULTS: Microcatheter navigation into the target pedicle as well as application of the simplified pressure cooker technique were successful in all cases. Complete dAVF occlusion was reached in 69.0% at a single stage. In case of complete dAVF occlusion, embolization via only one pedicle was enough. Subgroup analysis revealed a higher occlusion status (80%) if using the simplified pressure cooker technique than if not (57%) but reached not significance level. CONCLUSION: Using microcatheters with extra-long detachable tip for dAVF embolization seems to offer a safe and effective treatment option with exceptional high occlusion rate at a single stage. The high navigability facilitates catheterization of a single selected target pedicle that is often enough to reach complete dAVF occlusion. Combining these microcatheters with the simplified pressure cooker technique turned out to be safe and easy to handle and might allow an increasing dAVF occlusion rate.

Change your Angle of View : Sinusoidal C-Arm Movement in Cranial Flat-panel CT to Improve Image Quality.

BACKGROUND: Artifacts from surrounding bony structures, especially from the petrous bones, regularly impair soft tissue computed tomography (CT) imaging of the middle and posterior fossa. This affects flat-panel CT in particular. Sinusoidal movement of the C­arm during acquisition (i.e. craniocaudal tilting along with semicircular rotation) is supposed to reduce artifacts, thus enhancing soft tissue imaging quality. METHODS: In the work-up of ischemic stroke or subarachnoid hemorrhage 40 patients underwent multi-slice CT (MS-CT) and either plain circular (cFP-CT; n = 20) or sinusoidal (sFP-CT; n = 20) flat-panel CT within a short interval. Two independent readers analyzed MS-CT and FP-CT datasets for recognizability of eight different brain structures and three typical types of artifacts according to a predetermined score. RESULTS: Interrater reliability was moderate for cFP-CT (κ = 0.575) and good to very good for ratings of MS-CT and sFP-CT (κ = 0.651 to κ = 1). MS-CT was rated to be significantly better than cFP-CT and sFP-CT (p < 0.0001) in the overall score. Yet, sFP-CT was rated to be significantly superior to cFP-CT (overall p < 0.0001) regarding most anatomical regions and petrous bone artifacts. CONCLUSION: Compared to a standard circular protocol, sinusoidal C­arm movement in cranial FP-CT can significantly reduce artifacts in the posterior fossa and, moreover, can improve visualization of most supratentorial and infratentorial anatomical structures.

"Virtual stent" - clinical evaluation and user experience of on-the-fly stent simulation in treatment of cerebral aneurysms.

BACKGROUND: Predicting final stent position can be challenging when treating cerebral aneurysms. Third-Party software proved helpful in selecting proper stents in treatment planning. Recent angiographic systems provide basic stent simulation capabilities integrated in the post-processing software to simulate stent position. Goal of this analysis was to evaluate the simulation process and correlation with definite stent position. MATERIALS AND METHODS: Thirty-three datasets with fusiform (n = 10) and saccular (n = 23) aneurysms, treated with stent or flow-diverter, were processed. A "virtual stent" of the same (nominal) size was simulated and its position was compared to the treatment result. Simulated length was rated in five grades (too short, shorter, equal, longer, too long), with regard to side-branches, anchoring zone etc. Simulation quality (centerline recognition/adherence to vessel margins) was rated in three grades (no, minor or major corrections required). RESULTS: Simulation was successful in 32/33 cases (97%), with one abortive attempt (3%). In 27/33 simulations (82%), there was no need for centerline refinement. Minor corrections were necessary in four and major corrections in two cases. Simulated nominal length was rated "equal" in 14/33 (42%) cases and "shorter" or "longer" - but within acceptable range - in each 9/33 (27%) cases. CONCLUSION: Basic stent simulation tools available with genuine angiographic workplace software can provide good simulation capabilities without need for third-party equipment. They can facilitate treatment planning and help to avoid shortage of devices. Yet, lack of calculation of foreshortening in large vessel diameters leaves the user to rely on their experience to account for device-specific properties.

Neutrophil-to-lymphocyte ratio is associated with increased cerebral blood flow velocity in acute bacterial meningitis.

In community-acquired bacterial meningitis (CABM) intracranial vascular alterations are devastating complications which are triggered by neuroinflammation and result in worse clinical outcome. The Neutrophil-to-Lymphocyte ratio (NLR) represents a reliable parameter of the inflammatory response. In this study we analyzed the association between NLR and elevated cerebral blood flow velocity (CBFv) in CABM-patients. This study included all (CABM)-patients admitted to a German tertiary center between 2006 and 2016. Patients' demographics, in-hospital measures, neuroradiological data and clinical outcome were retrieved from institutional databases. CBFv was assessed by transcranial doppler (TCD). Patients', radiological and laboratory characteristics were compared between patients with/without elevated CBFv. Multivariate-analysis investigated parameters independently associated with elevated CBFv. Receiver operating characteristic(ROC-)curve analysis was undertaken to identify the best cut-off for NLR to discriminate between increased CBFv. 108 patients with CABM were identified. 27.8% (30/108) showed elevated CBFv. Patients with elevated CBFv and normal CBFv, respectively had a worse clinical status on admission (Glasgow Coma Scale: 12 [9-14] vs. 14 [11-15]; p = 0.005) and required more often intensive care (30/30 [100.0%] vs. 63/78 [80.8%]; p = 0.01).The causative pathogen was S. pneumoniae in 70%. Patients with elevated CBFv developed more often cerebrovascular complications with delayed cerebral ischemia (DCI) within hospital stay (p = 0.031). A significantly higher admission-NLR was observed in patients with elevated CBFv (median [IQR]: elevated CBFv:24.0 [20.4-30.2] vs. normal CBFv:13.5 [8.4-19.5]; p < 0.001). Multivariate analysis, revealed NLR to be significantly associated with increased CBFv (Odds ratio [95%CI] 1.042 [1.003-1.084]; p = 0.036). ROC-analysis identified a NLR of 20.9 as best cut-off value to discriminate between elevated CBFv (AUC = 0.713, p < 0.0001, Youden's Index = 0.441;elevated CBFv: NLR ≥ 20.9 19/30[63.5%] vs. normal CBFv: NLR > 20.9 15/78[19.2%]; p < 0.001). Intracranial vascular complications are common among CABM-patients and are a risk factor for unfavorable outcome at discharge. Elevated NLR is independently associated with high CBFv and may be useful in predicting patients' prognosis.

Stent-Assisted Coiling Using Leo+ Baby Stent : Immediate and Mid-Term Results.

BACKGROUND: Stent-assisted coiling is well-established for treatment of cerebral aneurysms. The technique enables treatment of wide-neck, bifurcation and recurrent aneurysms with high packing rates. While described in extenso for laser cut stents, the results of patients treated with the Leo+ Baby (Balt, Montmorency, France) braided microstent are presented. MATERIAL AND METHODS: Patients were included if treated with a Leo+ Baby and with digital subtraction angiography (DSA) follow-up available of at least 6 months. Data were evaluated for successful deployment, aneurysm occlusion according to the modified Raymond-Roy classification (MRRC), stent patency and procedure-related morbidity and mortality. RESULTS: A total of 81 patients were included and Leo+ Baby deployment was successful in all cases. Coils were used in 80 cases. In 1 case 2 stents were used stent-in-stent without additional coiling. Initial aneurysm occlusion rates were MRRCi1 51.9%, MRRCi2 11.1%, MRRCi3a 24.7% and MRRCi3b 12.3%. Occlusion rates after 6 months were MRRC6m1 78.9%, MRRC6m2 3.9%, MRRC6m3a 6.6% and MRRC6m3b 10.5%. Procedure-related morbidity was 1 case of acute stent thrombosis successfully treated with tirofiban and 1 case with transient hemiparesis due to stent thrombosis after 4 months. There was 1 case of coil-associated subarachnoid hemorrhage (SAH) which caused prolonged hospitalization. No procedure-related mortality was observed. CONCLUSION: The results confirm that stent-assisted coiling with the Leo+ Baby stent is safe and efficient for treatment of wide neck or recurrent cerebral aneurysms. Spontaneous progressive aneurysm occlusion over 6 months supports the theory of considerable flow-modulating effects of Leo+ Baby.

Two- to five-year follow-up of 78 patients after treatment with the Flow Redirection Endoluminal Device.

BACKGROUND AND PURPOSE: Flow-diverter stents are well-established for the treatment of cerebral aneurysms. Flow Redirection Endoluminal Device differs from other flow-diverter stents by its dual-layer design and has proved equality to other devices in numerous short-term surveys. However, follow-up data covering substantially more than one year are still limited for this device. We present our long-term experience with Flow Redirection Endoluminal Device. MATERIALS AND METHODS: Seventy-eight patients harboring distal internal carotid artery (91%) or vertebrobasilar (9%) cerebral aneurysms treated with Flow Redirection Endoluminal Device with or without adjunctive coiling met the inclusion criteria. All cases were evaluated for aneurysm occlusion (according to Modified Raymond Roy Classification, MRRC), for flow-diverter stents patency and configuration and for procedure- and device-related morbidity and mortality. RESULTS: Mean follow-up interval was 36.9 ± 9.5 months (<30 months: n = 18; 31-42 months: n = 31; >42 months: n = 24). Total and subtotal aneurysm occlusion after six months was assessed in 92.0% (MRRC1 = 77.3%, MRRC2 = 14.7%, MRRC3a =2.7%, MRRC3b = 4.1%) and increased to 95.9% (MRRC1 = 90.5%, MRRC2 = 5.4%, MRRC3a = 2.7%). There was one case of aneurysm growth requiring early re-treatment. Procedure-related morbidity was observed in three cases (3.8%; one transient hemiparesis, one suspected foreign-body reaction, and one micro-wire perforation). There was no procedure- or device-related mortality. In-stent stenosis due to intimal hyperplasia was observed in two cases and fish-mouthing in three cases. CONCLUSIONS: Our long-term data covering two to five years after flow diversion confirm that Flow Redirection Endoluminal Device is a safe and effective device for the treatment of cerebral aneurysms with progressive high aneurysm occlusion rates; recurrence rates were very low. Overall device-related morbidity was low and was not observed later than six months after intervention.

Classification of Primary Cerebral Lymphoma and Glioblastoma Featuring Dynamic Susceptibility Contrast and Apparent Diffusion Coefficient.

This study aimed to differentiate primary central nervous system lymphoma (PCNSL) and glioblastoma (GBM) via multimodal MRI featuring radiomic analysis. MRI data sets of patients with histological proven PCNSL and GBM were analyzed retrospectively. Diffusion-weighted imaging (DWI) and dynamic susceptibility contrast (DSC) perfusion imaging were evaluated to differentiate contrast enhancing intracerebral lesions. Selective (contrast enhanced tumor area with the highest mean cerebral blood volume (CBV) value) and unselective (contouring whole contrast enhanced lesion) Apparent diffusion coefficient (ADC) measurement was performed. By multivariate logistic regression, a multiparametric model was compiled and tested for its diagnostic strength. A total of 74 patients were included in our study. Selective and unselective mean and maximum ADC values, mean and maximum CBV and ratioCBV as quotient of tumor CBV and CBV in contralateral healthy white matter were significantly larger in patients with GBM than PCNSL; minimum CBV was significantly lower in GBM than in PCNSL. The highest AUC for discrimination of PCNSL and GBM was obtained for selective mean and maximum ADC, mean and maximum CBV and ratioCBV. By integrating these five in a multiparametric model 100% of the patients were classified correctly. The combination of perfusion imaging (CBV) and tumor hot-spot selective ADC measurement yields reliable radiological discrimination of PCNSL from GBM with highest accuracy and is readily available in clinical routine.

DSC Brain Perfusion Using Advanced Deconvolution Models in the Diagnostic Work-up of Dementia and Mild Cognitive Impairment: A Semiquantitative Comparison with HMPAO-SPECT-Brain Perfusion.

BACKGROUND: SPECT (single-photon emission-computed tomography) is used for the detection of hypoperfusion in cognitive impairment and dementia but is not widely available and related to radiation dose exposure. We compared the performance of DSC (dynamic susceptibility contrast) perfusion using semi- and fully adaptive deconvolution models to HMPAO-SPECT (99mTc-hexamethylpropyleneamine oxime-SPECT). MATERIAL AND METHODS: Twenty-seven patients with dementia of different subtypes including frontotemporal dementia (FTD) and mild cognitive impairment (MCI) received a multimodal diagnostic work-up including DSC perfusion at a clinical 3T high-field scanner and HMPAO-SPECT. Nineteen healthy control individuals received DSC perfusion. For calculation of the hemodynamic parameter maps, oscillation-index standard truncated singular value decomposition (oSVD, semi-adaptive) as well as Bayesian parameter estimation (BAY, fully adaptive) were performed. RESULTS: Patients showed decreased cortical perfusion in the left frontal lobe compared to controls (relative cerebral blood volume corrected, rBVc: 0.37 vs 0.27, p = 0.048, adjusted for age and sex). Performance of rBVc (corrected for T1 effects) was highest compared to SPECT for detection of frontal hypoperfusion (sensitivity 83%, specificity 80% for oSVD and BAY, area under curve (AUC) = 0.833 respectively, p < 0.05) in FTD and MCI. For nonleakage-corrected rBV and for rBF (relative cerebral blood flow), sensitivity of frontal hypoperfusion was above 80% for oSVD and for BAY (rBV: sensitivity 83%, specificity 75%, AUC = 0.908 for oSVD and 0.917 for BAY, p < 0.05 respectively; rBF: sensitivity 83%, specificity 65%, AUC = 0.825, p < 0.05 for oSVD). CONCLUSION: Advanced deconvolution DSC can reliably detect pathological perfusion alterations in FTD and MCI. Hence, this widely accessible technique has the potential to improve the diagnosis of dementia and MCI as part of an interdisciplinary multimodal imaging work-up. Advances in knowledge: Advanced DSC perfusion has a high potential in the work-up of suspected dementia and correlates with SPECT brain perfusion results in dementia and MCI.

Visualization of CSF Flow with Time-resolved 3D MR Velocity Mapping in Aqueductal Stenosis Before and After Endoscopic Third Ventriculostomy : A Feasibility Study.

PURPOSE: The aim of this study was to evaluate timed-resolved three-dimensional (3D) magnetic resonance (MR) velocity mapping as a method for investigation of cerebrospinal fluid (CSF) flow changes in patients with aqueductal stenosis (AS) treated by endoscopic third ventriculostomy (ETV). METHODS: The MR velocity mapping was performed in 12 AS patients before and after ETV and in 10 healthy volunteers by using a 3-Tesla MR system. Time-resolved 3D MR velocity mapping data were acquired with a standard 3D phase contrast (PC) sequence with cardiac triggering. Values of mean (vmean) and maximum (vpeak) velocity were measured at several ventricular structures using dedicated software. RESULTS: Of the patients 11 showed a satisfactory clinical improvement after ETV, whereas one patient needed subsequent shunt implantation. All AS patients showed significant hypomotile CSF flow dynamics in the third ventricle when compared to healthy subjects before surgery (p < 0.05). In contrast, CSF flow velocity was increased within the Foramen of Monro in AS patients. After ETV, all AS patients showed a decrease of CSF flow dynamics within the third ventricle. Mean and peak CSF flow velocities through the ventriculostomy were 1.72 ± 0.59 cm/s (vmean) and 3.53 ± 0.79 cm/s (vpeak), respectively after ETV. The patient who needed shunt implantation after ETV had the lowest flow velocities through the ventriculostomy. CONCLUSION: This study demonstrates that timed-resolved 3D MR velocity mapping is a useful imaging investigation for diagnostics and follow-up in patients with AS. This new technique provides an insight into the physiological CSF flow changes related with AS and its treatment.