General Anesthesia Versus Conscious Sedation in Acute Stroke Treatment: The Importance of Head Immobilization.

PURPOSE: While today mechanical thrombectomy is an established treatment option for main branch occlusions in anterior circulation stroke, there is still an ongoing debate on the kind of anesthesia to be preferred. Introducing a simple method for head stabilization, we analyzed safety and duration of endovascular recanalization procedures under general anesthesia (GA) and conscious sedation (CS). METHODS: We retrospectively identified 84 consecutive patients who underwent mechanical thrombectomy owing to acute anterior circulation stroke. Fifty-three were treated under GA and 31 under CS equipped with a standard cervical collar to reduce head movement. We evaluated recanalization results, in-house time to start recanalization, procedure times, technical and clinical complication rates, and conversion rates from CS to GA. RESULTS: Recanalization of mTICI ≥2b was achieved in 80 % under CS and in 81 % under GA. Median in-house time to start recanalization for CS was 60 min (IQR 28; 44-72) and 77 min (IQR 23; 68-91) for GA (P = 0.001). Median procedure time under CS was 35 min (IQR 43; 69-25) and 41 min (IQR 43; 66-23) for GA (P = 0.9). No major complications such as ICH occurred in either group, and no conversions from CS to GA were necessary. CONCLUSION: Mechanical thrombectomy can be performed faster and safely under CS in combination with simple head immobilization using a standard cervical collar.

Assessment and treatment planning of lateral intracranial dural arteriovenous fistulas in 3 T MRI and DSA: A detailed analysis under consideration of time-resolved imaging of contrast kinetics (TRICKS) and ce-MRA sequences.

OBJECTIVES: The current gold standard in the assessment of lateral intracranial dural arteriovenous fistulas (LDAVF) is digital subtraction angiography (DSA). However, magnetic resonance imaging (MRI) is a non-invasive emerging tool for the evaluation of such lesions. The aim of our study was to compare the DSA to our 3 T MR-imaging protocol including a highly spatial resolved (ce-MRA) and a temporal resolved ("time-resolved imaging of contrast kinetics", TRICKS) contrast-enhanced MR angiography to evaluate if solely DSA can remain the gold-standard imaging modality for the treatment planning of LDAVF. METHODS: We retrospectively reviewed matched pairs of DSA and 3 T MRI examinations of 24 patients with LDAVF (03/2008-04/2014) by the same list of relevant criteria for an endovascular LDAVF treatment planning. In particular, we determined intermodality agreement for the Cognard classification, the identifeication of arterial feeders, and the detailed assessment of each venous drainage pattern. RESULTS: Intermodality agreement for the Cognard classification was excellent (ĸ = 1.0). Whereas MRI failed in identifying small arterial feeders, it was superior to the DSA in the assessment of the sinus and the venous drainage pattern. CONCLUSIONS: The combination of MRI and DSA is the new gold standard in LDAVF treatment planning. KEY POINTS: • DSA is superior to the MRI in detecting LDAVF arterial feeders. • MRI excellently evaluates the venous side of an LDAVF. • MRI can replace DSA in initial diagnosis and monitoring of LDAVF. • MRI and DSA combined are the new gold standard in LDAVF treatment planning.

Resonator properties of paranasal sinuses: preliminary results of an anatomical study.

BACKGROUND: The contribution of the nasal and paranasal cavities to vocal tract resonator properties is unclear as are voice effects of sinus surgery. Here we investigate resonance phenomena of paranasal sinuses with and without selective occlusion of the middle meatus and maxillary ostium in a cadaver. METHODOLOGY: Nasal and paranasal cavities of a Thiel-embalmed cadaver were excited by sine-tone sweeps from an earphone in the epipharynx. The response was picked up by a microphone at the nostrils. Different conditions with blocked and unblocked middle meatus were tested. Additionally, infundibulotomy was performed allowing direct access to and selective occlusion of the maxillary ostium. RESULTS: Responses showed high reproducibility. Minor effects appeared after removal of meatal occlusion. A marked low frequency dip was detected after removal of occlusion of maxillary ostium following infundibulotomy. CONCLUSION: Reproducible frequency responses of nasal tract can be derived from cadaver measurements. Marked acoustic effects of the maxillary sinus appeared only after direct exposure of the maxillary ostium following infundibulotomy.

Use of flow-diverting devices in fusiform vertebrobasilar giant aneurysms: a report on periprocedural course and long-term follow-up.

BACKGROUND AND PURPOSE: Fusiform vertebrobasilar giant aneurysms are a rare (<1% of all intracranial aneurysms) but challenging aneurysm subtype. Little data are available on the natural history of this aneurysm subtype and the impact of the use of flow-diverting stents on the long-term clinical and imaging follow-up. In this article, we present our experience with the treatment of fusiform vertebrobasilar giant aneurysms by flow diverting stents. We aim to stimulate a discussion of the best management paradigm for this challenging aneurysm subtype. MATERIALS AND METHODS: We retrospectively identified 6 patients with fusiform vertebrobasilar giant aneurysms who had been treated with flow-diverting stents between October 2009 and March 2012 in our center. The available data were re-evaluated. The modified Rankin Scale score was assessed before intervention, during the stay in hospital, and at discharge. RESULTS: Six patients were identified (all male; age range, 49-71 years; median age, 60 years). Handling of material was successful in all cases. No primary periprocedural complications occurred. The mean follow-up was 13 months (15 days to 29 months). During follow-up, 3 of 6 patients had recurrent cerebral infarctions, but no patient experienced SAH. Two patients presented with acute thrombotic stent occlusion. The modified Rankin Scale score was not higher than 3 in any of the cases before intervention, whereas the best mRS score at the last follow-up was 5. Four of 6 patients died during follow-up. CONCLUSIONS: Endovascular treatment of fusiform vertebrobasilar giant aneurysms with flow-diverting devices is feasible from a technical point of view; however, changes in hemodynamics with secondary thrombosis are not predictable. We currently do not intend to treat fusiform vertebrobasilar giant aneurysms with flow-diverting devices until we have further understanding of the pathophysiology, natural history, and hemodynamic effects of flow diversion.

Dual-energy CT immediately after endovascular stroke intervention: prognostic implications.

PURPOSE: Posttreatment intracerebral hemorrhage (ICH) after recanalization therapy of acute ischemic stroke increases morbidity and mortality. Dual-energy (DE) computed tomography (CT) allows differentiation of blood-brain barrier disruption (BBBD) and ICH. We evaluated the incidence of ICH and BBBD immediately after endovascular recanalization therapy, the correlation between BBBD and final infarction or ICH size, and the prognostic value of postinterventional BBBD. METHODS: Imaging data sets (pretreatment CT, posttreatment DE-CT, and follow-up imaging by CT and/or magnetic resonance imaging) of 60 consecutive patients after endovascular recanalization therapy of acute ischemic stroke were retrospectively analyzed. After material differentiation, areas of increase attenuation in posttreatment DE-CT were correlated to ICH and infarction in follow-up imaging. RESULTS: Areas of hyperattenuation were observed in 80.0 % (48 of 60) of all posttreatment CT. In 10.4 % (5 of 48) of these, hyperattenuating areas matched the hyperdensities on virtual nonenhanced CT and were rated as hemorrhage. The remaining 89.6 % (43 of 48) of scans with hyperattenuating areas demonstrated hyperdensities exclusively on iodine-only images and were rated as BBBD. All suspected ICH on DE-CT were proven in follow-up imaging. There were no false-positive or false-negative findings of ICH in DE-CT. In 98.3 % (59 of 60) of cases, at least small ischemic infarctions were identified in follow-up imaging. No correlation between the extent of BBBD and the final infarct size and/or early ICH size was found. CONCLUSION: BBBD is a frequent finding after endovascular revascularization therapy. DE-CT allows for a reliable differentiation between frequent BBBD and rare ICH immediately after endovascular recanalization therapy.

Pharmacokinetic and pharmacodynamic evaluation of the novel CCR1 antagonist CCX354 in healthy human subjects: implications for selection of clinical dose.

The safety and pharmacokinetic (PK)/pharmacodynamic (PD) profile of the novel CCR1 antagonist CCX354 was evaluated in double-blind, placebo-controlled, single- and multiple-dose phase I studies (1-300 mg/day oral doses). CCX354 was well tolerated and displayed a linear dose-exposure profile, with half-life approaching 7 h at the 300-mg dose. The extent of CCR1 receptor blockade on blood monocytes, which correlated well with plasma concentrations of the drug, was assessed using fluorescently labeled CCL3 binding in whole blood from phase I subjects. High levels of receptor coverage at the 12-h time point were achieved after a single dose of 100 mg CCX354. Preclinical studies indicate that effective blockade of inflammatory cell infiltration into tissues requires ≥90% CCR1 inhibition on blood leukocytes at all times. The comparison of the properties of CCX354 with those published for other CCR1 antagonists has informed the dose selection for ongoing clinical development of CCX354 in rheumatoid arthritis (RA).

[Job satisfaction of radiologists in Germany - status quo]. / Berufszufriedenheit von Radiologen in Deutschland - aktueller Stand.

PURPOSE: The aim of this study was to identify and evaluate the work-related satisfaction of radiologists and its influencing factors in Germany. MATERIALS AND METHODS: For this purpose an invitational letter for an online opinion survey was sent to all member physicians of the Deutsche Roentgengesellschaft in 2008. 1200 questionnaires were completed (response rate 21 %) and evaluated statistically. RESULTS: 81.7 % of radiologists declared themselves as being "very" or "rather satisfied". The level of satisfaction was largely independent of age, gender, status, salary or family status. It increased over the last 5 years for 37.5 % of participants and decreased for 24.8 %. Nevertheless, 72 % of respondents indicated that they would not choose to specialize in radiology again. The main reason given was the workload. 65.6 % deemed it to be "considerably" or "rather too high". Concomitantly, more than 70 % of respondents indicated that the workload had increased "a lot" or "rather". Further reasons for not wanting to select the radiological profession again were "unfavorable working hours" and "unsatisfactory career perspectives". CONCLUSION: The job satisfaction of radiologists in Germany is generally very high in spite of the perception of an extensive and frequently increasing workload. The high workload was the dominant factor against a renewed selection of the field of radiology. These data have to be interpreted in light of the current lack of residents and trained radiologists in Germany to counteract the trend toward emigration.

[Magnetic resonance tomography in dental radiology (dental MRI)]. / Die Magnetresonanztomographie in der Dentalradiologie (Dental-MRT).

PURPOSE: To demonstrate the usefulness of Dental-MRT for imaging of anatomic and pathologic conditions of the mandible and maxilla. METHODS: Seven healthy volunteers, 5 patients with pulpitis, 9 patients with dentigerous cysts, 5 patients after tooth transplantation and 12 patients with atrophic mandibles were evaluated. Studies of the jaws using axial T1- and T2-weighted gradient echo and spin echo sequences in 2D and 3D technique have been to performed. The acquired images were reconstructed with a standard dental software package on a workstation as panoramic and cross sectional views of the mandible or maxilla. RESULTS: The entire maxilla and mandibula, teeth, dental pulp and the content of the mandibular canal were well depicted. Patients with inflammatory disease of the pulp chamber demonstrate bone marrow edema in the periapical region. Dentigerous cysts and their relation to the surrounding structures are clearly shown. After contrast media application marked enhancement of the dental pulp can be found. CONCLUSION: Dental-MRT provides a valuable tool for visualization and detection of dental diseases.

Computerized axiography for standardized evaluation of TMJ function and dysfunction.

Computerized axiography permits the recording of mandibular movement and offers analytic systems for evaluation. Data of both temporo-mandibular joints can be compared simultaneously in relation to changes in space and time [1]. The experienced dentist is able to detect early symptoms of disturbances in the stomatognathic system.

[Anatomy of the atrophic mandible. 1. The location of the mandibular canal in the atrophic mandible]. / Anatomische Untersuchungen an der atrophen Mandibula. Teil 1. Die Lage des Canalis mandibulae im atrophen Unterkiefer.

43 atrophic left hemimandibles were divided by 6 saw cuts made between the mental foramen and the third molar to analyze the location of the mandibular canal. Mandibles were classified by the severity of alveolar absorption using Atwood's classification and changes in the distances of the mandibular canal from the superior and inferior borders of the mandibular body were correlated wit the degree of atrophy. Measurements were obtained with a digitizer and a computer and results were analyzed statistically. The following statistically significant observations were made: The distance of the mandibular canal to the external lingua and buccal cortical layers did not change with increasing atrophy, but remained remarkably constant. By contrast, highly significant changes in the distance of the mandibular body were found to be present. These were more pronounced at the superior than at the inferior border. The changes seen were consistently most severe at the level of the first molar. Prior to surgical interventions involving an atrophic mandible the location of the mandibular canal should invariably be identified by imaging techniques such as orthopantomography, telemetric X-rays, tomographies, CT and MRI, if indicated, in order to avoid injuries of the inferior alveloar nerve and preclude forensic consequences.

[Dental care of HIV carriers]. / Zahnbehandlung bei HIV-Tragern. Probleme--Massnahmen--Konzepte.

As HIV infections continue to spread worldwide, the number of patients with known or unknown HIV positivity seen in dental practice is increasing. Some of the infected individuals need more frequent dental care than the general population, because HIV infections tend to be associated with specific oral manifestations. HIV-positive individuals have special psychosocial problems attributable both to their disease and to their frequent association with socially discriminated groups. These problems are also reflected in the dentist-patient relationships. Dental care of known HIV-positive individuals is much less hazardous than the treatment of undiagnosed HIV carriers. Building confidence between the dentist and the patient is essential. As HIV transmission is similar to that of hepatitis B, the full battery of hygienic precautions established for preventing hepatitis B should be observed in dental work to prevent HIV infections. Conditions of work in dental offices should meet the hygienic standards needed to preclude the risk of infections both for the dentists and their patients.