Ultraearly assessed reperfusion status after middle cerebral artery recanalization predicting clinical outcome.

OBJECTIVES: Mechanical thrombectomy has high evidence in stroke therapy; however, successful recanalization guarantees not a favorable clinical outcome. We aimed to quantitatively assess the reperfusion status ultraearly after successful middle cerebral artery (MCA) recanalization to identify flow parameters that potentially allow predicting clinical outcome. MATERIALS AND METHODS: Sixty-seven stroke patients with acute MCA occlusion, undergoing recanalization, were enrolled. Using parametric color coding, a post-processing algorithm, pre-, and post-interventional digital subtraction angiography series were evaluated concerning the following parameters: pre- and post-procedural cortical relative time to peak (rTTP) of MCA territory, reperfusion time, and index. Functional long-term outcome was assessed by the 90-day modified Rankin Scale score (mRS; favorable: 0-2). RESULTS: Cortical rTTP was significantly shorter before (3.33 ± 1.36 seconds; P = .03) and after intervention (2.05 ± 0.70 seconds; P = .003) in patients with favorable clinical outcome. Additionally, age (P = .005) and initial National Institutes of Health Stroke Scale score (P = .02) were significantly different between the patients, whereas reperfusion index and time as well as initially estimated infarct size were not. In multivariate analysis, only post-procedural rTTP (P = .005) was independently associated with favorable clinical outcome. 2.29 seconds for post-procedural rTTP might be a threshold to predict favorable clinical outcome. CONCLUSIONS: Ultraearly quantitative assessment of reperfusion status after successful MCA recanalization reveals post-procedural cortical rTTP as possible independent prognostic value in predicting favorable clinical outcome, even determining a threshold value might be possible. In consequence, focusing stroke therapy on microcirculatory patency could be valuable to improve outcome.

Optimized angiographic CT using intravenous contrast injection: a noninvasive imaging option for the follow-up of coiled aneurysms?

BACKGROUND AND PURPOSE: Because recanalization of coiled cerebral aneurysms is reported to occur, follow-up imaging is mandatory, ideally noninvasively. Our study aimed to evaluate the accuracy of an optimized angiographic CT by using intravenous contrast material injection in the assessment of coiled cerebral aneurysms, compared with MR angiography and digital subtraction angiography, the criterion standard. MATERIALS AND METHODS: We included 69 patients with 76 coiled cerebral aneurysms. In each patient, we performed an angiographic CT with intravenous contrast material injection with a dual rotational acquisition, a time-of-flight MR angiography, and a DSA. The angiographic CT with intravenous contrast material injection data was postprocessed by using newly implemented reconstructions modes and a dual-volume technique. An aneurysm occlusion rate was assessed in angiographic CT with intravenous contrast material injection and MRA; remnants were measured and correlated with DSA, respectively. RESULTS: Twenty-eight remnants were revealed by DSA with a mean size of 3.1 × 3.1 mm. Angiographic CT with intravenous contrast material injection demonstrated a sensitivity of 93% and a specificity of 96% in remnant detection. MRA showed almost identical accuracy (sensitivity of 93%, specificity of 100%). Assessment of remnant size by angiographic CT with intravenous contrast material injection and by MRA revealed a high significant correlation with DSA, respectively (P < .001). CONCLUSIONS: Optimized angiographic CT with intravenous contrast material injection and MRA demonstrated accuracy comparable with that of DSA in the follow-up of coiled aneurysms, respectively. The assessment of remnant size showed a high correlation with DSA for both techniques. Due to the lack of radiation exposure, MRA seems to be the preferred technique. However, angiographic CT with intravenous contrast material injection can be considered a reliable, noninvasive alternative in patients with MR imaging contraindications or in cases of compromising artifacts due to metal implants (ie, clips).

Parametric color coding of digital subtraction angiography in the evaluation of carotid cavernous fistulas.

PURPOSE: Angiographic assessment of carotid cavernous fistulas (CCFs) can be complex. Our purpose was to examine whether the use of parametric color coding in the postprocessing of DSA series is advantageous in the evaluation of CCFs. METHODS: We enrolled 16 patients with angiographically proven CCFs. Endovascular treatment was performed in 14 cases. For postprocessing of digital subtraction angiography (DSA) series, a newly implemented algorithm of parametric color coding was used, turning sequential images of two-dimensional (2D)-DSA series into a single color-coded image. Angiographic data of initial, interventional, and postinterventional 2D-DSA series were compared with color-coded images. Whether parametric color coding could facilitate evaluation of fistula architecture and provide a more precise estimation of fistula venous drainage patterns as well as whether flow analysis could reveal objective changes during and after treatment were investigated. RESULTS: In 56 % of the cases, parametric color coding was observed to facilitate visualization of fistula angioarchitecture. Estimation of fistula drainage flow patterns was considered to be improved in 31 % of the cases. For assessment of hemodynamic changes during and after treatment, parametric color coding was assumed to be helpful in 21 % of the cases, especially because revealing flow changes that were not visible on 2D-DSA series were now visible. CONCLUSIONS: Parametric color coding is a fast application tool that might provide additional support in the angiographic evaluation of CCFs. Visualization of complex fistula architecture could be facilitated, and flow analysis might improve assessment of venous drainage patterns, thereby increasing overall diagnostic confidence. During and after treatment, hemodynamic changes that were not visible on 2D-DSA series could now be depicted.

Intraprocedural angiographic CT as a valuable tool in the course of endovascular treatment of direct sinus cavernous fistulas.

This investigation aimed to demonstrate the potential of intraprocedural angiographic CT in monitoring complex endovascular coil embolization of direct carotid cavernous fistulas. Angiographic CT was performed as a dual rotational 5 s run with intraarterial contrast medium injection in two patients during endovascular coil embolization of direct carotid cavernous fistulas. Intraprocedural angiographic CT was considered helpful if conventional 2D series were not conclusive concerning coil position or if a precise delineation of the parent artery was impossible due to a complex anatomy or overlying coil material. During postprocessing multiplanar reformatted and dual volume images of angiographic CT were reconstructed. Angiographic CT turned out to be superior in the intraprocedural visualization of accidental coil migration into the parent artery where conventional 2D-DSA series failed to reliably detect coil protrusion. The delineation of coil protrusion by angiographic CT allowed immediate correct coil repositioning to prevent parent artery compromising. Angiographic CT can function as a valuable intraprocedurally feasible tool during complex coil embolizations of direct carotid cavernous fistulas. It allows the precise visualization of the cerebral vasculature and any accidental coil protrusion can be determined accurately in cases where conventional 2D-DSA series are unclear or compromised. Thus angiographic CT might contribute substantially to reduce procedural complications and to increase safety in the management of endovascular treatment of direct carotid cavernous fistulas.

Angiographic CT with intravenous contrast injection compared with conventional rotational angiography in the diagnostic work-up of cerebral aneurysms.

BACKGROUND AND PURPOSE: Noninvasive imaging of cerebral aneurysms is still considered inferior to conventional angiography. The purpose of this study was to evaluate the diagnostic accuracy of ivACT in the assessment of intracranial aneurysms compared with 3D-DSA. MATERIALS AND METHODS: We included 13 patients with 15 incidental unruptured saccular aneurysms scheduled for diagnostic angiographic work-up in our study. In each patient, we performed an ivACT and a conventional angiography including a 3D rotational run. During postprocessing, MPR images were generated for each technique. Maximal aneurysm diameter, neck diameter, aneurysm height, maximum width, bulge height, parent artery diameter, and angle between the parent artery and aneurysm apex were measured for each aneurysm. RESULTS: 3D-DSA and ivACT both provided images of high quality without artificial disturbances (ie, motion artifacts). Measurements of all parameters resulted in comparable values for both modalities with a strong correlation (P ≤ .001). CONCLUSIONS: ivACT is feasible for the noninvasive visualization of saccular cerebral aneurysms and may provide reliable diagnostic information for the assessment of aneurysm size and geometry comparable with conventional intra-arterial 3D rotational angiography. These preliminary results might be a first promising step to replacing conventional angiography in preinterventional aneurysm imaging.

Endovascular treatment of symptomatic radiation-induced basilar artery stenosis 25 years after medulloblastoma.

Intracranial stenosis as late sequela after cerebral radiation therapy for medulloblastoma is an exceptionally rare finding. We report for the first time a case of 31-year-old patient with a history of medulloblastoma 25 years ago and now presenting with radiation-induced high-grade basilar stenosis and recurrent ischemic symptoms despite best medical therapy. The stenosis was treated successfully with angioplasty followed by stenting using a self-expandable microstent. Additionally, MRI revealed multiple cavernomas, illustrating that radiation-induced microbleeds may occur.

[OSCE in the neurology clerkship. Experiences at the neurological department of the university hospital Erlangen]. / OSCE in der Neurologie. Erfahrungen an der neurologischen Universitätsklinik Erlangen.

BACKGROUND: In the German medical education program practical examinations at the end of the neurology clerkship are sparsely performed. By this way, motivation for practical learning and a method to assure quality of learning are not used. METHOD: The Anglo-Saxon concept of "objective structured clinical examination" (OSCE) is picked up and implemented as a practical examination at the end of the neurology clerkship of medical students in their 4th and 5th year. A catalogue of learning goals was defined and an OSCE of 5 stations was developed. A standard of a successful examination was defined. In two OSCE stations the competence in clinical decision making and reasoning were tested, in two stations the competence in practical examination skills and in one station the practical skill to perform a lumbar puncture at the phantom. The results of the OSCE stations were analysed for task difficulty, discriminatory power, normalized discrimination index and reliability. Using a questionnaire, the students evaluated the OSCE. RESULTS: N = 123 students (73 female, 50 male) with a mean age of 26.1 years (22 - 46 years) participated. The mean score was 40 +/- 3.6 of a total of 50 points (range 29 - 46). Female students (40.8 +/- 3.1) scored significantly higher than male ones (38.8 +/- 4; p = .002). One student (0.8 %) failed the examination. The difficulty of the stations ranged between 0.63 and 0.91, normalized discrimination index between 0.1 and 0.18 and the discriminatory power from r = 0.25 to r = 0.53. The reliability of the 5 stations was 0.65 (Cronbach's alpha). In the evaluation, the rating for innovation, organisation, length, clarity of the tasks, clinical reality and compatibility with general physician's competence, atmosphere during the examination and fairness was extremely positive. Most students would prefer an OSCE compared with a multiple-choice test. CONCLUSION: An OSCE at the end of the neurology clerkship is feasible. The quantitative analyses of the results are concordant with requirements of medical examinations. The OSCE is positively evaluated by the students.