Continuous selective intraarterial infusion of nimodipine for therapy of refractory cerebral vasospasm.

BACKGROUND: For endovascular treatment of vasospasm after aneurysmal subarachnoid hemorrhage (aSAH), an intraarterial treatment course with the calcium channel antagonist nimodipine infused for 30 min is proposed. As some patients still show ongoing vasospasm thereafter, we report on our experience with an extended time period of selective intraarterial nimodipine administration. METHODS: In nine patients with aSAH and refractory cerebral vasospasm, we left the catheter in place within the internal carotid artery after angiography. On the neurosurgical ICU, a continuous infusion of intraarterial nimodipine was commenced, combined with intraarterial heparin anticoagulation. Therapy was controlled with extended neuromonitoring techniques. RESULTS: Three patients died from refractory vasospasm and a fourth suffered lethal sepsis. Three patients survived in a good clinical condition, two of them without apparent neurologic deficit. The efficacy of intraarterial nimodipine was best verified with regional CBF monitoring. TCD failed to detect vasospasm in two patients and missed improvement in four. Brain tissue oxygenation increased in all patients, but was not indicative of vasospasm in one. CT perfusion reflected the treatment course adequately in the qualitative scans. CONCLUSION: Selective continuous intraarterial nimodipine treatment for refractory cerebral vasospasm after aSAH seems feasible and may add to the endovascular therapeutic options. Appropriate monitoring technology is essential for further investigation of this novel technique.

Preoperative embolization of intracranial meningiomas with Embosphere microspheres.

BACKGROUND: To reduce intraoperative bleeding and to facilitate surgery by inducing tumor softening, a preoperative embolization of meningiomas is commonly recommended. PATIENTS AND METHODS: We report on our experience with non-resorbable microspheres (Embosphere) in the preoperative endovascular embolization of 17 intracranial meningiomas. After adding contrast media to the particles sized 40-500 micron, the embolization process was followed under fluoroscopy. There was a good passage of microcatheters if high concentrations of particles were avoided. RESULTS: The obstruction of the tumor feeders by particles was accompanied by a regression of tumor blush in DSA. CT controls showed a diminished contrast accumulation of the tumors already 1-2 days after embolization. Histologically, Embosphere microspheres were easy detectable with all commonly used staining methods. Embolization triggered, microscopically detectable necrosis was found in 77 % of the tumors. The mean interval between embolization and tumor extirpation was 2.5 days. The average time required for tumor extirpation was 244 minutes, while the average blood loss was 749 ml. CONCLUSIONS: Our experiences show that Embosphere microspheres are effective embolic agents in obstructing meningeal feeders of preoperatively treated meningiomas.

Reversible segmental cerebral vasoconstriction (Call-Fleming syndrome): are calcium channel inhibitors a potential treatment option?

The Call-Fleming syndrome is characterized by sudden onset of thunderclap-like headache and focal neurological deficits. The pathophysiological correlate is a reversible segmental cerebral vasoconstriction frequently associated with focal cerebral ischaemia. The syndrome has been described in a variety of clinical conditions, and recently an association between the syndrome and exposure to vasoactive drugs was observed. Effective treatment options are not known. A 63-year-old female developed sudden 'worst ever' headache. Initial neurological examination, laboratory blood tests, CSF examination and brain magnetic resonance imaging (MRI) were normal. Previous medical history was unremarkable and she did not take vasoactive drugs. Eleven days after the onset of headache she developed visual field impairment and a right-sided hemiparesis. Brain MRI revealed bilateral posterior and left parietal ischaemic strokes. Cerebral catheter angiography showed segmental arterial vasoconstriction. A vasodilative therapy with calcium channel inhibitors was started and serial transcranial Doppler ultrasonography demonstrated resolution of cerebral arterial vasoconstriction. The present case illustrates that calcium channel inhibitors may be an effective therapy for segmental cerebral arterial vasoconstriction. However, more clinical data are needed to prove this observation.

Successful endovascular treatment of a spinal dural arteriovenous fistula with trisacryl gelatin microspheres.

We report on the endovascular treatment of a spinal dural arteriovenous fistula (SDAVF) in a 50-year-old man, who presented with rapidly progressive paraparesis of lower extremities. Standard treatment of SDAVFs is by either embolization with liquid adhesive agents like NBCA or microsurgery. In our case the fistula was successfully occluded by application of trisacryl gelatin microspheres (TGM). Due to a small size of the feeding intercostal artery a superselective catheterization of the fistula itself by a microcatheter could not be performed. The particles were hence delivered through a diagnostic spinal catheter positioned within the proximal part of the feeding intercostal artery. Control MRI five weeks after intervention showed normalized perimedullary veins, which were dilated and tortuous initially. It also displayed a clinically silent focal ischaemia within the spongiosa of an adjacent hemi-vertebra due to particle passage through intersegmental vascular collaterals. A control angiogram confirmed the disappearance of the fistula. The patient underwent physiotherapy and experienced significant improvement of his gait within three months after intervention.

[Diagnostic methods in spinal infections]. / Bildgebende Verfahren bei spinalen Infektionen.

A targeted successful treatment of spinal infectious diseases requires clinical and laboratory data that are completed by the contribution of imaging procedures. Neuroimaging only provides essential informations on the correct topography, localisation, acuity and differential diagnosis of spinal infectious lesions. MRI with its sensitivity concerning soft tissue lesions is a useful tool in detecting infectious alterations of spinal bone marrow, intervertebral disks, leptomeninges and the spinal cord itself. Crucial imaging patterns of typical spinal infections are displayed and illustrated by clinical case studies. We present pyogenic, granulomatous and postoperative variants of spondylodicitis, spinal epidural abscess, spinal meningitis and spinal cord infections. The importance of intravenous contrastmedia application is pointed out.

Congenital dilation of the cervical epidural venous plexus: neuroradiology and endovenous management.

We report a case of a 15-year-old girl suffering from cervicobrachialgia who was admitted to our service due to an enlarged neural foramen suspicious for a neurinoma. The cervical phlebography, however, revealed a space-occupying dilated epidural vein with increased blood supply from the suboccipital venous plexus. Lesions like this are absolutely rare, presumably of congenital origin and have not been described before. The lesion was treated by feeder occlusion applying platinum coils and enbucrilate via the internal jugular vein.

[Value of nuclear magnetic resonance tomography in leg edema of unknown origin. Preliminary report]. / Stellenwert der Kernspintomographie bei unklaren Beinödemen. Vorläufige Mitteilung.

Edemas of the leg sometimes pose problems for diagnosis. Invasive procedures like lymphography or phlebography are either difficult to perform or might endanger the lymphatics. The value of magnetic resonance imaging was assessed in 20 patients with lymphedema, lipedema and phlebedema. Images of patients with lipedema showed homogenous enlarged subcutaneous tissue. In lymphedema a honeycomb pattern in the subcutaneous tissue was observed; in phlebedema there was an increase of fluid within the muscle. Magnetic resonance imaging is useful in differentiating lymphedema, lipedema or phlebedema.

[Gliomatosis cerebri: the diagnostic potential of MRT]. / Gliomatosis cerebri: Diagnostisches Potential der MRT.

Gliomatosis cerebri is a rare tumor of neuroepithelial origin in middle aged persons presented by deterioration of cognitive functions, psychomotor retardation and cerebral convulsions. MRI predominantly shows a bilateral and diffuse infiltration of midline adjacent brain structures including medulla. Areas with focal anaplasia occasionally reveal an accumulation of contrast media. The diffuse tumor manifestation requires a differentiation from encephalitis and demyelinating diseases with a similar distribution pattern of lesions. Three cases have been examined. In conclusion the performance of MRI including control and brain biopsy are indicated to establish an in vivo diagnosis.

[MR tomography of nonspecific infectious spondylodiscitis]. / MR-Tomographie der unspezifischen infektiösen Spondylodiszitis.

In 14 cases of unspecific infectious spondylodiscitis 11 patients underwent MR tomography, 3 of them were followed up. At the acute stage of the disease characteristic MR patterns are revealed. The main symptoms are 1) transdiscal hypointensity of the affected segment in T1-weighted images without differentiation of disk and adjacent vertebral bodies as well as 2) the manifestation of a hyperintense signal of diseased disks, vertebral bodies and paravertebral inflammation on T2-weighted images. A signal void is produced by sclerotic reactions of spongiosa. The formation of intraspinal abscesses and the compression of the spinal cord are clearly outlined by MR. When therapy is successfully applied, signal alterations largely normalize.

[Magnetic resonance tomography of non-tumorous lesions of the pons]. / Magnetische Resonanztomographie (MR) nicht-tumoröser Ponsläsionen.

The paper gives details of the diagnostic value of MRI in 20 cases of non-tumorous lesions of the pons. MR findings in haematoma (3), vascular malformations (2), infarctions (6), encephalitis (1), demyelinations (6) and atrophies (2) resulted in signal changes typical of the kind of disease. A pontine volume increase or decrease was proved comparing the data of the normal and affected brain stem. The topography of lesions was clearly documented by MRI. Subacute haematomas were better outlined than by CT, while acute infarctions, foci of demyelination and one case of ponsencephalitis were proved only by MRI. Small calcifications and vessels of an arteriovenous malformation, however, caused the same MR signal patterns.

[Assessment of the muscles of the extremities with imaging procedures (CT and MR)]. / Beurteilung von Extremitätenmuskeln mit bildgebenden Verfahren (CT und MR).

Modern imaging techniques like CT-scanning and Magnetic Resonance imaging are advantageous for macroscopic evaluation of muscles in the extremities. By correct positioning of the patient the muscles of the arms can be scanned without artefact. Our experience is based on 160 CT and 47 MR cases. While healthy muscles reveal regular morphology, atrophic muscles become reduced in size as well as demonstrating complex structural alterations. The distribution pattern, type, and degree of atrophy can be accurately documented by both techniques. Furthermore, MR can clearly detect edema, hematoma, and myositis of muscles. Hence CT and MR may prove useful tools for preoperative assessment as well as a postoperative follow-up.

[MR and CT patterns of neurocysticercosis]. / MR- und CT-Muster der Neurozystizerkose.

MRI and CT manifestations were studied in five cases of neurocysticercosis. As demonstrated by long-term follow-ups the disease usually causes multiple lesions the morphology of which depends on the life cycle of the parasite. Tissue lesions consist of three main types: 1) vital cysticerci, 2) inflammatory parenchymatous reactions following degenerating cysts and 3) calcified granulomas. MRI provides all information that is given by CT except for small calcifications which are usually missed. Morphological details of vital cysticerci like cyst wall and scolex are better outlined by MRI. When i.v. contrast medium is applied, it leads to nodular or annular enhancement of inflamed tissue. The sensitivity of MRI towards edema caused by parasite exceeds that of CT by several weeks. CT and MRI are complementary methods providing at the present time the highest degree of specificity in diagnosing neurocysticercosis.

[MR-tomography and -spectroscopy of skeletal muscles using high magnetic field strengths]. / MR-Tomographie und -Spektroskopie der Skelettmuskulatur bei hohen Magnetfeldstärken.

Intact as well as neuromuscular affected skeletal muscles can be precisely analysed by MR tomography with high magnetic field strengths. The substitution of muscle by adipose tissue under atrophic conditions is seen most clearly in fat images, while the morphology of small structures is predominantly shown by water images. The aim of in-vivo spectroscopy is an identification and quantification of metabolites. A relative increase in the amount of adipose tissue within atrophic muscles was confirmed by the 1-H spectrum. As concluded from 13-C and 31-P spectra there was neither a change in adipose tissue composition nor a modification of energy metabolism.

[NMR tomography of the skeletal muscles in neuromuscular diseases]. / Kernspintomographie der Skelettmuskulatur bei neuromuskulären Erkrankungen.

MR tomography is a useful procedure for assessing changes in size and structure of skeletal muscles in three dimensions. It provides excellent soft tissue contrast resolution, but spatial resolution requires to be improved. Myatrophic alterations can be shown best by using short echo delay times (TE) and short repetition times (TR). Muscles with fatty degeneration reveal a change in signal intensity and in relaxation times. These reproducible MR findings indicate appropriate areas of EMG diagnosis and biopsy and provide objective follow-ups.

[Technic for computed tomographic study of skeletal muscles in neuromuscular diseases]. / Technik computertomographischer Skelettmuskeluntersuchungen bei neuromuskulären Erkrankungen.

Computed tomography provides a complete view of morphological alterations in skeletal muscle caused by neuromuscular diseases. A good image quality of the lower as well as of the upper limbs is obtained by choosing a small scanning-field and an appropriate scanning-position. The arms are best examined one by one. In follow-up studies muscular atrophy can be documented by planimetric and densimetric measurements. Furthermore CT-scanning is a convenient method for selecting suitable muscles for muscle biopsy.

[Computed tomography of the skeletal muscles in neuromuscular diseases]. / Computertomographie der Skelettmuskulatur bei neuromuskulären Erkrankungen.

CT-documentation of skeletal muscular lesions caused by neuromuscular diseases implies an essential contribution to conventional techniques in the macroscopic field. Size, distribution and degree of lesions as well as compensatory mechanisms are proved thereby. We report about the different effects on muscle appearance referring to 106 patients of our own experience in amyotrophic lateral sclerosis, spinal muscular atrophy, poliomyelitis, polyradiculitis, polyneuropathy as well as peripheral traumatic nerve lesions.

[Computed tomographic classification of gunshot wounds of the head]. / Computertomographische Klassifikation von Kopfschussverletzungen.

Twenty-four patients following head bullet injuries were analyzed by CT. The major part, concerning 10 patients, refers to acute perforating lesions. Five cases showed penetrating injuries, 3 cases bolt injuries, the other ones lesions of the facial skull and residues of former bullet injuries. Because of a tempory cavitation the bullet track is wider than the bullet itself. The position of the skull fragments gives a hint to the shot direction. A reconstruction of intracranial bullet movements and spontaneous bullet dislocations is made possible by CT. It further shows secondary posttraumatic lesions.

[Herpes simplex encephalitis on the computed tomogram]. / Die Herpes-simplex-Enzephalitis im Computertomogramm.

Referring to 9 patients of our own material we report on the pattern of distribution and the development of CT-changes in Herpes simplex encephalitis (HSE). Our cases include the outstanding findings of a primarily hemorrhagic HSE and an extensive calcification at the residual stage on the borderline of widespread tissue necrosis on a baby. With respect to literature we receive a quite homogeneous picture, reflecting the crucial characteristics of the disease as known from neuropathology.

[Computed tomographic studies in cervical spinal stenosis]. / Computertomographische Untersuchungen bei zervikaler spinaler Stenose.

Computed tomography was applied in 29 patients with cervical spinal stenosis. In 8 cases there was a congenital narrowed spinal canal. In 18 cases we found dorsal spondylotic ridges of the vertebral bodies and in three cases an atlanto-dental dislocation. The complaints showed either radicular character or in case of myelopathy came out as para- and quadriplegia. In 25 cases the spinal sagittal diameter was a lot below a critical borderline of about 13 mm. The kind and localisation of the underlying process can be demonstrated very excellent by computed tomography.