Thrombectomy in acute basilar artery dissection: A case report.

A 34-year-old patient was admitted with unclear coma and stretch synergisms. CT-imaging was strongly suspicious of basilar artery dissection, this was confirmed on subsequent DSA. The patient was lysed and a complex thrombectomy was performed. Despite sufficient recanalization, the patient unfortunately died shortly after. To the best of our knowledge, this is the first description of an acute basilar artery dissection treated by thrombectomy.

Embolization of the middle meningeal artery vs. second surgery-treatment response and volume course of recurrent chronic subdural hematomas.

BACKGROUND: Despite multiple studies on the embolization of the middle meningeal artery, there is limited data on the treatment response of recurrent chronic subdural hematomas (CSDH) to embolization and on the volume change. METHODS: We retrospectively compared the treatment response and volume change of recurrent CSDHs in a conventional group (second surgery) with an embolization group (embolization as stand-alone treatment) during the time-period from August 2019 until June 2022. Different clinical and radiological factors were assessed. Treatment failure was defined as necessity of treatment for second recurrence. Hematoma volumes were determined in the initial CT scan before first surgery, after the first surgery, before retreatment as well as in an early (1 day-2 weeks) and in a late follow-up CT scan (2-8 weeks). RESULTS: Fifty recurrent hematomas after initial surgery were treated either by second surgery (n = 27) or by embolization (n = 23). 8/27 (26,6%) surgically treated and 3/23 (13%) of the hematomas treated by embolization needed to be treated again. This leads to an efficacy in recurrent hematomas of 73,4% in surgically treated and of 87% in embolized hematomas (p = 0.189). In the conventional group, mean volume decreased significantly already in the first follow-up CT scan from 101.7 ml (SD 53.7) to 60.7 ml (SD 40.3) (p = 0.001) and dropped further in the later follow-up scan to 46.6 ml (SD 37.1) (p = 0.001). In the embolization group, the mean volume did decrease insignificantly from 75.1 ml (SD 27.3) to 68 ml (SD 31.4) in the first scan (p = 0.062). However, in the late scan significant volume reduction to 30.8 ml (SD 17.1) could be observed (p = 0.002). CONCLUSIONS: Embolization of the middle meningeal artery is an effective treatment option for recurrent CSDH. Patients with mild symptoms who can tolerate slow volume reduction are suitable for embolization, whereas patients with severe symptoms should be reserved for surgery.

Case report: Flattening of the tectal plate in obstructive hydrocephalus with auto-ventriculostomy.

BACKGROUND: Obstructive hydrocephalus in adulthood can be caused by stenosis in the aqueductal area. Chronic changes lead to a dilatation of the lateral ventricles and ballooning of infratentorial recesses. In rare cases a rupture of the floor of the third ventricle (so-called spontaneous ventriculostomy) has been described in the literature.Case presentation: We present two cases of chronic obstructive hydrocephalus due to aqueductal stenosis in adult patients. Magnetic resonance imaging included phase-contrast-imaging and revealed significant flow through the floor of the third ventricle in keeping with spontaneous ventriculostomy. In addition to other typical changes associated with chronic hydrocephalus, a distinct flattening of the tectal plate could be identified in one case. CONCLUSION: We present two cases of spontaneous ventriculostomy in patients with chronic hydrocephalus. To our knowledge, flattening of the tectal plate has not yet been described in the literature and may be caused by continuous cerebrospinal fluid-pulsation.

Case report: Scattered intraventricular lesions on MRI following epidermoid cyst resection.

Local recurrence after epidermoid cyst surgery is a frequently reported complication, but intraventricular spread after surgery has not yet been described in literature. We present the case of a 61-year-old male patient with steadily progressive headaches after surgical excision of an epidermoid cyst in the right cerebellopontine angle about two months ago. The MRI showed multiple intraventricular FLAIR-hyperintensities with diffusion restriction, suggestive of scattered remnants of the epidermoid cyst. We recommend early postoperative MRI-scans after cranial epidermoid surgery, which should be carefully inspected not only for local remnants but also rare complications like intraventricular spread.

Non-visualizable stent-occlusion after treatment of a fusiform PCA-aneurysm-a case report.

We report the case of a 17-year-old woman with extensive subarachnoidal hemorrhage due to a ruptured fusiform aneurysm of the right PCA (posterior cerebral artery). Endovascular treatment was successfully performed using a LVIS-EVO-Stent (Microvention Incorporation, Tustin, USA) as well as several coils. Short-term angiographic follow-up demonstrated extensive aneurysm progression and dilatation of the coil package, the stent could no longer be visualized and was not passable. Despite excellent distal vascular perfusion, a non-visible stent occlusion was suspected and subsequent occlusion of the patent artery was performed. We conclude that rapid progression of fusiform aneurysms after stent-assisted coiling may lead to expansion of the coil packages and non-assessability of the stent. Even with excellent distal perfusion, a stent-occlusion should be suspected in these cases. Therefore, we suggest short-term angiographic follow-up, especially after deploying multiple coil packages in fusiform aneurysms.

Improving diagnostic accuracy in assessing pulmonary edema on bedside chest radiographs using a standardized scoring approach.

BACKGROUND: To assess the value of a score-based system which allows standardized evaluation of pulmonary edema on bedside chest radiographs (CXRs) under routine clinical conditions. METHODS: Seven experienced readers assessed bedside CXRs of ten patients with an extravascular lung water (EVLW)-value of ≤ 8 mL/kg (range: 4-8 mL/kg; indicates no pulmonary edema) and a series of ten patients with an EVLW-value of ≥ 15 mL/kg (range: 15-21 mL/kg; = indicates a pulmonary edema) with and without customized software which would permit a standardized assessment of the various indications of pulmonary edema. The software provides a score that identifies patients with and without pulmonary edema. EVLW-values were measured instantly after bedside CXR imaging using a pulse contour cardiac output (PiCCO) system and served as a reference standard. The patients were non-traumatic and not treated with diuretics or dobutamine during bedside CXR imaging and the PiCCO measurements. Mean sensitivity, specificity, positive and negative predictive value, the percentage of overall agreement and the free-marginal multirater kappa value was calculated for both the standard and the standardized score-based approach. The net reclassification index was calculated for each reader as well as for all readers. RESULTS: Evaluation of bedside CXRs by means of the score-based approach took longer (23 ± 12 seconds versus 7 ± 3 seconds without the use of the software) but improved radiologists' sensitivity (from 57 to 77%), specificity (from 90 to 100%) and the free-marginal multirater kappa value (from 0.34 to 0.68). The positive predictive value was raised from 85 to 100% and the negative predictive value from 68 to 81%. A net reclassification index of 0.3 (all readers) demonstrates an improvement in prediction performance gained by the score-based approach. The percentage of overall agreement was 67% with the standard approach and 84% with the software-based approach. CONCLUSIONS: The diagnostic accuracy of bedside CXRs to discriminate patients with elevated EVLW-values from those with a normal value can be improved with the use of a standardized score-based approach. The investigated system is freely available as a web-based application (accessible via: http://www.radiologie.uk-erlangen.de/aerzte-und-zuweiser/edema).