Outbreak of Pseudomonas aeruginosa infections after CT-guided spinal injections.

BACKGROUND: Meningitis and spinal infections with Gram-negative bacteria after local injections for treatment of chronic back pain are rare. This study investigated an outbreak of Pseudomonas aeruginosa infections following computed tomography (CT)-guided spinal injections (SI). METHODS: A case was defined as a spinal infection or meningitis with P. aeruginosa after SI between 10th January and 1st March 2019 in the same outpatient clinic. Patients without microbiological evidence of P. aeruginosa but with a favourable response to antimicrobial therapy active against P. aeruginosa were defined as probable cases. FINDINGS: Twenty-eight of 297 patients receiving CT-guided SI during the study period developed meningitis or spinal infections. Medical records were available for 19 patients. In 15 patients, there was microbiological evidence of P. aeruginosa, and four patients were defined as probable cases. Two of 19 patients developed meningitis, while the remaining 17 patients developed spinal infections. The median time from SI to hospital admission was 8 days (interquartile range 2-23 days). Patients mainly presented with back pain (N=18; 95%), and rarely developed fever (N=3; 16%). Most patients required surgery (N=16; 84%). Seven patients (37%) relapsed and one patient died. Although the source of infection was not identified microbiologically, documented failures in asepsis when performing SI probably contributed to these infections. CONCLUSIONS: SI is generally considered safe, but non-adherence to asepsis can lead to deleterious effects. Spinal infections caused by P. aeruginosa are difficult to treat and have a high relapse rate.

Multimodal Imaging in Malignant Brain Tumors: Enhancing the Preoperative Risk Evaluation for Motor Deficits with a Combined Hybrid MRI-PET and Navigated Transcranial Magnetic Stimulation Approach.

BACKGROUND AND PURPOSE: Motor deficits in patients with brain tumors are caused mainly by irreversible infiltration of the motor network or by indirect mass effects; these deficits are potentially reversible on tumor removal. Here we used a novel multimodal imaging approach consisting of structural, functional, and metabolic neuroimaging to better distinguish these underlying causes in a preoperative setting and determine the predictive value of this approach. MATERIALS AND METHODS: Thirty patients with malignant brain tumors involving the central region underwent a hybrid O-(2-[(18)F]fluoroethyl)-L-tyrosine-PET-MR imaging and motor mapping by neuronavigated transcranial magnetic stimulation. The functional maps served as localizers for DTI tractography of the corticospinal tract. The spatial relationship between functional tissue (motor cortex and corticospinal tract) and lesion volumes as depicted by structural and metabolic imaging was analyzed. RESULTS: Motor impairment was found in nearly all patients in whom the contrast-enhanced T1WI or PET lesion overlapped functional tissue. All patients who functionally deteriorated after the operation showed such overlap on presurgical maps, while the absence of overlap predicted a favorable motor outcome. PET was superior to contrast-enhanced T1WI for revealing a motor deficit before the operation. However, the best correlation with clinical impairment was found for T2WI lesion overlap with functional tissue maps, but the prognostic value for motor recovery was not significant. CONCLUSIONS: Overlapping contrast-enhanced T1WI or PET-positive signals with motor functional tissue were highly indicative of motor impairment and predictive for surgery-associated functional outcome. Such a multimodal diagnostic approach may contribute to the risk evaluation of operation-associated motor deficits in patients with brain tumors.

Mechanical thrombectomy in tandem occlusion: procedural considerations and clinical results.

INTRODUCTION: Acute tandem occlusions of the cervical and distal internal carotid artery (ICA) or middle cerebral artery (MCA) are associated with major stroke with intravenous (i.v.) thrombolysis alone in approximately 90 % of patients. The data on endovascular management of tandem occlusions is still limited. The purpose of this study was to review technical aspects and the current state of the literature on acute ICA stenting in combination with stent retriever-based intracranial thrombectomy. METHODS: We retrospectively reviewed the data of 37 consecutive patients with tandem occlusions including clinical parameters, angiographic results, procedural aspects, complications, and hemorrhages. RESULTS: Median National Institutes of Health Stroke Scale (NIHSS) on admission was 17 (3-30). Intracranial thrombectomy was performed prior to ICA stenting in 25/37 (67.6 %) and after stenting in 12/37 (32.4 %) patients. ICA stenting was successful in all cases, and a thrombolysis in cerebral infarction (TICI) scale 2b/3 result was achieved in 27/37 (73 %) cases. The mean angiography time was significantly shorter in the "thrombectomy first" group (43.1 ± 30.8 vs. 110.8 ± 43.0 min, p < 0.001), and more patients had favorable outcomes after 3 months (13/25 = 52.0 vs. 4/12 = 33.3 %, p = 0.319). In this group, intermediate catheters were used and successfully prevented embolism to unaffected territories in all cases. CONCLUSION: Acute stenting of the cervical ICA in combination with intracranial thrombectomy was technically feasible and safe in our series. Thrombectomy prior to proximal stenting was associated with shorter reperfusion times and a tendency towards better clinical outcome leading to a good outcome in about 50 % of the patients. Therefore, we recommend this approach in tandem occlusion requiring stent angioplasty.

3D computerized occlusion rating of embolized experimental aneurysms using noninvasive 1.5T MR imaging.

BACKGROUND AND PURPOSE: For embolized cerebral aneurysms, the initial occlusion rate is the most powerful parameter to predict aneurysm rerupture and recanalization. However, the occlusion rate is only estimated subjectively in clinical routine. To minimize subjective bias, computer occlusion-rating (COR) was successfully validated for 2D images. To minimize the remaining inaccuracy of 2D-COR, COR was applied to 1.5T 3D MR imaging. MATERIALS AND METHODS: Twelve experimental rabbit aneurysms were subjected to stent-assisted coil embolization followed by 2D DSA and 3D MR imaging. Subjective occlusion-rate (SOR) was estimated. Linear parameters (aneurysm length, neck width, parent vessel diameter) were measured on 2D DSA and 3D MR imaging. The occlusion rate was measured by contrast medium-based identification of the nonoccluded 2D area/3D volume in relation to the total aneurysm 2D area/3D volume. 2D and 3D parameters were statistically compared. RESULTS: There were no limiting metallic artifacts by using 3D MR imaging. Linear parameters (millimeters) were nearly identical on 2D DSA and 3D MR imaging (aneurysm length: 7.5 ± 2.6 versus 7.4 ± 2.5, P = .2334; neck width: 3.8 ± 1.0 versus 3.7 ± 1.1, P = .6377; parent vessel diameter: 2.7 ± 0.6 versus 2.7 ± 0.5, P = .8438), proving the high accuracy of 3D MR imaging. COR measured on 3D MR imaging was considerably lower (61.8% ± 26.6%) compared with the following: 1) 2D-COR (65.6% ± 27.1%, P = .0537) and 2) 2D-SOR estimations (69.2% ± 27.4%, P = .002). These findings demonstrate unacceptable bias in the current clinical standard SOR estimations. CONCLUSIONS: 3D-COR of embolized aneurysms is easily feasible. Its accuracy is superior to that of the clinical standard 2D-SOR. The difference between 3D-COR and 2D-COR approached statistical significance. 3D-COR may add objectivity to the ability to stratify the risk of rerupture in embolized cerebral aneurysms.