New recommendations on cerebral venous and dural sinus thrombosis from the German consensus-based (S2k) guideline.

Over the last years, new evidence has accumulated on multiple aspects of diagnosis and management of cerebral venous and dural sinus thrombosis (CVT) including identification of new risk factors, studies on interventional treatment as well as treatment with direct oral anticoagulants. Based on the GRADE questions of the European Stroke Organization guideline on this topic, the new German guideline on CVT is a consensus between expert representatives of Austria, Germany and Switzerland. New recommendations include:• CVT occurring in the first weeks after SARS-CoV-2 vaccination with vector vaccines may be associated with severe thrombocytopenia, indicating the presence of a prothrombotic immunogenic cause (Vaccine-induced immune thrombotic thrombocytopenia; VITT).• D-dimer testing to rule out CVT cannot be recommended and should therefore not be routinely performed.• Thrombophilia screening is not generally recommended in patients with CVT. It should be considered in young patients, in spontaneous CVT, in recurrent thrombosis and/or in case of a positive family history of venous thromboembolism, and if a change in therapy results from a positive finding.• Patients with CVT should preferably be treated with low molecular weight heparine (LMWH) instead of unfractionated heparine in the acute phase.• On an individual basis, endovascular recanalization in a neurointerventional center may be considered for patients who deteriorate under adequate anticoagulation.• Despite the overall low level of evidence, surgical decompression should be performed in patients with CVT, parenchymal lesions (congestive edema and/or hemorrhage) and impending incarceration to prevent death.• Following the acute phase, oral anticoagulation with direct oral anticoagulants instead of vitamin K antagonists should be given for 3 to 12 months to enhance recanalization and prevent recurrent CVT as well as extracerebral venous thrombosis.• Women with previous CVT in connection with the use of combined hormonal contraceptives or pregnancy shall refrain from continuing or restarting contraception with oestrogen-progestagen combinations due to an increased risk of recurrence if anticoagulation is no longer used.• Women with previous CVT and without contraindications should receive LMWH prophylaxis during pregnancy and for at least 6 weeks post partum.Although the level of evidence supporting these recommendations is mostly low, evidence from deep venous thrombosis as well as current clinical experience can justify the new recommendations.This article is an abridged translation of the German guideline, which is available online.

Treatment of Proximal Posterior Inferior Cerebellar Artery Aneurysms by Intrasaccular Flow Disruption: A Multicenter Experience.

BACKGROUND AND PURPOSE: Treatment of PICA aneurysms can be technically challenging by either surgical or endovascular means. Our aim was to report our preliminary experience with intrasaccular flow disruption using the Woven EndoBridge (WEB) for the treatment of proximal PICA aneurysms. MATERIALS AND METHODS: Sixteen PICA aneurysms treated with the WEB at 3 institutions were retrospectively reviewed. Baseline patient and aneurysm characteristics, procedural specifics, clinical outcomes, and angiographic results were evaluated. RESULTS: All aneurysms were located at the proximal, anteromedullary segment of the PICA. Seven aneurysms were ruptured. The median aneurysm size was 3.9 mm (range, 2-12 mm), and all aneurysms were wide-neck. WEB deployment failed in 1 case due to WEB protrusion in a small PICA aneurysm. Additional stent implantation was required for 2 aneurysms to improve intra-aneurysmal WEB positioning. One patient developed a partial posterior cerebral artery territory infarction with transient hemianopsia. Intraoperative rerupture of a ruptured aneurysm could be immediately stopped by WEB deployment due to intrasaccular stasis; however, it might have contributed to a slight disability of the patient. At last angiographic follow-up, 12/15 aneurysms (80%) were completely occluded and 3/15 (20%) had a neck remnant. CONCLUSIONS: The preliminary results indicate that WEB treatment of proximal PICA aneurysms is feasible with a reasonable safety and efficacy profile. The advantages of intrasaccular flow disruption include preservation of the PICA, durable aneurysm occlusion, and omission of antiplatelet therapy. The low-profile WEB 17 delivery system might enable navigation to distal PICA aneurysms, which needs to be addressed further.

Automated Color-Coding of Lesion Changes in Contrast-Enhanced 3D T1-Weighted Sequences for MRI Follow-up of Brain Metastases.

BACKGROUND AND PURPOSE: MR imaging is the technique of choice for follow-up of patients with brain metastases, yet the radiologic assessment is often tedious and error-prone, especially in examinations with multiple metastases or subtle changes. This study aimed to determine whether using automated color-coding improves the radiologic assessment of brain metastases compared with conventional reading. MATERIALS AND METHODS: One hundred twenty-one pairs of follow-up examinations of patients with brain metastases were assessed. Two radiologists determined the presence of progression, regression, mixed changes, or stable disease between the follow-up examinations and indicated subjective diagnostic certainty regarding their decisions in a conventional reading and a second reading using automated color-coding after an interval of 8 weeks. RESULTS: The rate of correctly classified diagnoses was higher (91.3%, 221/242, versus 74.0%, 179/242, P < .01) when using automated color-coding, and the median Likert score for diagnostic certainty improved from 2 (interquartile range, 2-3) to 4 (interquartile range, 3-5) (P < .05) compared with the conventional reading. Interrater agreement was excellent (κ = 0.80; 95% CI, 0.71-0.89) with automated color-coding compared with a moderate agreement (κ = 0.46; 95% CI, 0.34-0.58) with the conventional reading approach. When considering the time required for image preprocessing, the overall average time for reading an examination was longer in the automated color-coding approach (91.5 [SD, 23.1] seconds versus 79.4 [SD, 34.7 ] seconds, P < .001). CONCLUSIONS: Compared with the conventional reading, automated color-coding of lesion changes in follow-up examinations of patients with brain metastases significantly increased the rate of correct diagnoses and resulted in higher diagnostic certainty.

True first-pass effect in basilar artery occlusions: First-pass complete reperfusion improves clinical outcome in stroke thrombectomy patients.

BACKGROUND: Complete reperfusion (mTICI 3) in anterior circulation ischemic stroke patients after a single mechanical thrombectomy (MT) pass has been identified as a predictor of favorable outcome (modified Rankin Score 0-2) and defined as true first-pass effect recently. This effect has not yet been demonstrated in posterior circulation ischemic stroke. We hypothesized a true first-pass effect for the subgroup of acute basilar artery occlusions (BAO). METHODS: Consecutive patients with acute thromboembolic occlusions in the posterior circulation, treated between 2010 and 2017, were screened and all BAO patients with complete angiographic reperfusion and known symptom onset included for unmatched and matched analysis after adjustment for multiple confounding factors (demographics, time intervals, stroke severity, posterior circulation Alberta Stroke Program early computed tomography Score and comorbidity. The primary objective was outcome at 90 days between matched cohorts of single pass vs. multi pass complete reperfusion patients. RESULTS: 90 MTs in BAO were analyzed, yielding 56 patients with known symptom onset, in whom we achieved complete reperfusion (mTICI 3), depending on whether complete reperfusion was achieved after a single pass (n = 28) or multiple passes (n = 28). Multivariable analysis of 56 non-matched patients revealed a significant association between first-pass complete reperfusion and favorable outcome (p < 0.01). In matched cohorts (n = 7 vs. n = 7), favorable outcome was only seen if complete reperfusion was achieved after a single pass (86% vs. 0%). CONCLUSION: Single pass complete reperfusion in acute basilar artery occlusion is an independent predictor of favorable outcome. Achieving complete reperfusion after multiple passes might impair favorable patient recovery.

Postinterventional Assessment after Stent and Flow-Diverter Implantation Using CT: Influence of Spectral Image Reconstructions and Different Device Types.

BACKGROUND AND PURPOSE: CTA provides a noninvasive alternative technique to DSA in the follow-up after endovascular aneurysm treatment to evaluate aneurysm occlusion and exclude intraluminal narrowing after stent or flow-diverter implantation; however, assessability may be impeded by stent material artifacts. The objective of this in vitro study was to compare the visual assessability of different conventional stents and flow diverters as well as different reconstructions of dual-layer CT images. MATERIALS AND METHODS: Four conventional intracranial stents and 4 flow diverters were implanted in identical aneurysm phantoms. Conventional and monoenergetic images (40, 50, 60, 90, 120, 180 keV) were acquired to evaluate attenuation alteration, visible lumen diameter, and SNR. Image quality was rated subjectively by 2 independent radiologists using a 4-point Likert scale. RESULTS: Low kiloelectron volt (40-60 keV) monoenergetic reconstructions showed an improved SNR and an improved lumen density ratio compared with high kiloelectron volt reconstructions (90-180 keV) and conventional reconstructions, however without reaching significance compared with the latter. Assessment of the adjacent aneurysm and subjective evaluation was not affected by the imaging technique and stent type. Artifact susceptibility varied with the device used and increased among flow diverters. CONCLUSIONS: Low kiloelectron volt reconstructions improved the assessment of the stent lumen in comparison with high kiloelectron volt reconstructions. No significant improvement in image quality could be shown compared with conventional images. For some devices, iodine-specific reconstructions led to severe artifacts and are therefore not recommended. There was no relevant improvement in the assessability of the adjacent aneurysm.

[Brain metastases-Interdisciplinary approach towards a personalized treatment]. / Hirnmetastasen ­ interdisziplinär zu einer personalisierten Behandlung.

The incidence, treatment and prognosis of patients with brain metastases have substantially changed during the last decades. While the survival time after diagnosis of cerebral metastases was on average a maximum of 3-6 months only 10 years ago, the survival time could be significantly improved due to novel surgical, radiotherapeutic and systemic treatment modalities. Only a few years ago, the occurrence of brain metastases led to a withdrawal from systemic oncological treatment and the exclusion of drug therapy studies and to a purely palliatively oriented treatment in the sense of whole brain radiation therapy (WBRT) with or without surgery. The increasing availability of targeted and immunomodulatory drugs as well as adapted radio-oncological procedures enable increasingly more personalized treatment approaches. The aim of this review article is to demonstrate the progress and complexity of the treatment of brain metastases in the context of modern comprehensive interdisciplinary concepts.

Mortality after mechanical thrombectomy in anterior circulation stroke may be higher at nighttime and on weekends.

OBJECTIVES: The objective of this study was to compare clinical outcome and procedural differences of mechanical thrombectomy (MT) during on-call with regular operating hours. We particularly focused on dosimetric data which may serve as potential surrogates for patient outcome. METHODS: A total of 246 consecutive patients who underwent MT in acute anterior circulation stroke between November 2017 and March 2020 were retrospectively included. Patients treated (1) during standard operational hours (n = 102), (2) daytime on-call duty (n = 38) and (3) nighttime on-call duty (n = 106) were compared with respect to their pre-interventional status, procedural specifics, including dosimetrics (dose area product (DAP), fluoroscopy time and procedural time), and outcome. RESULTS: The collectives treated outside the regular operational hours showed an increased in-hospital mortality (standard operational hours 7% (7/102), daytime on-call duty 16% (6/38), nighttime on-call duty 20% (21/106), p = 0.02). Neither the dosimetric parameters nor baseline characteristics other procedural specifics and outcome parameters differed significantly between groups (p > 0.05 each). In most cases (> 90%), a successful reperfusion was achieved (TICI ≥ 2b). CONCLUSIONS: We found an increased in-hospital mortality in patients admitted at night and during weekends which was not explained by technical aspects of MT. KEY POINTS: • There is an increased mortality of stroke patients admitted at night and on weekends. • This is not explained by technical aspects of mechanical thrombectomy. • There were no statistical differences in the comparison of parameters linked to the radiation exposure, such as DAP, fluoroscopy time and procedure time.

Comparative analysis of CGUARD embolic prevention stent with Casper-RX and Wallstent for the treatment of carotid artery stenosis.

Stent protected Angioplasty of extracranial carotid artery stenosis using the dual-layered CGUARD stent is a novel treatment option. In this study we evaluate the feasibility and the safety of the CGUARD in symptomatic and asymptomatic patients in comparison to Casper-RX and Wallstent. This is a multi-center study of consecutive patients treated with the CGUARD, Casper-RX and Wallstent at two German high volume neurovascular centers between April 2017 and May 2018. Patient characteristics, neuroimaging data and angiographic outcome were retrospectively analyzed. The primary end points of the study were acute occlusion of the carotid stent and symptomatic intracerebral hemorrhage (sICH). Carotid artery stenting was performed in 76 patients; of those 26 (34%) were treated with the CGUARD, 25 (33%) with Casper-RX, and 25 (33%) with Wallstent. In 58/76 (76%) cases carotid artery stenosis was symptomatic with a median baseline National Institutes of Health Stroke Scale of 4. Angioplasty and stenting as part of a mechanical thrombectomy for acute ischemic stroke was performed in 25/76 (33%) patients. Baseline patient characteristics were similar between the treatment groups, except for a higher portion of scheduled cases in the Casper-RX group. There were no significant differences in the rate of acute in stent occlusions (CGUARD, 2/26 (8%); Casper-RX, 1/25(4%); Wallstent, 1/25 (4%)) and postinterventional sICH (1/26 (4%), 0/25(0%), 0/25 (0%)). Clinical outcome at discharge did not differ between groups. Treatment of carotid artery stenosis using CGUARD is feasible with a good safety profile comparable to that of Casper-RX and Wallstent.

Low-Profile Intra-Aneurysmal Flow Disruptor WEB 17 versus WEB Predecessor Systems for Treatment of Small Intracranial Aneurysms: Comparative Analysis of Procedural Safety and Feasibility.

BACKGROUND AND PURPOSE: The Woven EndoBridge 17 has recently been introduced to the market for facilitated endovascular treatment of small bifurcation aneurysms (≤7 mm) with low-profile microcatheters. We compared the Woven EndoBridge 17 with its predecessor versions in terms of procedural safety and feasibility. MATERIALS AND METHODS: This was a multicenter review of aneurysms ranging from 3 to 7 mm treated with the Woven EndoBridge between 2011 and 2019. Aneurysm characteristics, procedural parameters, and complications were retrospectively compared between treatment with the Woven EndoBridge 17 and a control group that was treated with its predecessor versions, using inverse probability of treatment weighting. RESULTS: Thirty-eight aneurysms treated with a Woven EndoBridge 17 (mean size, 4.9 ± 1.5 mm) and 70 treated with a predecessor version of the Woven EndoBridge 17 (mean size, 5.6 ± 1.4 mm) were included. The predecessor version of the Woven EndoBridge 17 had a higher failure rate (10.3%) than the Woven EndoBridge 17 (0%, P = .05). Additional stent placement was performed more often with the predecessor version of the Woven EndoBridge 17 (10.0%) than with the Woven EndoBridge 17 (2.6%, adjusted P = .005). The predecessor version of the Woven EndoBridge 17 was associated with a higher thromboembolic event rate (14.3%) than the Woven EndoBridge 17 (5.3%, adjusted P = .002). Neurologic complications (Woven EndoBridge 17: 2.6%; predecessor version of the Woven EndoBridge 17: 2.9%, adjusted P = 1.0) and immediate complete aneurysm occlusion rates (Woven EndoBridge 17: 57.9%; predecessor version of the Woven EndoBridge 17: 54.3%, adjusted P = .21) did not differ significantly between groups. CONCLUSIONS: In the current study, the Woven EndoBridge 17 was associated with a potentially lower thromboembolic event rate than the predecessor version of the Woven EndoBridge 17, without compromising the immediate aneurysm occlusion rate. Long-term clinical and angiographic outcome analysis will be necessary to draw a definite conclusion.

Visualization and Classification of Deeply Seated Collateral Networks in Moyamoya Angiopathy with 7T MRI.

BACKGROUND AND PURPOSE: Collateral networks in Moyamoya angiopathy have a complex angioarchitecture difficult to comprehend on conventional examinations. This study aimed to evaluate morphologic patterns and the delineation of deeply seated collateral networks using ultra-high-field MRA in comparison with conventional DSA. MATERIALS AND METHODS: Fifteen white patients with Moyamoya angiopathy were investigated in this prospective trial. Sequences acquired at 7T were TOF-MRA with 0.22 × 0.22 × 0.41 mm3 resolution and MPRAGE with 0.7 × 0.7 × 0.7 mm3 resolution. Four raters evaluated the presence of deeply seated collateral networks and image quality in a consensus reading of DSA, TOF-MRA, and MPRAGE using a 5-point scale in axial source images and maximum intensity projections. Delineation of deeply seated collateral networks by different imaging modalities was compared by means of the McNemar test, whereas image quality was compared using the Wilcoxon signed-rank test. RESULTS: The relevant deeply seated collateral networks were classified into 2 categories and 6 pathways. A total of 100 collateral networks were detected on DSA; 106, on TOF-MRA; and 73, on MPRAGE. Delineation of deeply seated collateral networks was comparable between TOF-MRA and DSA (P = .25); however, both were better than MPRAGE (P < .001). CONCLUSIONS: This study demonstrates excellent delineation of 6 distinct deeply seated collateral network pathways in Moyamoya angiopathy in white adults using 7T TOF-MRA, comparable to DSA.

11C-MET PET/MRI for detection of recurrent glioma.

INTRODUCTION: Radiological assessment of brain tumors is widely based on the Radiology Assessment of Neuro-Oncology (RANO) criteria that consider non-specific T1 and T2 weighted images. Limitation of the RANO criteria is that they do not include metabolic imaging techniques that have been reported to be helpful to differentiate treatment related changes from true tumor progression. In the current study, we assessed if the combined use of MRI and PET with hybrid 11C-MET PET/MRI can improve diagnostic accuracy and diagnostic confidence of the readers to differentiate treatment related changes from true progression in recurrent glioma. METHODS: Fifty consecutive patients with histopathologically proven glioma were prospectively enrolled for a hybrid 11C-MET PET/MRI to differentiate recurrent glioma from treatment induced changes. Sole MRI data were analyzed based on RANO. Sole PET data and in a third evaluation hybrid 11C-MET-PET/MRI data were assessed for metabolic respectively metabolic and morphologic glioma recurrence. Diagnostic performance and diagnostic confidence of the reader were calculated for the different modalities, and the McNemar test and Mann-Whitney U Test were applied for statistical analysis. RESULTS: Hybrid 11C-MET PET/MRI was successfully performed in all 50 patients. Glioma recurrence was diagnosed in 35 of the 50 patients (70%). Sensitivity and specificity were calculated for MRI (86.11% and 71.43%), for 11C-MET PET (96.77% and 73.68%), and for hybrid 11C-MET-PET/MRI (97.14% and 93.33%). For diagnostic accuracy hybrid 11C-MET-PET/MRI (96%) showed significantly higher values than MRI alone (82%), whereas no significant difference was found for 11C-MET PET (88%). Furthermore, by rating on a five-point Likert scale significantly higher scores were found for diagnostic confidence when comparing 11C-MET PET/MRI (4.26 ± 0,777) to either PET alone (3.44 ± 0.705) or MRI alone (3.56 ± 0.733). CONCLUSION: This feasibility study showed that hybrid PET/MRI might strengthen RANO classification by adding metabolic information to conventional MRI information. Future studies should evaluate the clinical utility of the combined use of 11C-MET PET/MRI in larger patient cohorts.

Electrophysiological detection of scalar changing perimodiolar cochlear electrode arrays: a long term follow-up study.

The position of the cochlear electrode array within the scala tympani is essential for an optimal hearing benefit. An intraoperative NRT-ratio was established, which can provide information about the intraoperative intracochlear electrode array position for perimodiolar electrodes. The aims of this study were to verify the longterm reliability for the NRT-ratio in perimodiolar electrodes. In a retrospective controlled study in a Tertiary Referral Center the electrophysiological data sets of 123 patients with implanted Nucleus Contour Advance electrodes were enclosed. Intraoperative and up to 1 year follow-up Auto-NRTs were evaluated. A NRT-ratio was calculated by dividing the average Auto-NRT data from electrode 16 to 18 with the average from electrode 5 to 7. Using a flat panel tomography system, the position of the electrode array was certified radiological. 31 patients with perimodiolar electrodes with 1 year follow-up data were included in the study. Eleven patients showed regular follow-up NRT-ratio with a correlated and radiologically confirmed electrode position. 20 patients showed mismatches between the NRT-ratio and the radiological position. These patients were highly variable in terms of duration of deafness and neural spectrum disorders. The NRT-ratio can be used to determine the intracochlear position of the electrode array for perimodiolar electrodes. Intraoperatively the NRT-ratio predicts the array position within the cochlea highly reliable for perimodiolar electrodes. We showed that after 6 months and a year, the NRT-ratio remains unchanged in most of the cases and shows a good correlation to the radiological determined position of the array. Nevertheless, the condition of the neural structures is highly important for reproducible responses. Limited validity is given in patients with degenerative and structural neural disorders.

Ventricular Microaneurysms in Moyamoya Angiopathy Visualized with 7T MR Angiography.

The pathophysiologic role of hemodynamic alteration to peripheral vessels in Moyamoya angiopathy and the formation of microaneurysms remains unclear. The purpose of this study was to investigate microaneurysms in collateral Moyamoya vessels by using 7T ultra-high-field MR imaging. Ten patients with Moyamoya disease were evaluated with TOF-MRA at 7T acquired with 0.22 × 0.22 × 0.41 mm(3) resolution. In 10 patients, 4 microaneuryms located in the ventricles were delineated. The mean diameters of collateral vessels and microaneurysms arising from those vessels were 0.87 mm (range, 0.79-1.07 mm) and 0.80 mm (range, 0.56-0.96 mm), respectively. In 1 case with follow-up scans 6 months after a direct extracranial-intracranial bypass operation, the microaneurysm disappeared. Ventricular microaneurysms in Moyamoya angiopathy collateral vessels, inaccessible by conventional imaging techniques, can be detected by 7T TOF-MRA.

Comparison of clinical, electrophysiological, sonographic and MRI features in CIDP.

INTRODUCTION: We investigated the applicability of nerve ultrasound and magnetic resonance imaging (MRI) in chronic inflammatory demyelinating polyneuropathy (CIDP). METHODS: We systematically examined several nerves with ultrasound and the lumbar roots and tibial nerve in the popliteal fossa of nine CIDP patients with MRI additionally to the nerve conduction studies. RESULTS: Patients with overall disability sum score (ODSS) 2-3 were characterised by normal fascicular structure in MRI and ultrasound. Patients with higher ODSS showed isolated enlarged fascicles and increased cross sectional area (CSA) of the peripheral nerves and of the diameter of the cauda equina and L5 root, whereas two of them showed atrophic fascicles in both imaging techniques. CONCLUSIONS: Nerve ultrasound and MRI findings show the same morphological fascicle alterations in peripheral nerves in correlation to ODSS. Nerve ultrasound as an affordable tool, easy and quick to perform, could replace MRI in daily routine for monitoring peripheral nerve morphology.

[Intraocular Tumors other than Retinoblastoma in Children]. / Intraokulare Raumforderungen im Kindesalter ohne Retinoblastom.

The diagnosis of an intraocular mass in children can be challenging as invasive procedures are not allowed, in particular if a retinoblastoma may be present. In eyes with a unilateral tumour mass and loss of function enucleation with subsequent histopathological processing might be the only option to establish a diagnosis and to exclude a malignant tumour. The present paper deals with intraocular tumours other than retinoblastoma in children, with a special focus on the correlation of modern imaging techniques and histopathological findings.

Neural circuitry of abdominal pain-related fear learning and reinstatement in irritable bowel syndrome.

BACKGROUND: Altered pain anticipation likely contributes to disturbed central pain processing in chronic pain conditions like irritable bowel syndrome (IBS), but the learning processes shaping the expectation of pain remain poorly understood. We assessed the neural circuitry mediating the formation, extinction, and reactivation of abdominal pain-related memories in IBS patients compared to healthy controls (HC) in a differential fear conditioning paradigm. METHODS: During fear acquisition, predictive visual cues (CS(+)) were paired with rectal distensions (US), while control cues (CS(-)) were presented unpaired. During extinction, only CSs were presented. Subsequently, memory reactivation was assessed with a reinstatement procedure involving unexpected USs. Using functional magnetic resonance imaging, group differences in neural activation to CS(+) vs CS(-) were analyzed, along with skin conductance responses (SCR), CS valence, CS-US contingency, state anxiety, salivary cortisol, and alpha-amylase activity. The contribution of anxiety symptoms was addressed in covariance analyses. KEY RESULTS: Fear acquisition was altered in IBS, as indicated by more accurate contingency awareness, greater CS-related valence change, and enhanced CS(+)-induced differential activation of prefrontal cortex and amygdala. IBS patients further revealed enhanced differential cingulate activation during extinction and greater differential hippocampal activation during reinstatement. Anxiety affected neural responses during memory formation and reinstatement. CONCLUSIONS & INFERENCES: Abdominal pain-related fear learning and memory processes are altered in IBS, mediated by amygdala, cingulate cortex, prefrontal areas, and hippocampus. Enhanced reinstatement may contribute to hypervigilance and central pain amplification, especially in anxious patients. Preventing a 'relapse' of learned fear utilizing extinction-based interventions may be a promising treatment goal in IBS.

Posterior Reversible Encephalopathy Syndrome: The Spectrum of MR Imaging Patterns.

AIM: The aim of this study was to describe lesion patterns, distribution, and evolution in posterior reversible encephalopathy syndrome (PRES) in a larger single-center population. METHODS: Scans and follow-up, if available, of 50 patients with PRES between 2002 and 2011 were reviewed retrospectively. Lesion patterns, extent, and signal intensity changes were identified and graded on fluid-attenuated inversion recovery (FLAIR) and diffusion-weighted images. Hemorrhagic changes were identified on T2* or susceptibility-weighted images, and gadolinium enhancement on T1-weighted images was identified if available. RESULTS: The most frequently affected regions on FLAIR were the frontal lobes in 54 %, occipital lobes in 34.3 %, and parietal lobes in 31.0 % of cases, thus 65.3 % in the posterior regions. Temporal lobes were affected in 10.6 %, the cerebellum in 6.5 %, and basal ganglia in 1.6 %. Division into vascular supply showed involvement in the anterior circulation in 66.5 % and in the posterior circulation in 33.5 % of cases. On diffusion-weighted imaging (DWI), vasogenic edema was observed in 6.9 %, cytotoxic edema in 9.1 %, and both in 2 % of cases. In 31.9 %, there was shine through, and in 15.9 %, there was shine through as well as cytotoxic or vasogenic edema. Topologic distribution on DWI showed affection of the frontal lobes in 43.5 %, occipital lobes in 25.8 %, parietal lobes in 17.7 %, temporal lobes in 11.3 %, and cerebellum in 1.6 %. T2* or susceptibility-weighted images showed spot-like hemosiderin accumulation in 17.2 % of cases. In 23.1 %, enhancement was seen. Follow-up magnetic resonance imaging showed complete resolution in 66.6 % of patients. CONCLUSION: The spectrum of imaging findings in PRES is wide. Almost always subcortical and cortical structures are involved. Although posterior changes are prominent in this syndrome, frontal involvement is more frequent than posterior on FLAIR imaging and DWI. On DWI, mixed patterns are not uncommon. Reversibility generally takes place independent of DWI pathology. Hypertension was not a prognostic factor.

Benefit of second catheter angiography in patients with nontraumatic subarachnoidal hemorrhage.

PURPOSE: This study aimed to determine the yield of repetitive catheter angiography (digital subtraction angiography (DSA)) for the detection of causative vascular lesions in patients with nontraumatic subarachnoidal hemorrhage (SAH) and negative initial DSA. We hypothesize that a second DSA might be helpful to detect an initially occult bleeding source. METHODS: We retrospectively evaluated 649 patients with acute SAH and invasive catheter angiographies between 2004 and 2012. In 90 SAH patients initial imaging was negative concerning a causative bleeding source. A total of 113 repetitive DSA were performed. Two neuroradiologists reanalyzed the initial imaging and the result of the reangiography independently. RESULTS: In 4/90 patients (4.5 %) bleeding source was first detected in the second or third DSA. In all other patients, no causative vascular lesion was found. Reasons for the initially false negative diagnostics were one dissecting aneurysm and thrombosis of three aneurysms within the acute phase of SAH. CONCLUSIONS: Repetitive DSA revealed the cause of SAH in 4.5 % of the cases. These findings have a therapeutic and prognostic impact. We think that at least a second DSA should be part of diagnostic work-up in patients with SAH and missing bleeding source, even considering the risk of an additional invasive angiography itself.