Moderne Mehrzeilen-CT-Scanner bieten die Möglichkeit einer multimodalen CT-Bildgebung mit einer nativen CT, einer CT-Angiografie und einer CT-Perfusion. Die Perfusions-CT kann routinemäßig eingesetzt werden, wenn das Scan-Protokoll zur Reduktion der Strahlendosis optimiert wird. Sie erhöht die Detektionsrate ischämischer Schlaganfälle im Vergleich zur Nativ-CT ± CT-Angiografie, insbesondere bei kortikalen, peripheren Ischämien, und erlaubt eine Abschätzung der Kollateralsituation bei akutem Gefäßverschluss. Die Perfusions-CT erhöht die diagnostische und therapeutische Sicherheit in der Akutsituation und erlaubt ähnlich wie die Schlaganfall-MRT die Definition von Risikogewebe nach dem Mismatch-Konzept.

In this pediatric case of vanishing white matter disease with early onset, rapidly progressive course, and fatal outcome, the white matter vanishing process in patient was for the first time documented morphologically in detail: An initial magnetic resonance imaging documented a normal appearing brain maturation. Rapid progressive brain lesions initiated morphologically DE NOVO in the former well myelinated deep white matter were observed six months later after disease onset, including concentric ongoing signs of restricted proton diffusion cytotoxic edema on diffusion weighted imaging. Cyst-like defects at the lesion center of the deep white matter were detected more clearly on MRI ten months later. A pathomechanism like tumor necrosis factor induced oligodendrocyte apoptosis and primary demyelination was postulated. The case demonstrates that in the presence of clinically progressive symptoms, the development of VWM is possible even if first MRI findings are negative.

Aims: Carotid artery stenting (CAS) may be associated with clinically silent cerebral embolic events. We prospectively evaluated the association of the sonographic echogenicity of carotid artery plaque with solid cerebral microembolism during CAS.

BACKGROUND AND PURPOSE:Carotid artery stent placement (CAS) may be associated with clinically silent cerebral lesions. We prospectively evaluated the association of the number of solid cerebral microemboli during unprotected CAS with the frequency of silent cerebral lesions as detected by diffusion-weighted MR imaging (DWI).METHODS:We performed multifrequency transcranial Doppler detection of solid microemboli in the ipsilateral middle cerebral artery (MCA) during CAS in 27 consecutive patients with symptomatic high-grade carotid stenoses. No embolus protection was used in any of the cases. DWI before and 24 +/- 2 hours after CAS was used to detect new ischemic lesions.RESULTS:We detected 484 solid microemboli in 17 patients (63%). On MR imaging 24 +/- 2 hours after CAS, 6 patients (22%) had developed 13 new clinically silent DWI lesions within the ipsilateral MCA territory. In patients with Doppler evidence of solid emboli during CAS, the incidence of new DWI lesions was higher (29%) than in patients without Doppler evidence of solid emboli during the procedure (10%); this difference was not statistically significant (P = .25). The number of solid microemboli during CAS in patients with new ipsilateral DWI lesions was not significantly different from that in patients without new ipsilateral DWI lesions.CONCLUSIONS:Solid microembolism is a common event during unprotected CAS; however, the frequency of procedure-related silent cerebral lesions appears to be independent of the number of solid cerebral microemboli during the procedure.

MR imaging in a 73-year-old man presenting with hemispheric stroke revealed a subcortical diffusion-weighted imaging lesion associated with a high-grade stenosis of the proximal internal carotid artery, which suggested hemodynamic infarction. Collateral supply was absent. After failure of conservative therapy, successful unprotected carotid artery stent placement (CAS) was performed followed by a complete neurologic recovery. Emergency CAS should be considered in acute stroke patients with severe hemodynamic impairment if conservative treatment options are not successful.

BACKGOUND AND PURPOSE: Stent-protected carotid angioplasty (SPAC) is an option for treating cervical symptomatic high-grade internal carotid artery (ICA) stenosis. So far, knowledge about hemodynamic changes in the early postinterventional phase is limited. The purpose of this study was to evaluate these changes.METHODS: Thirty-four consecutive patients with a high-grade ICA stenosis (according to European Carotid Surgery Trial criteria) and 10 healthy volunteers were enrolled. Hemodynamics of the cerebral circulation were assessed before and within 6 hours after SPAC. ICA flow volume, cerebral blood volume flow (CBVF), and collateral flow volume were sonographically assessed. The ratio of flow velocities in the middle cerebral artery (MCA) ipsilateral to the ICA stenosis was calculated and compared with that in the contralateral MCA. This ratio was designated rMCA.RESULTS: Preinterventional CBVF, ICA flow volume, and rMCA were significantly reduced compared with results in healthy volunteers. After SPAC, CBVF, ICA flow volume, and rMCA increased significantly. The rMCA did not exceed 1.0. Collateral flow volume decreased in patients with posterior collateral flow only. Postinterventional CBVF and ICA flow volume in patients did not differ from values in healthy volunteers.CONCLUSION: Cerebral hemodynamics appear to be impaired in patients with symptomatic high-grade ICA stenosis. After SPAC, hemodynamic parameters normalize within 6 hours. We did not detect hyperperfusion. However, flow volume in the contralateral ICA remains increased in patients with former anterior cross-filling.

We tested the hypothesis that the type of vascular occlusion, recanalisation and collateralisation are predictive of outcome after thrombolytic therapy in acute ischaemic stroke. We carried out angiography and local intra-arterial (97) or systemic (14) thrombolysis within 6 h of the onset in patients with an ischaemic stroke in the territory of the internal carotid artery. Early ischaemic signs (EIS) on pretreatment CT and angiographic findings were classified and analysed in relation to clinical outcome at 3 months. A favourable outcome (Barthel index [BI]≥ 90) was found in 40% of patients with an occlusion of the middle cerebral artery trunk whereas intracranial occlusion of the internal carotid artery ("carotid T occlusion") was followed by death or severe disability (BI<50) in 87%. Significant univariate predictors of favourable outcome were occlusion type (P<0.01), recanalisation (P<0.01) and collateralisation (P<0.01). However, multivariate analysis revealed a significant relationship only between collateralisation and favourable outcome (odds ratio 5.9, 95% confidence interval 1.3–26.7, P=0.02). EIS were not predictive in either case. Occlusion type and recanalisation, are related to outcome only if adequate collateralisation prevents infarction until recanalisation occurs.

Background: To evaluate the effect of occlusion type and fibrinolytic agent on recanalization success and clinical outcome in patients undergoing local intra-arterial fibrinolysis (LIF) in acute hemispheric stroke. Methods: LIF was performed in 137 patients with angiographically established occlusion in the carotid circulation within 6 h of stroke onset. Retrospective analysis included recanalization success, recanalization time, type of occlusion and fibrinolytic treatment mode. Five types of occlusion were categorized: intracranial bifurcation (carotid ‘T’) of the internal carotid artery (ICA; n = 35); proximal segment of the middle cerebral artery (MCA; n = 66); distal segment of the MCA (n = 20); extracranial ICA with MCA embolism (n = 8); multiple peripheral branches of the anterior cerebral artery and the MCA (n = 8). Neurologic outcome was evaluated after 3 months by Barthel Index (BI) as good (BI >90), moderate (BI 50–90), poor (BI <50) or death. Results: Recanalization was achieved in 74 patients (54%). Mean recanalization time in recanalized patients was 91 min. Neurologic outcome was good in 48 patients (35%), moderate in 34 (25%), poor in 30 (22%) and 25 died (18%). Outcome was significantly better in recanalized than in nonrecanalized patients (p < 0.001). Treatment results were significantly better in proximal and distal MCA occlusion than in carotid ‘T’ occlusions (p < 0.001). Recanalization success hardly differed between urokinase and rt-PA. Combined treatment with rt-PA and lys-plasminogen tended toward a faster recanalization. Parenchymal hemorrhage occurred in 13 patients (9%). Conclusion: The type of occlusion is of high prognostic value for successful fibrinolysis in the anterior circulation. However, recanalization is a time-consuming process even with an intra-arterial approach. Recanalization did not differ between type or dosage of plasminogen activators. Further innovative attempts are warranted towards hastening recanalization time in endovascular acute stroke treatment.

BACKGROUND AND PURPOSE:Previous acute stroke studies found diffusion-weighted (DW) imaging superior to CT for detection of early ischemic signs (EIS). However, these findings were confounded by a large time interval in favor of DW imaging. We compared DW images and CT scans obtained with a short time delay in patients with acute stroke to define the sensitivity and interrater agreement of both imaging techniques. METHODS:CT scans and DW images were obtained within 6 hours of symptom onset in 46 patients with acute stroke. Three neuroradiologists and three neurologists reviewed the images for EIS in five regions of the middle cerebral artery (MCA) territory and estimated the extent of EIS (< or > one-third of the MCA territory). RESULTS:The mean delay between imaging with both modalities was 24.5 minutes (range, 10-41 minutes). Forty-five of 46 patients had an ischemic stroke. EIS were seen on 33 of 45 CT scans (73% sensitivity; 95% confidence interval [CI]: 58-85%) and on 42 of 45 DW images (93% sensitivity; 94% CI: 82-99%). Interrater agreement was moderate (kappa = 0.57) for CT and excellent (kappa = 0.85) for DW imaging. CT studies had a moderate interrater agreement for estimation of EIS greater than one-third of the MCA territory (kappa = 0.40), whereas DW imaging showed good results (kappa = 0.68). Sensitivity for detection of greater than one-third of the MCA territory was equally poor (57%, 95% CI: 29-82%) for both CT and DW imaging. CONCLUSION:DW imaging helped identify EIS with higher sensitivity than that of CT. The interrater variability of the one-third rule was high for CT, and thus the clinical applicability of CT is limited. Our results support the application of stroke MR imaging for the treatment of patients with acute stroke.

PURPOSEPresentation of the clinical and radiological findings in spinal dural arteriovenous fistulas (SDAVF) based on the experience in 54 patients.MATERIAL AND METHODSEvaluation of patients' records and myelography (n = 23), MRI (n = 54) as well as conventional angiography (n = 54) with respect to history, symptoms, clinical and radiological results.RESULTSClinically, a long history (mean 20 months) with progressive ascending paresis (100 %), sensory deficits (93 %) and loss of control over bladder and bowel function (89 %) in male patients (78 %) of advanced age (mean 60 years) indicates the disease. Typical signs in MRI are central cord hyperintensity (100 %) with slight medullary distension (74 %), contrast enhancement (79 %) and distended perimedullary veins (89 %), the latter being disclosed by myelography in 78 % of cases. For diagnosis spinal angiography is necessary which most often shows a thoracic location of the fistula (69 %), more than one feeding artery (67 %) and caudal as well as rostral venous drainage (63 %).CONCLUSIONMRI is superior to myelography to detect diagnostic signs of SDAVF in patients with typical clinical presentation. For definitive diagnosis spinal angiography is still indispensable.

BACKGROUND AND PURPOSE:We prospectively studied the incidence and natural history of Horner syndrome following stent-supported percutaneous angioplasty of the carotid artery (SPAC). We assessed the hypothesis that postinterventional Horner syndrome is related to ipsilateral carotid wall hematoma.METHODS:We performed duplex sonography of the carotid arteries and clinical examination in 28 consecutive patients before and 4 hours +/- 2, 24 hours +/- 2, and 7 days +/- 1 after SPAC.RESULTS:Within 24 hours +/- 2 after SPAC, 11 of the 28 patients developed ipsilateral Horner syndrome. Ten of these 11 patients had a postinterventional sonographic appearance of a carotid wall hematoma, whereas only two of the 17 patients without Horner syndrome had this finding (P <.001). In all patients, both Horner syndrome and carotid wall hematoma had resolved 7 days +/- 1 after SPAC.CONCLUSION:Horner syndrome appears to be a common yet transient event after SPAC. Although postinterventional Horner syndrome is significantly related to ipsilateral carotid wall hematoma, causality of the procedure-related formation of a carotid wall hematoma and oculosympathetic disturbance remains unproven.

Endovascular treatment of ruptured vertebrobasilar artery aneurysms with Gugliemi detachable coils (GDC) has become an alternative to surgery. Mid-term angiographic follow-up can now be reported. Of 111 vertebrobasilar aneurysms in 110 patients we treated with GDC since 1992, 53 underwent angiography within 1 year and 59 after more than 18 months. We did not achieve complete occlusion on initial treatment of 23 aneurysms (21%). Complications were observed in 19 patients (17%), leading to permanent clinical disability in eight. Enlargement of the neck or reopening was seen in 12 (23%) of 53 aneurysms followed by angiography within 12 months. Documented recanalisation was treated in four (8%). Angiography was performed after 18-78 months in 59 patients, of whom nine, including three with initially incomplete occlusions, were retreated with GDC. Within the entire second observation period, three (5%) of the 59 patients had a further haemorrhage and were retreated with GDC. Rebleeding proved to be the only factor influencing the clinical outcome of retreated patients.

Background — Acute vertebrobasilar occlusion remains a disease with a high mortality even after treatment by local intra-arterial fibrinolysis. Adjunctive treatment with platelet glycoprotein IIb/IIIa receptor inhibitors such as abciximab may facilitate recanalization and improve the neurological outcome. Results after treatment of 3 patients by combined intravenous abciximab and local intra-arterial tissue plasminogen activator (tPA) are reported. Case Descriptions — Treatment was performed within 6 hours of stroke onset. Angiography revealed embolic occlusion of the basilar artery in 2 patients and atherothrombotic occlusion at the vertebrobasilar junction in 1 patient. Therapy consisted of intravenous abciximab bolus administration (0.25 mg/kg) followed by 12-hour infusion therapy (0.125 μg/kg per minute) and local intra-arterial thrombolysis with tPA (10 mg/h). Heparin was only applied for catheter flushing (500 IU/h). The patient with the atherothrombotic occlusion was treated with additional percutaneous transluminal angioplasty and stenting. Complete recanalization of the basilar artery occurred in 2 patients, whose conditions improved clinically to functional independence. In the third patient only partial recanalization was seen, with only slight clinical improvement. This patient died of cardiac failure 2 months later. Besides a subtle subarachnoid hemorrhage (n=1), no intracranial or extracranial bleeding complication was observed. Conclusions — The combination of glycoprotein IIb/IIIa receptor inhibitor with local intra-arterial tPA might be a promising therapy for patients with acute vertebrobasilar occlusion. Further studies are necessary to define the clinical benefit and the bleeding rate of this new pharmacological approach.

PURPOSE:Technical essentials and therapeutic results of carotid stenting without cerebral protection are presented.MATERIALS AND METHODS:In 161 patients, 167 high grade carotid stenoses were stented, followed by percutaneous transluminal angioplasty, with subsequent evaluation of the clinical and angiographic results. Diffusion-weighted MRI was carried out in 108 patients to detect cerebral sequelae.RESULTS:Endovascular therapy was successful (residual stenosis < 25 %) in 166 stenoses (99.4 %). Twelve patients (7.5 %) had cerebrovascular complications within the 30-day perioperative period, seven of which occurred during the procedure. After treatment, diffusion-weighted MRI disclosed at least one new cerebral lesion in 40 patients (37 %), which were symptomatic in six patients.CONCLUSION:Even without cerebral protection, high grade carotid stenosis can be safely treated with stent-protected percutaneous angioplasty. Microemboli detected by postoperative MRI are infrequently symptomatic.

Background and Purpose— We sought to study the role of MRI-derived cerebral blood flow (CBF) measurements for the prediction of lesion development in acute stroke patients. Methods— Thirty-two patients were treated with tissue plasminogen activator. Diffusion-weighted (DWI) and perfusion-weighted MRI, T2-weighted imaging, and MR angiography were performed before treatment (2.8±0.9 hours after symptom onset) and on follow-up (days 1 and 7). CBF thresholds (12 and 22 mL/100 g per minute) were applied to bolus tracking MRI maps to determine predictive cutoff levels. Results— In 21 patients (group A), the terminal lesion volume (T2-weighted imaging) was larger than the initial DWI lesion volume (89±93 versus 21±38 mL). In 11 patients (group B), the terminal lesion volume was smaller than the initial DWI lesion volume (7±27 versus 15±29 mL). The initial DWI lesion volume did not differ between both groups. The presence of a tissue volume ≥50 mL with a CBF value ≤12 mL/100 g per minute was predictive for lesion enlargement to day 7 in T2-weighted imaging (positive predictive value, 0.80). Conclusions— The presence of a tissue volume ≥50 mL with a CBF value ≤12 mL/100 g per minute predicts further lesion growth in hyperacute stroke patients. MRI-derived CBF values, with all their present limitations, are valuable in early estimation of prognosis of stroke patients.

In view of the poor prognosis for patients with acute intracranial vertebrobasilar occlusion (VBO), factors were sought that predict survival and good neurologic outcome after acute endovascular treatment by means of local intra-arterial fibrinolysis (LIF) and percutaneous transluminal angioplasty (PTA). LIF was performed in 83 patients with angiographically established acute VBO. A significant residual stenosis after LIF was treated by additional PTA in 8 patients. The types of occlusion were classified as either embolic occlusion (EO) or atherothrombotic occlusion (AO). Outcome was evaluated after 3 months by the Barthel Index (BI) as favorable (BI >90), unfavorable (BI <90) or death and compared for each of 3 diagnostic or treatment variables: recanalization success, occlusion type and time to treatment. Four fibrinolytic treatment modes [urokinase, low-dose and high-dose recombinant tissue-type plasminogen activator (rt-PA), rt-PA + Lys-plasminogen] were also analyzed. The outcome was favorable in 19 patients (23%), unfavorable in 14 (17%) and 50 died (60%). Recanalization was successful in 54 patients (66%). The neurologic outcome was better in recanalized than in nonrecanalized patients (favorable outcome: 30 vs. 10%, mortality: 54 vs. 72%; p = 0.118). The neurologic outcome was better in EO than in AO (favorable outcome: 31 vs. 17%, mortality: 47 vs. 70%, p = 0.112). Under combined treatment by LIF and PTA in 8 patients with AO, 4 survived, 3 with a favorable outcome (38%). Early treatment onset (≤6 h) led to a significantly better neurologic outcome than delayed treatment onset (>6 h; favorable outcome: 36 vs. 7%, mortality: 52 vs. 70%, p = 0.005). Although no statistically significant differences were found between the types of fibrinolytic agents, treatment with rt-PA and Lys-plasminogen tended toward better results. Early treatment onset proved to be the most important factor for successful endovascular therapy in acute VBO, whereas recanalization and presence of an embolic occlusion also tended toward better results. Additional PTA may be a promising therapy in cases of significant residual stenosis after LIF.

Case Reports| August 14 2000 Cerebrocutaneous Xanthoma disseminatum and Disseminated Demyelinating Encephalomyelitis Subject Area: Neurology and Neuroscience G. Pfeiffer; G. Pfeiffer aDepartments of Neurology, Search for other works by this author on: This Site PubMed Google Scholar C. Hagel; C. Hagel bNeuropathology, Search for other works by this author on: This Site PubMed Google Scholar B. Eckert; B. Eckert cNeuroradiology, Search for other works by this author on: This Site PubMed Google Scholar R. Zschaber; R. Zschaber dHematology and Oncology and Search for other works by this author on: This Site PubMed Google Scholar G. Gross; G. Gross fDepartment of Dermatology, University Hospital Rostock, Germany Search for other works by this author on: This Site PubMed Google Scholar C.M. Bamberger C.M. Bamberger eMedicine, University Hospital Hamburg-Eppendorf, Hamburg, and Search for other works by this author on: This Site PubMed Google Scholar Eur Neurol (2000) 44 (2): 123–124. https://doi.org/10.1159/000008211 Article history Published Online: August 14 2000 Content Tools Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn Email Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation G. Pfeiffer, C. Hagel, B. Eckert, R. Zschaber, G. Gross, C.M. Bamberger; Cerebrocutaneous Xanthoma disseminatum and Disseminated Demyelinating Encephalomyelitis. Eur Neurol 1 August 2000; 44 (2): 123–124. https://doi.org/10.1159/000008211 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll JournalsEuropean Neurology Search Advanced Search Article PDF first page preview Close Modal This content is only available via PDF. 2000Copyright / Drug Dosage / DisclaimerCopyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements. You do not currently have access to this content.