Purpose Chronic pituitary dysfunction is increasingly recognized as a sequela of traumatic brain injury (TBI). Our aim was to rule out any late morphometric changes of the pituitary gland and hypothalamus in survivors of TBI during childhood requiring intensive care.Methods We assessed morphometric abnormalities of the sella region and hypothalamus in patients who sustained TBI during childhood. The patients showed no clinical hormonal dysfunction at the acute phase and pituitary hormone levels at the time of our study were within normal limits. From the 18 enrolled patients in the magnetic resonance study, five were removed due to morphological changes or anatomical variations. We studied the MRI of 13 male survivors (mean age 27 years, mean time after trauma 20 years) and compared them to 13 male control subjects who were matched in terms of age (mean age, 26 years), education and ethnicity. Analyses of the pituitary gland and sella on a midsagittal T2- and T1-weighted image were performed. We used voxel-based morphometry (VBM), an unbiased MRI morphometric method to investigate hypothalamic region in this group of patients.Results There was only a trend towards a reduced pituitary gland width in the patient group compared to controls. However, no significant morphological and morphometric abnormality was seen and VBM showed no hypothalamic grey matter loss. Conclusion In the absence of hormonal dysfunction, no persisting morphometric changes of the pituitary gland and hypothalamus were seen in survivors of childhood TBI requiring intensive care.

BACKGROUND AND PURPOSE: Endovascular placement of coronary balloon-expandable stents in patients with recurrent cerebral ischemia has emerged as a treatment option for intracranial arterial occlusive disease. We have developed an in vitro model matching the tortuous curve of the carotid siphon that allows the assessment of apposition of stents to a curved vessel wall.METHODS: Six types of balloon-expandable coronary stents were implanted in a silicone model of the carotid siphon. Digital radiographs and 3D rotational angiograms were obtained. Stent morphology was evaluated and the degree of apposition between stent and wall of the model was measured on a digital workstation.RESULTS: All 6 stents showed lack of apposition between stent and the wall at the convexity of the anterior segment of the carotid siphon and the wall at the concavity at both extremities of the stent. In and around the curve, the modules of the stents did not expand completely to their nominal diameter and were distorted to an oval shape.CONCLUSION: The tested coronary balloon-expandable stents did not completely conform to the vessel wall of the model of the carotid siphon and further development is needed to approach the goal of an "ideal intracranial stent."

Intracranial stenoses cause 5-10% of all strokes and are increasingly detected by means of modern imaging methods. The stroke danger of high-grade symptomatic stenoses is relatively high, with an annual risk of approximately 10% under medical treatment. Coumadin increases the risk of hemorrhage, and after risk/benefit considerations, antiplatelets should be preferred for antithrombotic therapy. Despite optimized medical treatment, a small group of patients with recurrent symptoms or symptomatic stenoses without adequate collateral supply probably carry higher spontaneous stroke risk and may be considered for intracranial stenting, which itself is associated with procedural risks of up to 10%. Currently published case series show relatively high complication rates as a major drawback of endovascular treatment, mainly strokes after occlusion of perforating branches extending from the stenotic vessel segment or hemorrhagic complications. According to data from smaller feasibility studies, stroke rates in follow-up after successful stenting seem to be low. The average rate of high-grade restenosis with possible indication for reintervention is 10%. Improvements in endovascular treatment aim at reducing vessel wall trauma during balloon angioplasty by underdilatation or the use of self-expanding stents. Until complication rates are dependably reduced to values of 5-6%, indication for endovascular treatment should be restricted to patients without therapeutic alternatives. According to limited data with large variation between different studies, a prospective multicentric registry is proposed for systematic evaluation and further development of the method.

BACKGROUND:Diagnosis of brainstem lesions in children based on magnetic resonance imaging alone is a challenging problem. Magnetic resonance spectroscopy (MRS) is a noninvasive technique for spatial characterization of biochemical markers in tissues and gives information regarding cell membrane proliferation, neuronal damage, and energy metabolism.METHODS:We measured the concentrations of biochemical markers in five children with brainstem lesions and evaluated their potential diagnostic significance. Images and spectra were acquired on a 1.5-T imager. The concentrations of N-acetylaspartate, tetramethylamines (e.g., choline), creatine, phosphocreatine, lactate, and lipids were measured within lesions located at the brainstem using Point-resolved spectroscopy sequences.RESULTS:Diagnosis based on localized proton spectroscopy included brainstem glioma, brainstem encephalitis, demyelination, dysmyelination secondary to neurofibromatosis type 1 (NF 1), and possible infection or radiation necrosis. In all but one patient, diagnosis was confirmed by biopsy or by clinical follow-up.CONCLUSIONS:This small sample of patients suggests that MRS is important in the differential diagnosis between proliferative and nonproliferative lesions in patients without neurofibromatosis. Unfortunately, in cases of NF 1, MRS can have a rather misdiagnosis role.

Intracranial stenoses cause 5-10% of all strokes and are increasingly detected by means of modern imaging methods. The stroke danger of high-grade symptomatic stenoses is relatively high, with an annual risk of approximately 10% under medical treatment. Coumadin increases the risk of hemorrhage, and after risk/benefit considerations, antiplatelets should be preferred for antithrombotic therapy. Despite optimized medical treatment, a small group of patients with recurrent symptoms or symptomatic stenoses without adequate collateral supply probably carry higher spontaneous stroke risk and may be considered for intracranial stenting, which itself is associated with procedural risks of up to 10%. Currently published case series show relatively high complication rates as a major drawback of endovascular treatment, mainly strokes after occlusion of perforating branches extending from the stenotic vessel segment or hemorrhagic complications. According to data from smaller feasibility studies, stroke rates in follow-up after successful stenting seem to be low. The average rate of high-grade restenosis with possible indication for reintervention is 10%. Improvements in endovascular treatment aim at reducing vessel wall trauma during balloon angioplasty by underdilatation or the use of self-expanding stents. Until complication rates are dependably reduced to values of 5-6%, indication for endovascular treatment should be restricted to patients without therapeutic alternatives. According to limited data with large variation between different studies, a prospective multicentric registry is proposed for systematic evaluation and further development of the method.

Intrakranielle Stenosen verursachen 5–10% der Schlaganfälle und werden mit zunehmender Häufigkeit mittels moderner bildgebender Verfahren detektiert. Das Schlaganfallrisko symptomatischer Stenosen im Spontanverlauf unter konservativer Behandlung liegt mit Werten um 10% pro Jahr relativ hoch. Die Behandlung mit Marcumar führt zu erhöhten Blutungsrisiken, so dass in der Nutzen-Risiko-Abwägung Thrombozytenaggregationshemmer bevorzugt werden sollten. Eine kleinere Gruppe von Patienten mit unter medikamentöser antithrombotischer Therapie rezidivierend symptomatischen oder einmalig symptomatischen hämodynamisch relevanten Stenosen ohne adäquate Kollateralversorgung hat möglicherweise ein noch höheres Schlaganfallrisiko im Spontanverlauf, so dass für diese Patienten eine endovaskuläre Behandlung eine Therapieoption darstellt, die aber mit einem bis zu 10%igen prozeduralen Risiko verbunden ist. Ein Problem der nur mit kleinen Fallzahlen angewandten neuartigen Methode sind die für einen prophylaktischen Eingriff relativ hohen Komplikationsraten. Infarkte durch Verschlüsse der aus dem stenosierten Segment abgehenden perforierenden Äste und Blutungskomplikationen stehen dabei im Vordergrund. Nach erfolgreich durchgeführter Intervention sind die Schlaganfallraten im Verlauf nach den bisherigen Daten niedrig. Die Rate an hochgradigen und eventuell erneut interventionsbedürftigen Restenosen beträgt etwa 10%. Verbesserungen der Methode zielen auf die Verringerung des Gefäßwandtraumas bei der Ballonangioplastie durch bewusste Unterdilatation oder die Verwendung von selbstexpandierenden Stents. Solange die Komplikationsraten nicht zuverlässig in einen Bereich von 5–6% gesenkt werden können, kommt die interventionelle Behandlung nur mit strenger Indikationsstellung bei Patienten ohne therapeutische Alternative in Betracht. Angesichts der bisherigen spärlichen Daten mit großer Streubreite zwischen den einzelnen Studien wird ein multizentrisches prospektives Register zur weiteren Evaluation und Entwicklung der Methode angeregt.

Eine hämodynamische Insuffizienz aufgrund von Pseudookklusionen oder Verschlüssen der A. carotis interna ist eine seltene Ursache des akuten Schlaganfalls. Eine akute Revaskularisation des Gefäßes kann die zerebrale Perfusion wieder herstellen.

Die Entwicklung endovaskulärer Techniken zur Behandlung des akuten Schlaganfalls begann mit der Einführung der lokalen intraarteriellen Fibrinolyse. Parallel zur Entwicklung neuer systemischer Therapieansätze wurden in den letzten Jahren Kathetersysteme zur Auflockerung, Zerkleinerung oder Extraktion zerebraler Thromben alternativ oder in Ergänzung zu einer fibrinolytischen Behandlung erprobt. So wurde die mechanische Alteration intrakranieller Thromben durch Ballonkatheter, Manipulationen mit dem Führungsdraht oder endovaskulär eingestrahlten Ultraschallwellen sowie Techniken der Thrombusaspiration, Schlingenextraktion oder komplexere hydrodynamische oder lasergestützte Thrombektomiesysteme in Machbarkeitsstudien getestet, was deren grundsätzliche Funktionsfähigkeit und relative Sicherheit ergab. Eine breite klinische Anwendung außerhalb von Studien kann noch nicht empfohlen werden, da sich die neuen Kathetersysteme noch in einem frühen Stadium der klinischen Erprobung befinden.

This paper describes the rare MR and CT features of central nervous system (CNS) lymphoma in immunocompetent children and in survivors of childhood acute lymphoblastic leukemia (ALL) and discusses the causative role of cranial irradiation and/or leukoencephalopathy preceding central nervous system (CNS) lymphoma in survivors of childhood leukemia. The authors reviewed MR and CT scans of 3 children with biopsy-proved CNS lymphoma. One child had tumor infiltration within the optic nerve sheaths and optic chiasm by previously known non-Hodgkin lymphoma. In 2 patients, CNS lymphoma developed 8 and 10 years after initial ALL treatment. In both cases CNS lymphoma was preceded by cranial irradiation and leukoencephalopathy. A single lesion was present in 3 out of 4 patients. All lesions were isointense or hypointense on the T1-weighted images relative to gray matter and showed homogeneous enhancement. One lesion was centered in the central gray matter, one lesion was centered within a cerebral hemisphere, one lesion was in optic nerve, and there were 2 parasellar lesions. CNS lymphoma has a variable appearance in children. Knowledge of risk factors in children may help in the early recognition of disease, allowing for timely intervention. This may prompt early biopsy or a conservative management in the appropriate clinical setting.

Magnetic resonance imaging is currently the gold standard in the assessment of brain myelination. The normal pattern of brain myelination conforms to a fixed chronological sequence. Focal accelerated myelination is a usual pathological state and previously has only been associated with Sturge‐Weber syndrome. The purpose of our study is to describe alternate causes for accelerated myelination. We retrospectively reviewed serial MR scans, MR angiography, conventional angiography and the clinical progress of three children with accelerated myelination. Two patients with accelerated myelination had an underlying cerebral sinovenous thrombosis. The third patient had Sturge‐Weber syndrome. Our study strongly suggests that cerebral venous thrombosis with the consequent restriction of venous outflow could be a key factor in the induction of accelerated myelination. We recommend that in patients with accelerated myelination, the search for an underlying etiology should include careful evaluation of the intracranial vascular pathology, especially cerebral venous thrombosis.

This study demonstrates that in experienced hands, intracranial angioplasty is a feasible and safe option in a selected group of patients with severe (>50% stenosis) symptomatic vasospasm following subarachnoid hemorrhage. Cerebral circulation time is a surrogate parameter closely linked to cerebral perfusion. The study presented shows that not only stenosis but also changes in circulation time are obtained by angioplasty. Twenty angioplasties of one or two vessel segments were performed over 2 years in 18 consecutive patients with posthemorrhagic vasospasm fulfilling criteria for invasive treatment. In all patients, degree of stenosis and circulation time could be reduced by angioplasty. Clinical results were ranked according to Glasgow Outcome Scale. Imaging after 15/20 angioplasties showed no additional infarction. In 4/20 cases, CT showed demarcation of infarction after angioplasty. In 1/20 cases of posterior circulation angioplasty, CT is not sensitive enough to exclude smaller infarctions. Imaging and clinical outcome reveal a definite benefit.

Hemodynamic impairment caused by pseudo-occlusion or occlusion of the internal carotid artery (ICA) is a rare etiology of stroke. Acute revascularization of the vessel can restore the flow to the brain. This retrospective study shows that ICA stenting with proximal and distal protection devices in patients with acute stroke and pseudo-occlusion or occlusion of the ICA is technically feasible and can prevent further hemodynamic strokes. In contrast, selected patients have a high risk of reperfusion syndrome with intracranial hemorrhage and peri-interventional monitoring of blood pressure in an ICU is recommended.

The development of endovascular techniques for the treatment of acute stroke began with the introduction of local intra-arterial fibrinolysis. In parallel to designing new systemic therapy approaches, catheter systems for loosening, disintegrating, or removing cerebral thrombi have undergone assessment in recent years to serve as alternatives or supplements to fibrinolytic treatment. Mechanical alteration of intracranial thrombi with balloon catheters, manipulations with the guide wire, or ultrasound waves transmitted into the vascular system as well as techniques for thrombus aspiration, snare extraction, or more complex hydrodynamic or laser-guided thrombectomy systems have been tested in feasibility studies, which evidenced basic functionality and relative safety. Broad clinical applications outside of the clinical trial setting cannot yet be recommended since the new catheter systems are still in early phase clinical testing.

The treatment of intracranial atherosclerotic stenoses, which account for 10-15% of all ischemic strokes, is technically feasible for few years by the use of new flexible stent devices. Especially patients who fail best medical treatment have a poor prognosis and stenting becomes a reasonable treatment option. Herein we discuss treatment concepts and the principles of stent placement against the background of epidemiology and pathophysiologic basics.

Die endovaskuläre Behandlung von Karotisstenosen findet zunehmende Verbreitung. Bei der Karotisstentimplantation werden häufig temporäre Filter oder Okklusionsballons in die A. carotis interna distal der Stenose eingesetzt, um einen zusätzlichen Schutz vor zerebralen Embolien zu erreichen. Die Notwendigkeit einer solchen distalen Protektion ist wissenschaftlich allerdings immer noch umstritten. Die folgende Übersicht über die bestehenden Techniken und deren Ergebnisse soll eine kritische Würdigung der vorhandenen Daten ermöglichen und die Auswahl geeigneter Techniken und Materialien erleichtern.

We report three children with leukaemia (two acute myeloid and one acute lymphoblastic) and granulocytic sarcoma in the skull, orbit and sinuses. Lesions in these sites in children, with or without bone changes, are suggestive of systemic diseases such as lymphoproliferative conditions. Although involvement by granulocytic sarcoma, with or without acute myeloid leukaemia, is described, an association with acute lymphoblastic leukaemia is rare. Recognition of this rare entity is important, because early aggressive chemotherapy can bring about regression of the tumour and improve survival.

Endovascular treatment of carotid stenoses is increasingly used. Frequently temporary occlusion balloons or filters are placed distal to the stenosis to gain additional protection against cerebral emboli. There is still a scientific debate about the usefulness of such distal protection devices. The following contribution reviews existing techniques and their clinical results and should allow for a critical discussion and selection of current techniques and materials.

Die Behandlung intrakranieller atherosklerotischer Stenosen, die in 10–15% Ursache eines ischämischen Schlaganfalls sind, ist seit einigen Jahren durch die Entwicklung kleiner und flexibler Stents und Trägersysteme technisch möglich. Insbesondere Patienten mit rezidivierender Symptomatik unter medikamentöser Behandlung haben eine schlechte Prognose, und die Behandlung mit einem Stent entwickelt sich zunehmend zu einer Behandlungsoption. In diesem Beitrag werden endovaskuläre Behandlungskonzepte, Techniken der intrakraniellen Stentapplikation und ihre Limitationen vor dem Hintergrund von Epidemiologie und pathophysiologischen Grundlagen diskutiert.