Purpose: The approximately 4.7 times higher signal at 7 T compared with that at 1.5 T may improve image quality of clinical MR-angiograms and should therefore provide a superior visualization of intracranial arteries and aneurysms. The purpose of this study was to determine whether 7 T ToF-MR-angiography is superior to 1.5 T ToF-MR-angiography in the detection and evaluation of intracranial aneurysms.

BACKGROUND AND PURPOSE: Endovascular therapy of intracranial arterioverous malformations (AVMs) is increasingly used. However, it is still under discussion which embolic material is optimal. We report our experience in the treatment of AVMs with ethylene-vinyl alcohol copolymer (Onyx).MATERIALS AND METHODS: Between July 2002 and January 2008, brain AVMs were embolized with Onyx in 82 consecutive patients in our department. There were 41 females and 41 males with a mean age of 44.2 years (range, 15-85 years), Clinical presentation included symptoms due to intracerebral hemorrhage (n = 37), seizures (n = 18), nonhemorrhagic neurologic deficits (n = 8), headaches (n 9), or incidental symptoms (n = 10). According to the Spetzler-Martin scale, 59 AVMs were grades I-II, 16 were grade III, and 7 were grades IV-V.RESULTS: Complete obliteration at the end of all endovascular procedures was achieved in 20/82 patients (24.4%), with an average of 75% (range, 30%-100%) volume reduction. A mean of 2.9 (range, 1-10) feeding pedicles was embolized per patient, whereas an average of 2.6-mL Onyx was used per patient. Procedure-related permanent disabling morbidity was 3.8%, whereas mortality was 2.4%..CONCLUSIONS: The overall initial complete obliteration rate of intracranial AVMs with Onyx embolization is relatively high, compared with other embolic agents, with evidence of stability with time, Morbidomortality rates due to AVM embolization as a single treatment method or as a part of a multimodality treatment should be further assessed regarding the natural course of the disease.

BACKGROUNDIn order to assess the efficiency of flow-controlled shunts in reducing shunt failure in the treatment of adult hydrocephalus (with a special focus on overdrainage complications), a series of 289 patients was analyzed through a retrospective and comparative study performed in three neurosurgical departments.METHODSA group of 142 adult patients suffering from hydrocephalus were operated on using a conventional differential pressure (DP) shunt and compared with a group of 147 adult patients operated on using flow-controlled (FC) system (Orbis-Sigma, Cordis). Only the first complication, which required a surgical revision within the first 2 years after shunt implantation, was taken into account for each patient and analyzed using life-table methods.RESULTSThe actuarial risk of shunt infection in the two groups is respectively 8.3% and 10.9% at 1 year (nonsignificant difference). The actuarial risk of mechanical complications at 1 year is 38% for the DP patients and 10% for the FC patients (p = 0.0001); this difference is largely due to a decrease of complications related to overdrainage phenomenon (14142 subdural collections were observed in the DP group versus 1147 in the FC group) (p = 0.0001).CONCLUSIONThe conclusion of this cooperative and retrospective study is that the use of a flow-controlled system decreases the risk of mechanical complications related to the hydrodynamic properties of the shunts used in the treatment of adult hydrocephalus, especially those related to overdrainage.

Purpose: The objective of our study was to detect and characterize intracranial gliomas at 1.5 T MRI in comparison to 7 T MRI. The theoretically 4.7 times higher signal-to-noise ratio (SNR) of a 7 T whole-body MR system offers an increase in spatial resolution and hence may provide a superior visualization of intracranial tumors compared with that of 1.5 T systems. The aim of this study was to determine whether 7 T MRI is superior to 1.5 T MRI in the visualization and characterization of the microvascularity of gliomas and the microarchitecture of different tumor constituents.

Ziele: Ziel der Studie ist die vergleichende Visualisierung von Astrozytomen Grad II bis IV (WHO) und die Bestimmung ihrer Infiltrationstiefe in angrenzendes Hirnparenchym in der MRT mit 1,5-T (Tesla) bzw. 7,0-T. Das 4,7-fach höhere Signal bei 7,0-T gewährleistet eine 1,7-fach geringere Voxelgröße in allen drei Raumrichtungen gegenüber 1,5-T und somit eine detaillierte Darstellung der Tumorränder und Binnenstruktur von Hirntumoren. Methode: 15 konsekutive Patienten mit im 1,5-T MRT diagnostizierten, intrakraniellen Astrozytomen, wurden anschließend mit einem 7,0-T MRT (Siemens) untersucht. Die Lokalisation und Infiltrationstiefe der Astrozytome wurde von zwei Neuroradiologen ohne Kenntnis von Voraufnahmen und klinischen Angaben beurteilt. Die Bildqualität wurde anhand einer 5-Punkte-Skala evaluiert. Ergebnis: Bei einigen Patienten ist bei 7 Tesla die Heterogenität der Tumormatrix deutlich besser zu erkennen. Die Infiltrationstiefe ist mit 7 Tesla grundsätzlich besser sichtbar. Schlussfolgerung: Die Visualisierung von Astrozytomen bei 7,0-T erlaubt eine mehr als adäquate, diagnostische Darstellung von tumorinfiltriertem und gesundem Hirngewebe im Vergleich zu 1,5-T.

Ziele: Das 4,7-fach höhere Signal der 7,0-T (Tesla) MRT soll gegenüber der 1,5-T MRT aufgrund der 1,7-fach geringeren Voxelgröße eine detaillierte Darstellung und Charakterisierung intrakranieller Aneurysmen gewährleisten. Wir wollen untersuchen, ob die 7,0-T TOF MR-Angiographie im Vergleich zur 1,5-T TOF MR-Angiographie und der DSA – als Goldstandard – eine überlegene Methode zur Identifizierung und Visualisierung von intrakraniellen Aneurysmen ist. Methode: 10 konsekutive Patienten mit in der DSA nachgewiesenen, unversorgten Hirnarterienaneurysmen wurden einer 1,5-T TOF MRA und einer 7,0-T TOF MRA unterzogen. Das Vorhandensein und die Lokalisation der Aneurysmen wurde von zwei Neuroradiologen ohne Kenntnis der klinischen Daten und Voraufnahmen dokumentiert. Ferner wurden die Angiographien bezüglich der Bildqualität anhand einer 5-Punkte-Skala evaluiert. Ergebnis: Alle in der DSA dokumenierten Aneurysmen wurden auch in der 1,5-T und 7,0-T TOF MRA nachgewiesen. Die 7,0-T MR-Angiogramme erreichten eine annähernd vergleichbare Bildqualität zur DSA und eine signifikant höhere, mediane Bildqualität als die korrespondierenden 1,5-T MR-Angiogramme bei überlegener Darstellung von kleinen Aneurysmen und der Gefäßperipherie. Schlussfolgerung: Die 3 D TOF MR-Angiographie bei 7,0 T zeigt annähernd vergleichbare Ergebnisse zur DSA und eine verbesserte Bildqualität gegenüber der 1.5-T TOF MRA in Bezug auf die Identifizierung und Charakterisierung von intrakraniellen Hirnarterienaneurysmen.

RATIONALE:Meningiomas in the pediatric age group are very rare tumors, comprising about 1-4.2% of all primary pediatric intracranial tumors.CASE REPORT:We present a 17-year-old patient who suffered from an intraventricular malignant meningioma. At the age of 2 years, acute lymphatic leukemia (common ALL [cALL]) was diagnosed and successfully treated with chemotherapy. There was no cranial radiation therapy. In December 2001, 13 years after diagnosis of cALL, he complained of headache, vomiting, and walking difficulties. Magnetic resonance imaging showed an enhancing mass with cystic components in the trigone of the right lateral ventricle. The tumor was removed completely. Histological diagnosis revealed a malignant papillary meningioma. After removal of a recurrent meningioma 16 months later, he received local radiotherapy.CONCLUSION:Pathogenetic mechanisms, treatment options, and prognosis of meningiomas and secondary malignancies of this age group are discussed.

A rare case of a cerebral metastasis 13 months after open heart surgery because of an undifferentiated sarcoma of the left atrium is presented.

Subdural haematomas as a consequence of severe head injury often constitute the indication for operative evacuation. Despite intensive care management postoperative computed tomography scans are essential. This is illustrated by an unusual case report of a patient suffering from an epidural haematoma after operation of an subdural haematoma. In addition, the importance of the skull X-ray in the emergency setting and intracranial pressure monitoring are discussed.

OBJECTIVE:To describe the clinical results in patients with aneurysms of the vertebral artery and posterior inferior cerebellar artery complex (VA-PICA) treated by endovascular embolization or surgically in cases considered untreatable by endovascular methods.PATIENTS AND METHODS:During a 5-year-period a total of 28 patients with a VA-PICA complex aneurysm out of 600 patients received definitive treatment, 19 patients by endovascular embolization and 9 patients surgically. Mean age was 54 years (range 9-75 years). Clinical data, intraoperative observations and procedural complications were evaluated. The mean follow-up was 9 months.RESULTS:Hunt-Hess (HH) grades were HH 0-II in 10 patients (35.7 %), HH III in 6 patients (21.4 %) and HH IV + V in 12 patients (42.9 %). Aneurysm size ranged from 2 to 40 mm (mean size 5.5 mm). Aneurysm configuration was saccular 18, fusiform 7 and multilobed 3. Complete occlusion was achieved in all cases. Overall 67.9 % (n = 19) showed a favorable outcome (Glasgow Outcome Score IV + V). Overall procedure-related rate for permanent morbidity and mortality was 3.6 % (n = 1) and 3.6 % (n = 1), respectively. Predictive factors of clinical outcome were the initial clinical HH grade and the Fisher grade.CONCLUSION:Endovascular embolization is an effective method for the treatment of VA-PICA aneurysms. Surgical clipping is still an alternative and should be considered for "uncoilable" lesions. Outcomes showed a close correlation to the initial clinical state and were not dependent on the treatment modality.

More recent findings suggest a possible role of the cerebellum in nonmotor functions. Disability of individuals with cerebellar damage in rapidly shifting attention is one frequently used example to support cerebellar involvement in mental skills. The original proposal was based on findings in five children with chronic surgical lesions of the cerebellum and a young adult with a degenerative disorder. The aim of the present study was to repeat Akshoomoff and Courchesne's initial findings in a larger group of children with focal cerebellar lesions. Ten children with cerebellar lesions and 10 age- and sex-matched controls were tested. Neocerebellar areas were affected in all children with cerebellar damage except one based on detailed analysis of MRI scans. Subjects had to perform a focus and a shift attention task. Two visual and two auditory stimuli were presented in a pseudorandom order. An ellipse and a high-pitched tone were presented less frequently than a circle and a low-pitched tone. Rare stimuli were presented at five different time intervals. In the focus tasks, subjects had to react to the same rare stimulus of one of the two modalities. In the shift task, subjects had to switch between the two rare stimuli. Motor deficits based on reaction times were small in cerebellar children compared with controls. The ability of target detection did not significantly differ in the children with cerebellar lesions compared with the control children in both the focus and the shift attention task. In particular, children with cerebellar damage showed no significant impairment in rapid (<2 s) shifts of attention. The present findings indicate that the cerebellum may be less critical in attention related processes than suggested previously.

Objectives: The aim of this study was to evaluate the prognostic value of intraoperative aneurysm rupture (IAR) in patients with subarachnoid hemorrhage (SAH) undergoing surgery for cerebral aneurysms. Patients and methods: Between July 1997 and April 2000, 292 consecutive patients were admitted to our institution with SAH due to ruptured intracranial aneurysms. Of these, 169 patients were treated surgically according to standard microsurgical procedures and were included in this study. Mean age was 47 years. Initial clinical state was graded according to the classification of Hunt and Hess (HH). Outcome was classified according to the Glasgow Outcome Scale as favorable (grades IV and V) and unfavorable (grades I–III). Outcome of patients with intraoperative ruptured and non-ruptured aneurysms was analyzed in correlation to the preoperative clinical state and with respect to the time of surgery and to aneurysm localization. Results: Different rupture rates were observed with respect to the localization of the aneurysm: anterior circulation (n=69) 39.1%, middle cerebral artery (n=46) 34.8%, internal carotid artery (n=48) 31.2%, and posterior circulation (n=6) 16.7%. Patients with HH-grades I–III showed a favorable outcome in 72.2% (61 of 84 patients) without intraoperative rupture and in 71.7% (33 of 46 patients) with intraoperative aneurysm rupture. The corresponding values for patients with HH-grades IV/V were: favorable outcome in 34.6% (9 of 26 patients) and 23.1% (3 of 13 patients), respectively. Poor initial clinical condition (HH IV and V) as well as the initial Fisher grades III and IV were strongly associated with poor clinical outcome. Conclusions: Intraoperative aneurysm rupture has no impact on the outcome, neither in patients with good initial condition nor for poor grades patients.

Subduralhämatome sind häufig Folge eines Schädel-Hirn-Traumas (SHT) und stellen vielfach eine dringliche Operationsindikation dar. Die Patienten werden postoperativ mittels Sedierung und Relaxierung abgeschirmt. Trotz intensivmedizinischer Maßnahmen sind computertomographische Kontrolluntersuchungen unerlässlich. Anhand einer ungewöhnlichen Kasuistik eines Patienten mit akutem Subduralhämatom und nachfolgendem Epiduralhämatom soll dies nochmals veranschaulicht werden. Darüber hinaus soll der Stellenwert der konventionellen Röntgenaufnahme des Schädels im Rahmen der Primärdiagnostik und die Anlage einer intrakraniellen Druckmessung diskutiert werden.

Our clinical studies revealed significantly increased soluble HLA-G (sHLA-G) plasma levels in patients suffering from malignant melanoma, glioma, breast and ovarian cancer. Specific ELISpot assays demonstrate that sHLA-G molecules expressing intron-4 sequences are preferentially secreted by peripheral blood monocytes. In vitro, the sHLA-G secretion of monocytes and tumor cells was strongly enhanced by TH1 cytokines like IFN-alpha, -beta, -gamma whereas TH2 cytokines (e.g. IL-4, -10) had minor effects. As sHLA-G can inhibit the functions of T and NK cells high concentration of these molecules should systemically or at the tumor side reduce the immune surveillance and thus favour the progression of cancer.

In a prospective series of symptomatic adult hydrocephalus characterized by gait disturbance, cognitive impairment, and/or urinary incontinence, 88 of 118 patients (75%) had additional akinetic, tremulous, hypertonic, or hyperkinetic movement disorders. Their prevalence was highest in patients with idiopathic normal pressure hydrocephalus (NPH) of the elderly (56/65 patients, 86%), and they were less frequent in patients with secondary NPH (10/15, 66%), with nonhydrodynamic atrophic/other hydrocephalus (20/33, 61%), and with obstructive hydrocephalus/aqueductal stenosis (2/5, 40%). Akinetic symptoms were found in 73 of 118 patients (62%), and the most frequent movement disorder was upper extremity bradykinesia (55%). Akinetic, tremulous, hypertonic, and hyperkinetic movement disorders were exclusively secondary to causes not related to hydrocephalus in 24 of 118 patients (20%). The proportion of patients with movement disorders not attributable to only such causes was highest in the idiopathic NPH group (44/65, 68%). Thirteen of 118 patients (11%) presented with a parkinsonian syndrome. There was evidence for coexistent Parkinson's disease in four of these patients. Parkinsonism was found to be secondary to NPH in five patients and was found improved after shunting. Akinetic symptoms in patients with NPH generally responded favorably to CSF diversion, which was evident in 80% of a subset of this group. Various other movement disorders did not show definite improvement. The high prevalence of bradykinesia and other akinetic symptoms in NPH and the beneficial effect of shunting on such symptoms suggest that NPH may cause a more generalized disorder of motor function.

We report the impact of diagnostic ventricular CSF removal (VCR) on the gait disturbance in 24 patients with suspected normal pressure hydrocephalus (NPH) who had an intraventricular catheter for studies of CSF dynamics in order to select patients for shunt surgery. There were no complications related to removal of 24 ml CSF over a period of 6 hours in four instances or to the removal of 15-18 ml at one time in twenty instances. Seventeen out of 24 patients were diagnosed as having NPH. Two of those patients who had relatively mild symptoms had a prolonged amelioration of their gait disturbance after diagnostic VCR. Thirteen patients underwent subsequent shunt operations. Eleven of them had good functional and symptomatic improvement on follow-up. In those six patients who had a marked amelioration of their gait disturbance after diagnostic VCR, not only improvement of the gait disturbance was observed after shunting, but a consistent overall improvement as well. The predictive value of VCR was more variable in those six patients who had only a moderate response to VCR. No change of the gait disturbance after VCR was noted in seven patients in whom the diagnosis of NPH was not confirmed. Diagnostic VCR might be a valuable ancillary test in specialized centers which routinely use intraventricular CSF monitoring in the selection of patients for shunt surgery.

BACKGROUND AND PURPOSE:There is some evidence from previous studies that idiopathic normal-pressure hydrocephalus (NPH) of the elderly might be linked to vascular leukoencephalopathy. The purpose of this study was to examine the prevalence and impact of vascular risk factors and vascular diseases in idiopathic NPH compared with a control cohort.METHODS:The prevalence of arterial hypertension; diabetes mellitus; hypercholesterolemia; hyperlipidemia; smoking; obesity; and cardiac, cerebrovascular, and other arteriosclerotic diseases was assessed in 65 patients with idiopathic NPH. The findings were compared with those of 70 patients with comparable age distribution. To describe the differences of the prevalences of vascular risk factors, odds ratios were obtained by univariate and multivariate analyses.RESULTS:The univariate analysis revealed significant associations between idiopathic NPH and arterial hypertension (prevalence, 54 of 65 [83%]; control group, 25 of 70 [36%]; P < .001) and diabetes mellitus (prevalence, 31 of 63 [49%]; control group, 20 of 70 [29%]; P < .015) but not with other vascular risk factors. After multivariate regression analysis, only hypertension remained significantly associated with NPH (P < .0001). There was also a significant association between NPH and cardiac (P < .001), cerebral arteriosclerotic (P = .007), and other arteriosclerotic diseases (P = .001). A positive association was found between the severity of clinical symptoms of NPH and the presence of hypertension, especially for gait disturbance. The presence of hypertension was not related to the duration of NPH.CONCLUSIONS:Our data show a highly significant association between idiopathic NPH and arterial hypertension. Arterial hypertension might be involved in the pathophysiological mechanisms promoting idiopathic NPH.

The interpretation of data from continuous monitoring of intracranial pressure (ICP) in patients with suspected normal pressure hydrocephalus (NPH) is the subject of controversy. Despite the fact that overnight ICP monitoring is widely used for the diagnosis of NPH, normative criteria are poorly defined. The present study demonstrates that there is a relationship between the relative frequency, the absolute amplitude, the wavelength and the morphology of B-waves and different sleep stages. Intraventricular intracranial pressure was recorded continuously overnight in 16 patients with suspected normal pressure hydrocephalus. Simultaneous polysomnography was performed to investigate the relation of spontaneous ICP oscillations to different sleep stages. A correlative analysis was done with the data of 13 patients. Three patients were excluded, one who was awake throughout the night and two in whom polysomnography was incomplete due to technical reasons. The mean resting cerebrospinal fluid (CSF) pressure was 12.87 cm CSF. B-waves were observed in the ICP recordings of all patients. They were present for a mean of 72% of the total recording time. The relative frequency of B-waves was higher during REM sleep and sleep stage 2 as compared to wakefulness (87.8% and 83.2% vs. 56. p < 0.05). The absolute amplitude was higher during REM sleep than in wakefulness (9.56 vs. 3.44 cm CSF, p < 0.05). Wavelengths were longer in REM sleep than in wakefulness and stages 1 and 2 (62.4 vs. 42, 40.7 and 44.8 sec, p < 0.05). The morphology of B-waves was also related to different sleep stages. Ramp-type B-waves were associated with REM sleep in six patients, however, were also present in sleep stage 2 in three of them. Knowledge of the relation of spontaneous ICP oscillations to different sleep stages may help to establish physiological foundations and alterations. Furthermore, polysomnography may be useful to avoid erroneous interpretation of ICP recordings due to sleep stage related variability.