Thrombolyse der Arteria cerebri media

Zusammenfassung: In den ersten 3h nach Eintritt eines akuten ischämischen Hirninfarkts ist die intravenöse Thrombolyse (IVT) die evidenzbasierte Therapie (IVT 3-4,5h: "off-label use" mit Einverständnis des Patienten). Die intraarterielle Thrombolyse (IAT) führt in der A.cerebri media (ACM) allerdings häufiger zur Rekanalisation als die IVT. Daher ist die IAT in dafür ausgerüsteten Kliniken ergänzend oder alternativ zur IVT bis zu 6h nach Symptombeginn zu erwäge

Long-term sequelae after acquired pediatric hemorrhagic cerebellar lesions

Purpose: The aim of the present study was to assess cognitive, affective, and motor long-term sequelae after acquired focal pediatric cerebellar lesions. Methods: Eight patients with a history of isolated acquired hemorrhagic cerebellar lesions before the age of 13 participated in this study. All participants underwent a neurologic examination, including the Zurich Neuromotor Assessment (ZNA) and the International Cooperative Ataxia Rating Scale (ICARS). Cognitive functions have been evaluated with a general cognitive assessment and an extensive neuropsychological battery. Furthermore, patients and parents filled in questionnaires about quality of life and possible behavioral or emotional problems. Results: The results revealed that all patients exhibited motor problems (ZNA). Most participants had further restricted oculomotor movements (ICARS). Age at injury and the full scale IQ were significantly positively correlated (Pearson correlation 0.779; p = 0.023). Conversely, no overall neuropsychological profile could be identified except for marginally reduced reaction times and susceptibility to interference. In addition, borderline results in semantic and phonemic word fluency tasks were apparent. A dysexecutive syndrome was diagnosed in one patient. However, verbal performance and reading abilities were non-pathologic in all participants. The patients reported having a good quality of life without major physical restrictions. Conclusions: Emotional disturbances and the presence of a mild cerebellar cognitive affective syndrome (as frequently described in adult patients) could only be confirmed in adolescents with vermis lesions. Nevertheless, in laboratory conditions, neuropsychological impairments were present in all patients. Heterogeneity of age at injury and exact lesion site may have led to interpersonal differences in neuropsychological outcom

Closing the gap between coil and balloon in the neurointerventional armamentarium? Initial clinical experience with a nitinol vascular occlusion plug

Introduction: The use of vascular plug devices for the occlusion of high-flow lesions is a relatively new and successful procedure in peripheral and cardiopulmonary interventions. We report on the use and efficiency of the Amplatzer vascular plug in a small clinical series and discuss its potential for occlusion of large vessels and high-flow lesions in neurointerventions. Methods: Between 2005 and 2007 four patients (mean age 38.5years, range 16-62years) were treated with the device, in three patients to achieve parent artery occlusion of the internal carotid artery, in one patient to occlude a high-flow arteriovenous fistula of the neck. The application, time to occlusion, and angiographic and clinical results and the follow-up were evaluated. Results: Navigation, positioning and detachment of the device were satisfactory in all cases. No flow-related migration of the plug was seen. The cessation of flow was delayed by a mean of 10.5min after deployment of the first device. In the procedures involving vessel sacrifice, two devices had to be deployed to achieve total occlusion. No patient experienced new neurological deficits; the 3-month follow-up revealed stable results. Conclusion: The Amplatzer vascular plug can be adapted for the treatment of high-flow lesions and parent artery occlusions in the head and neck. In this small series the use of the devices was uncomplicated and safe. The rigid and large delivery device and the delayed cessation of flow currently limit the device's use in neurointervention

Endovascular and surgical treatment of spinal dural arteriovenous fistulas

Introduction: The aim of this retrospective study was to evaluate the clinical outcome of patients with spinal dural arteriovenous fistulas (SDAVFs) that were treated with surgery, catheter embolization, or surgery after incomplete embolization. Methods: The study included 21 consecutive patients with SDAVFs of the thoracic, lumbar, or sacral spine who were treated in our institution from 1994 to 2007. Thirteen patients were treated with catheter embolization alone. Four patients underwent hemilaminectomy and intradural interruption of the fistula. Four patients were treated by endovascular techniques followed by surgery. The clinical outcome was assessed using the modified Aminoff-Logue scale (ALS) for myelopathy and the modified Rankin scale (MRS) for general quality of life. Patient age ranged from 44 to 77years (mean 64.7years). Results: Surgical as well as endovascular treatment resulted in a significant improvement in ALS (−62.5% and −31.4%, respectively, p < 0.05) and a tendency toward improved MRS (−50% and −32%, respectively) scores. Patients that underwent surgery after endovascular treatment due to incomplete occlusion of the fistula showed only a tendency for improvement in the ALS score (−16.7%), whereas the MRS score was not affected. Conclusion: We conclude that both endovascular and surgical treatment of SDAVFs resulted in a good and lasting clinical outcome in the majority of cases. In specific situations, when a secondary neurosurgical approach was required after endovascular treatment to achieve complete occlusion of the SDAVF, the clinical outcome was rather poor. The best first line treatment modality for each individual patient should be determined by an interdisciplinary tea

Prevent Cracking in Deposition of Carbon Steel on Inconel 625

Welding procedure of clad steel including deposition of carbon steel on nickel base alloy usually gives unaccepted mechanical properties. Cracks were formed along type II boundary in nickel base alloy pass and a martensitic layer was formed in carbon steel pass. In this paper, cracks along type II boundary were prevented by lowering the martensitic start temperature (TMs) of the martensitic layer. Decreasing of TMs was obtained by two methods: Dilution method and Grain refining method. Three levels of TMs (approximately 350, 200, and 50⁰C) are obtained. The results showed that: cracks along type II boundary were prevented at TMs lower than 200⁰C; however type II boundary itself was prevented at TMs lower than 50. Also post weld heat treatment was necessary to achieve accepted impact properties

Cognitive improvement in patients with carotid stenosis is independent of treatment type

Treatment of carotid artery stenosis decreases the long-term risk of stroke and may enhance cerebral blood flow. It is therefore expected to have the potential to prevent cognitive decline or even improve cognition over the long-term. However, intervention itself can cause peri-interventional cerebral infarcts, possibly resulting in a decline of cognitive performance, at least for a short time. We investigated the long-term effects of three treatment methods on cognition and the emotional state one year after intervention. In this prospective observational cohort study, 58 patients with extracranial carotid artery stenosis (≥ 70%) underwent magnetic resonance imaging and assessment of cognition, mood and motor speed before carotid endarterectomy (n = 20), carotid stenting (n = 10) or best medical treatment (n = 28) (i.e., time-point 1 [TP1]), and at one-year follow-up (TP2). Gain scores, reflecting cognitive change after treatment, were built according to performance as (TP2 -TP1)/TP1. Independent of the treatment type, significant improvement in frontal lobe functions, visual memory and motor speed was found. Performance level, motor speed and mood at TP1 were negatively correlated with gain scores, with greater improvement in patients with low performance before treatment. Active therapy, whether conservative or interventional, produces significant improvement of frontal lobe functions and memory in patients with carotid artery disease, independent of treatment type. This effect was particularly pronounced in patients with low cognitive performance prior to treatment

Vascular Dynamics of Cerebral Gliomas Investigated with Selective Catheter Angiography, Perfusion CT and MRI

Purpose:: To assess if intratumoral blood circulation parameters from dynamic susceptibility contrast (DSC) MRI and dynamic CT deliver comparable results and to compare tumor-related changes in regional cerebral blood flow (rCBF) and regional cerebral blood volume (rCBV) with arterial, intratumoral, and venous transition detected with digital subtraction angiography (DSA). Patients and Methods:: Ten patients with cerebral gliomas were prospectively studied with DSC-MRI, dynamic CT and DSA. Tumor areas were segmented and perfusion maps for rCBF, rCBV, and mean transit time (MTT) were computed from DSC-MRI and dynamic CT. Arterial circulation time (ACT), intermediate circulation time (ICT), and venous appearance time (VAT) were measured with DSA. Asymmetry indices (AIs) were calculated for MRI- and CT-based perfusion values, for ICT and VAT and compared among each other. Results:: DSC-MRI and dynamic CT yielded comparable AI values for rCBF (MRI: 39.5 ± 20.4, CT: 36.0 ± 17.9, Pearson's correlation r2 = 0.91) and rCBV (MRI: 44.6 ± 20.9 vs. CT: 40.9 ± 16.3, r2 = 0.84). The MTT AI (MRI: -4.7 ± 11.2 vs. CT: -0.5 ± 10.4, r2 = 0.47) showed only a weak correlation. ICT correlated with rCBV (ICT: 38.4 ± 14.7, r2 = 0.59, and dynamic CT: r2 = 0.81) and VAT with rCBF (VAT: 31.7 ± 17.6, r2 = 0.73, and dynamic CT: r2 = 0.87), but not with MTT. Conclusion:: CT and MRI methods provide consistent information about tumor vascularity of cerebral gliomas in accordance with DS

Cognitive and emotional effects of carotid stenosis.

PRINCIPLES: Patients with carotid artery stenosis (CAS) are at risk of ipsilateral stroke and chronic compromise of cerebral blood flow. It is under debate whether the hypo-perfusion or embolism in CAS is directly related to cognitive impairment. Alternatively, CAS may be a marker for underlying risk factors, which themselves influence cognition. We aimed to determine cognitive performance level and the emotional state of patients with CAS. We hypo-thesised that patients with high grade stenosis, bilateral stenosis, symptomatic patients and/or those with relevant risk factors would suffer impairment of their cognitive performance and emotional state. METHODS: A total of 68 patients with CAS of ≥70% were included in a prospective exploratory study design. All patients underwent structured assessment of executive functions, language, verbal and visual memory, motor speed, anxiety and depression. RESULTS: Significantly more patients with CAS showed cognitive impairments (executive functions, word production, verbal and visual memory, motor speed) and anxiety than expected in a normative sample. Bilateral and symptomatic stenosis was associated with slower processing speed. Cognitive performance and anxiety level were not influenced by the side and the degree of stenosis or the presence of collaterals. Factors associated with less co-gnitive impairment included higher education level, female gender, ambidexterity and treated hypercholesterolemia. CONCLUSIONS: Cognitive impairment and increased level of anxiety are frequent in patients with carotid stenosis. The lack of a correlation between cognitive functioning and degree of stenosis or the presence of collaterals, challenges the view that CAS per se leads to cognitive impairment