Cerebrospinal fluid pulse wave velocity measurements: In vitro and in vivo evaluation of a novel multiband cine phase-contrast MRI sequence

Purpose Intracranial and intraspinal compliance are parameters of interest in the diagnosis and prediction of treatment outcome in patients with normal pressure hydrocephalus and other forms of communicating hydrocephalus. A noninvasive method to estimate the spinal cerebrospinal fluid (CSF) pulse wave velocity (PWV) as a measure of compliance was developed using a multiband cine phase-contrast MRI sequence and a foot-to-foot algorithm. Methods We used computational simulations to estimate the accuracy of the MRI acquisition and transit-time algorithm. In vitro measurements were performed to investigate the reproducibility and accuracy of the measurements under controlled conditions. In vivo measurements in 20 healthy subjects and 2 patients with normal pressure hydrocephalus were acquired to show the technical feasibility in a clinical setting. Results Simulations showed a mean deviation of the calculated CSF PWV of 3.41% +/- 2.68%. In vitro results were in line with theory, showing a square-root relation between PWV and transmural pressure and a good reproducibility with SDs of repeated measurements below 5%. Mean CSF PWV over all healthy subjects was 5.83 +/- 3.36 m/s. The CSF PWV measurements in the patients with normal pressure hydrocephalus were distinctly higher before CSF shunt surgery (33.80 +/- 6.75 m/s and 31.31 +/- 7.82 m/s), with a decrease 5 days after CSF shunt surgery (15.69 +/- 3.37 m/s). Conclusion This study evaluates the feasibility of CSF PWV measurements using a multiband cine phase-contrast MRI sequence. In vitro and in vivo measurements showed that this method is a potential tool for the noninvasive estimation of intraspinal compliance

Case report of Tako-Tsubo cardiomyopathy associated with repetitive anaesthesia in a female patient with Tako-Tsubo cardiomyopathy

Background: Tako-Tsubo cardiomyopathy (TTC) is a rare disorder with high relevance for anaesthesia. It is an acute cardiac syndrome characterized by an acute onset of reversible left ventricular dysfunction associated with emotional and physical stress. This is the only case published of a patient having five severe Tako-Tsubo incidents in five consecutive general anaesthesia procedures within one year. Case presentation: A 61 years old female patient (height 1.65 m; weight 70 kg) presented with a haemorrhagic pituitary adenoma with compression of the optic chiasm and was scheduled for transnasal endoscopic tumour resection. We report a case series with five consecutive anaesthesia procedures in the same patient for neurosurgery. This case series is remarkable since the severe symptoms occurred during every anaesthesia procedure. The female patient was resuscitated two times including therapeutic hypothermia, but fortunately no neurological or cognitive deficit was detectable. Conclusions: TTC may initially present in the perioperative period with pulmonary oedema, electrocardiographic (ECG) changes, elevation of cardiac enzymes, and cardiogenic shock or cardiac arrest. Since the risk of recurrence is considered to be low in TTC, this case report is of high interest. In each procedure similar clinical signs were found which resulted in severe haemodynamic derangements in every manifestation and cardiac arrest in two of the manifestations. Despite cardiopulmonary resuscitation twice, the patient survived without any neurological deficiency

Prediction of hemorrhagic transformation after thrombolytic therapy of clot embolism - An MRI investigation in rat brain

Background and Purpose-Thrombolytic treatment of stroke carries the risk of hemorrhagic transformation. Therefore, the potential of MRI for prediction of recombinant tissue plasminogen activator (rtPA)-induced bleeding is explored to identify patients in whom rtPA treatment may provoke such complications. Methods-Spontaneously hypertensive rats (SHR) (n=9) were submitted to middle cerebral artery (MCA) clot embolism, followed 3 hours later by intra-arterial infusion of 10 mg/kg rtPA. Untreated SHR (n=9) were infused with saline. MRI imaging was performed before treatment and included apparent diffusion coefficient (ADC), T2, and per-fusion mapping and contrast enhancement with gadolinium-DTPA. The distribution of intracerebral hemorrhages was studied 3 days later by histological staining. Results-Clot embolism led to the rapid decline of ADC in the territory of the occluded artery. Tissue lesion volume derived from ADC imaging increased by 155 +/- 69% in the untreated animals and by 168 +/- 87% in the treated animals (P=NS), determined on the histological sections after 3 days. This same lesion growth in both groups indicated absence of therapeutic effect after 3-hour treatment delay. Hemorrhagic transformations were significantly more frequent in treated SHR (P<0.05). In untreated rats, hemorrhages were found in the border zone of the ischemic territory in treated animals, hemorrhagic transformations occurred in the ischemic core region. rtPA-induced hemorrhages were predicted by a disturbance of the blood-brain barrier in 3 of 4 animals before treatment by Gd-DTPA contrast enhancement but not by ADC, T2, or per-fusion imaging. The region of contrast enhancement colocalized with subsequent bleeding in these animals. Conclusions-The disturbance of blood-brain barrier but not of other MR parameters allows risk assessment for hemorrhagic transformation induced by subsequent thrombolytic treatment

Is clipping better than coiling in the treatment of patients with oculomotor nerve palsies induced by posterior communicating artery aneurysms? A systematic review and meta-analysis

Objective: Posterior communicating artery aneurysms (PcomAAs) are the second most common aneurysm, accounting for 25% of all aneurysms and 50% of internal carotid artery aneurysms. It has been estimated that oculomotor nerve palsy (ONP) occurs in up to one-third of patients with posterior communicating artery (PcomA) aneurysms. Recent research showed a better outcome of ONP in patients with PcomAA after surgical clipping when compared to endovascular coiling. We compared the effect of clipping and coiling on recovery of ONP in the management of patients with PcomAAs. Methods: A meta-analysis of studies that compared surgical clipping with endovascular coiling was conducted by searching the literature via Pubmed, Embase and Cochrane Library databases without restricting the publication year. We extracted the following information: author names and publication year; clinical outcome (number of complete and incomplete recovery of ONP); perioperative data (number of pre-operatively complete or incomplete ONP, subarachnoid hemorrhage or not, number of complications (hydrocephalus, recurrence of PcomAA)). Except for author names and publication year, the data was pooled to perform a mean effect size estimate. The effects of two treatment modalities were then analyzed. Results: Nine published reports of eligible studies involving 297 participants met the inclusion criteria. Overall, compared with endovascular coiling, surgical clipping had no statistically significant difference on the complete recovery of ONP, although there was an obvious trend in favor of clipping [RR= 1.48, 95%CI (0.95, 2.29), p=0.08]. There was no significant difference in the total efficiency (any degree of change) on ONP [RR= 1.08, 95%CI (0.94, 1.25), p > 0.05], the overall complications [RR= 0.60, 95%CI (033, 1.10), p >0.05], the efficacy on the complete recovery of ONP in patients without SAH [RR= 0.83, 95%CI (0.53, 1.31), p > 0.05], the effect on the complete recovery of ONP in patients with pre-operatively complete or incomplete ONP [RR= 1.12, 95%CI (0.68, 1.85), p > 0.05], [RR= 1.12, 95%0 (0.79, 1.59), p >0.05]. In a comparison of a small cohort of patients that had suffered an SAH (17 vs. 22) there was a significant difference on the effect on complete recovery of ONP between clipping and coiling [RR= 1.70, 95%CI (1.08, 2.67), p < 0.05]. Conclusions: A superiority of clipping over coiling for the complete recovery of oculomotor nerve palsy in patients that had suffered an SAH from a ruptured aneurysm of the posterior communicating artery was found in the present meta-analysis. Limited by the relatively small sample sizes included, there were no significant differences observed in the clinical outcome between coiling and clipping in the treatment of unruptured PcomAA causing ONP. More evidence from advanced multi-center studies of large scale is needed to provide insight into the optimal treatment for outcome of ONP caused by PcomAAs. (C) 2016 Elsevier B.V. All rights reserved

Interdisciplinary Treatment of Intracranial Infectious Aneurysms

Objective: Intracranial infectious aneurysms (IIAs) are a rare clinical entity without a definitive treatment guideline. In this study, we evaluate the treatment options of these lesions based on our own clinical experience and review the current knowledge of therapy as portrayed in the literature. Methods: We conducted a single-center retrospective analysis of all patients with an IIA and performed a systematic review of the literature using the MEDLINE database. We undertook a comprehensive literature search using the OVID gateway of the MEDLINE database (1950-October 2015) using the following keywords (in combination): 'infectious', 'mycotic', 'cerebral aneurysm', 'intracranial aneurysm'. 1,721 potentially relevant abstracts were identified and 63 studies were selected for full review. The studies were analysed regarding ruptured versus unruptured aneurysms, aneurysm localization and treatment, as well as clinical and radiological outcome. Results: Our institutional series consisted of 6 patients (median age 57 [32-76]) treated between 2011 and 2015. All patients presented with ruptured IIAs located on the middle cerebral artery (MCA, 5 patients) and anterior cerebral artery (ACA, 1 patient). Five patients were treated by clipping and resecting the aneurysm, 1 patient underwent coiling. All patients received antibiotic therapy and 1 patient died. We further identified 814 patients (median age 35.5 [0-81]) in 63 studies. Locations of the aneurysms were mentioned in 55 studies. The most frequent locations of the aneurysms were: MCA (63.5%), posterior cerebral artery (14%), ACA (9.0%) and others (13.5%). Treatment for IIAs was described in 62 studies: antibiotic treatment (56.1%), a combination of antibiotics and surgery (20.9%) or antibiotics and endovascular treatment (23.0%). Outcome was mentioned in 82.4% of the patients with a mortality rate of 16.8%. An evaluation of treatment outcome was limited due to the heterogeneity of patients in the published case series. Conclusion: Antibiotic therapy of patients with IIA is mandatory. However, due to the complexity of the disease and its accompanying comorbidities, a general treatment algorithm could not be defined. Analogous to non-mycotic aneurysms, further treatment decisions require an interdisciplinary approach involving neurosurgeons, interventionists and infectious disease specialists. (C) 2016 S. Karger AG, Base