Case report of MR perfusion imaging in Sinking Skin Flap Syndrome: growing evidence for hemodynamic impairment

<p>Abstract</p> <p>Background</p> <p>The syndrome of the sinking skin flap (SSSF) with delayed sensorimotor deficits after craniectomy is not well known and often neglected. Among various postulated causes, there is evidence that disturbed brain perfusion may be related to the observed symptoms, and that cranioplasty reliably alleviates these symptoms. We report a case of sinking skin flap syndrome (SSFS) with recovery from neurological sensorimotor deficits after cranioplasty correlated with pre- and postsurgical MR brain perfusion studies.</p> <p>Case Presentation</p> <p>A 42-year-old woman presented with slowly progressive sensorimotor paresis of her left arm after decompressive extensive craniectomy due to subarachnoid hemorrhage four months ago. Her right cranium showed a "sinking skin flap". After cranioplastic repair of her skull defect, the patient fully recovered from her symptoms. Before cranioplasty, reduced brain perfusion in the right central cortical region was observed in MR-perfusion images. After cranioplasty, a marked increase in brain perfusion was observed which correlated with objective clinical recovery.</p> <p>Conclusion</p> <p>There is increasing evidence that impaired blood flow is responsible for delayed motor deficits in patients with sinking skin flap syndrome in the area of compressed brain regions. Symptoms should be evaluated by brain perfusion imaging complementing surgical decision-making.</p

Patient characteristics and imaging of hemorrhagic lesions in FPCT compared to MDCT.

<p>Patient characteristics and imaging of hemorrhagic lesions in FPCT compared to MDCT.</p

Depiction of intracranial hemorrhage on FPCT and MDCT.

<p>Figure shows axial reconstructions from FPCT and MDCT in a patient with intracerebral and intraventricular hemorrhage. In the upper row, regions of interest were drawn on the MDCT image and superimposed onto the co-registered FPCT image. The same images without superimposed regions of interest are shown in the bottom row.</p

Lesion only detectable on review of both the axial and sagittal DWI together.

<p>B-1000 images and ADC-maps of the lesion (arrows) that was only detected on review both the axial (left) and the sagittal (right) DWI together (R_ax+sag).</p

Lesions additionally detectable on sagittal DWI.

<p>Sagittal (first row) and corresponding axial (second row) B-1000 images and ADC-maps (third and fourth row) of the five DWI lesions (arrows) that were additionally detectable on the sagittal DWI (R_SAG).</p

Improved detectability of acute and subacute brainstem infarctions by combining standard axial and thin-sliced sagittal DWI

<div><p>Background and purpose</p><p>Most false negative findings in DWI of ischemic stroke are in patients with minor deficits clinically localized to the brainstem. Our goal was to evaluate the benefit of a thin-sliced sagittal DWI in addition to conventional axial DWI at 1.5T for the detection of brainstem infarctions.</p><p>Methods</p><p>Data of patients with symptoms consistent with acute and subacute brainstem infarction and an MRI examination including standard axial DWI and thin-sliced sagittal DWI were retrospectively analyzed. Patients with the later diagnosis of a TIA, an inflammation or a tumor of the brainstem were excluded from analysis. Diffusion restrictions were identified by two independent raters blinded for the final clinical diagnosis in three separate reading steps: First, only axial DWI, secondly only sagittal DWI, and lastly both DWIs together. Presence and size of DWI-lesions were documented for each plane. Differences between the observers were settled in consensus in a separate joint reading.</p><p>Results</p><p>Of 73 included patients, 46 patients were clinically diagnosed with brainstem infarction. Inter-observer agreement was excellent for the detection of brainstem lesions in axial and sagittal DWI (kappa = 0.94 and 0.97). In 28/46 patients (60.9%) lesions were detected in the axial plane alone, whereas in 6 more patients (73.9%) lesions were detected in the review of both sequences together. All lesions undetectable in the axial plane were smaller than 5 mm in cranio-caudal direction.</p><p>Conclusions</p><p>Thin-sliced sagittal DWI in addition to axial DWI improves the detection rate of brainstem infarction with little additional expenditure of time.</p></div

Randomized trial of transcranial direct current stimulation for poststroke dysphagia

ObjectiveWe evaluated whether transcranial direct current stimulation (tDCS) is able to enhance dysphagia rehabilitation following stroke. Besides relating clinical effects with neuroplastic changes in cortical swallowing processing, we aimed to identify factors influencing treatment success. MethodsIn this double-blind, randomized study, 60 acute dysphagic stroke patients received contralesional anodal (1mA, 20 minutes) or sham tDCS on 4 consecutive days. Swallowing function was thoroughly assessed before and after the intervention using the validated Fiberoptic Endoscopic Dysphagia Severity Scale (FEDSS) and clinical assessment. In 10 patients, swallowing-related brain activation was recorded applying magnetoencephalography before and after the intervention. Voxel-based statistical lesion pattern analysis was also performed. ResultsStudy groups did not differ according to demographic data, stroke characteristics, or baseline dysphagia severity. Patients treated with tDCS showed greater improvement in FEDSS than the sham group (1.3 vs 0.4 points, mean difference=0.9, 95% confidence interval [CI]=0.4-1.4, p<0.0005). Functional recovery was accompanied by a significant increase of activation (p<0.05) in the contralesional swallowing network after real but not sham tDCS. Regarding predictors of treatment success, for every hour earlier that treatment was initiated, there was greater improvement on the FEDSS (adjusted odds ratio=0.99, 95% CI=0.98-1.00, p<0.05) in multivariate analysis. Stroke location in the right insula and operculum was indicative of worse response to tDCS (p<0.05). InterpretationApplication of tDCS over the contralesional swallowing motor cortex supports swallowing network reorganization, thereby leading to faster rehabilitation of acute poststroke dysphagia. Early treatment initiation seems beneficial. tDCS may be less effective in right-hemispheric insulo-opercular stroke. Ann Neurol 2018;83:328-34

Findings of the consensus rating of R_AX, R_SAG and R_ax+sag compared to the clinical diagnosis.

<p>Findings of the consensus rating of R_AX, R_SAG and R_ax+sag compared to the clinical diagnosis.</p