Decompressive craniectomy for early therapy and secondary prevention of cerebral infarction.
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Animals↗
Biomedical subjects
M Forsting
Publications and source records attributed to M Forsting.
Combination of decompressive craniectomy and mild hypothermia ameliorates infarction volume after permanent focal ischemia in rats.
BACKGROUND AND PURPOSE: Both hypothermia and decompressive craniectomy (DC) have been shown to reduce ischemic injury in experimental middle cerebral artery (MCA) infarction. This study was designed to evaluate the effect of combined DC and hypothermia on infarction size and neurological outcome in a rat model of MCA occlusion (MCAO). METHODS: MCAO was performed in 72 Wistar rats assigned to groups A through F. In group A, mild hypothermia (32 degrees C) was induced 1 hour after MCAO for 5 hours; normothermia was maintained in group B. After 6 hours of survival, infarction size was calculated for animals of groups A and B. In group C, DC alone was performed 4 hours after MCAO; hypothermia without DC was performed 1 hour after MCAO and maintained for 5 hours in group D. Combined DC and hypothermia were performed in group E. No therapy was performed in group F (control). Infarction size and neurological performance after 24 hours were used as study end points (groups C through F). RESULTS: Permanent postischemic hypothermia significantly reduced infarction size 6 hours after MCAO compared with controls (group A, 6.6+/-2.4%; group B, 20.2+/-2.6%; P<0.01). Twenty-four hours after MCAO, infarction size was not significantly reduced by hypothermia alone (group D, 21.9+/-3.6%). Compared with controls (group F, 23.3+/-3.3%), infarction size was significantly reduced and neurological performance was significantly improved in animals treated by DC (group C, 11.8+/-3.4; P<0.001). Combined hypothermia and DC resulted in additional reduction of infarction size (group E, 9.1+/-2.4%) and improved neurological score (P<0.01). CONCLUSIONS: Early DC significantly reduces infarction size and improves neurological outcome in MCA infarction in rats. Temporary mild hypothermia delays infarct evolution but does not significantly reduce definite infarction size or improve neurological outcome. Combined hypothermia and DC yield significant additional benefit.
Animals↗
MR contrast agents in acute experimental cerebral ischemia: potential adverse impacts on neurologic outcome and infarction size.
The purpose of the study was to investigate the effects of magnetic resonance (MR) contrast agents on neurologic outcome and infarction size in a rat stroke model. Focal cerebral ischemia was induced in 80 rats using an endovascular occlusion technique of the middle cerebral artery. Four hours after occlusion, 64 animals (4 groups of 16 each) received gadodiamide (Gd-DTPA-BMA) in a single (0.1 mmol/kg) or triple (0.3 mmol/kg) clinical dose or the ultrasmall superparamagnetic iron oxide particles contrast agent NC 100150 in a single (0.03 mmol/kg, 1.5 mg Fe(2+)/kg) or double (0.06 mmol/kg, 3.0 mg Fe(2+)/kg) clinical dose, respectively. Sixteen animals received equivolumetric saline (control group). Neurologic score and body weight were recorded every 8 hours. Twenty-four hours after vessel occlusion, infarction size was measured by 2,3, 5-triphenyl-tetrazolium-chloride (TTC) staining. Neither the normal nor the triple clinical dose of gadodiamide or NC 100150 in the single or double dose had any statistically significant effects on infarction volume, mortality, body weight, or neurologic outcome (P > 0.05). Our results suggest that bolus injection of gadodiamide and the ultrasmall superparamagnetic iron oxide particles NC 100150 in clinically relevant doses does not significantly affect infarction volume and clinical outcome of acute cerebral ischemia.
Animals↗
Cerebral MR perfusion imaging: first clinical application of a 1 M gadolinium chelate (Gadovist 1.0) in a double-blinded randomized dose-finding study.
The purpose of this study was to evaluate efficacy and safety of the 1 M gadolinium chelate Gadovist 1.0 for assessment of cerebral hemodynamics with dynamic susceptibility contrast-enhanced magnetic resonance (MR) imaging. Eighty-nine patients with carotid artery stenosis or cerebral infarcts were included in this multicenter, double-blinded study using five dose groups from 0.1 to 0.5 mmol/kg. Imaging was performed with 1-T scanners using a T2*-weighted fast low-angle shot (FLASH) sequence. Dose-dependent changes in quantitative and qualitative parameters describing signal-time curves and relative regional cerebral blood volume maps were investigated. For safety evaluation, vital signs, clinical and laboratory tests, and adverse events were assessed. The quantitative measurements revealed an optimal dose of 0.4 mmol/kg. The qualitative evaluation revealed that the required qualitative assessment for clinical purposes was already reached at a dose of 0. 3 mmol/kg. No significant changes in vital signs and laboratory tests were found. No serious adverse events were observed. The combined results revealed the dose of 0.3 mmol/kg as the diagnostically adequate dose given the gradient-echo sequence and field strength used. Gadovist 1.0 has been shown to be a safe and well-tolerated contrast agent. J. Magn. Reson. Imaging 2000;12:371-380.
Adolescent↗
Combined endovascular therapy of ruptured aneurysms and cerebral vasospasm.
We describe two patients with subarachnoid haemorrhage due to a ruptured intracranial aneurysm and severe symptomatic vasospasm. The aneurysm was occluded with detachable coils followed by intra-arterial infusion of papaverine to treat vasospasm as an one-stage procedure. There was significant resolution of the vasospasm. The long-term clinical outcome in one patient was excellent, the other still has minor deficits. Combined endovascular aneurysm therapy followed by intra-arterial spasmolysis with papaverine is a technically feasible therapeutic alternative in patients with symptomatic vasospasm.
Adult↗
MRI of intracranial toxoplasmosis after bone marrow transplantation.
Toxoplasma encephalitis was confirmed by biopsy in three patients with bone marrow (BMT) or peripheral blood stem-cell transplantation (PBSCT). All had MRI before antimicrobial therapy. The intensity of contrast enhancement was very variable. One patient had one large, moderately enhancing cerebral lesion and several smaller almost nonenhancing lesions. The second had small nodular and haemorrhagic lesions without any enhancement. The third had late cerebral toxoplasmosis and showed multiple lesions with marked contrast enhancement. The moderate or absent contrast enhancement in the two patients in the early phase of cerebral toxoplasmosis may be related to a poor immunological response, with a low white blood cell count in at least one patient. Both received higher doses of prednisone than the patient with late infection, leading to a reduced inflammatory response. In patients with a low leukocyte count and/or high doses of immunosuppressive therapy, typical contrast enhancement may be absent.
Adult↗
Endovascular treatment of a giant aneurysm of the internal carotid artery in a child with visual loss: case report.
We report on a case of a giant aneurysm of the internal carotid artery in a 11-year old boy presenting with gradual unilateral visual loss, combined with slight headache and retro-orbital pain. Endovascular balloon occlusion of the internal carotid artery combined with monitoring of somatosensory evoked potentials was performed. Follow-up MR imaging six months after balloon occlusion revealed complete thrombosis and considerable retraction of the aneurysm. However, visual loss persisted, since therapy was initiated too late and optic nerve atrophy had already occurred. It is important to emphasize that visual disturbance should be considered as an emergency, and, although rare, aneurysms do occur in the pediatric population.
Balloon Occlusion↗
Endovascular therapy of arteriovenous fistulae with electrolytically detachable coils.
We report our experience in using Guglielmi electrolytically detachable coils (GDC) alone or in combination with other materials in the treatment of intracranial or cervical high-flow fistulae. We treated 14 patients with arteriovenous fistulae on brain-supplying vessels--three involving the external carotid or the vertebral artery, five the cavernous sinus and six the dural sinuses--by endovascular occlusion using electrolytically detachable platinum coils. The fistula was caused by trauma in six cases. In one case Ehlers-Danlos syndrome was the underlying disease, and in the remaining seven cases no aetiology could be found. Fistulae of the external carotid and vertebral arteries and caroticocavernous fistulae were reached via the transarterial route, while in all dural fistulae a combined transarterial-transvenous approach was chosen. All fistulae were treated using electrolytically detachable coils. While small fistulae could be occluded with electrolytically detachable coils alone, large fistulae were treated by using coils to build a stable basket for other types of coil or balloons. In 11 of the 14 patients, endovascular treatment resulted in complete occlusion of the fistula; in the remaining three occlusion was subtotal. Symptoms and signs were completely abolished by this treatment in 12 patients and reduced in 2. On clinical and neuroradiological follow-up (mean 16 months) no reappearance of symptoms was recorded.
Adult↗
MR imaging of the brain: metabolic and toxic white matter diseases.
Metabolic disorders of the brain are rare, complex and confusing. The diagnostic modality of choice nowadays is MRI. The high diagnostic sensitivity, however, is coupled with a lack of specificity and usually results in the depiction of similar appearing but clinically diverse white matter processes. For this reason it is essential to perform the MRI as early as possible during the course of the disease and to keep in close contact to the referring clinician to optimize image interpretation. Another precondition is to know the natural course of brain myelination and to know how this appears on the individual MR machine with different parameters. In some diseases like phenylketonuria MRI seems to be an excellent tool to monitor dietary treatment and patient compliance. In patients after radio- and / or chemotherapy MRI reveals the radiation induced leucencephalopathy and can usually differentiate between a recurrent malignancy.
Brain↗
Iodixanol in cerebral computed tomography: a randomized, double-blind, phase-III, parallel study with iodixanol and iohexol.
Iodixanol is a new nonionic dimer, isotonic with blood at all clinically relevant concentrations. Iodixanol (270 mg I/ml) was compared in a double-blind, randomized, parallel-group, phase-III study to the monomeric nonionic iohexol (300 mg I/ml) for evaluation of safety, tolerability and radiographic efficacy during cerebral CT. One hundred adult patients scheduled to undergo contrast-enhanced cerebral CT were randomly allocated to receive either iodixanol or iohexol. All completed the trial. Safety was evaluated by recording discomfort and other adverse events, tolerance by assessing intensity and incidence of discomfort. Radiographic efficacy was assessed from the diagnostic information and the radiographic density. No serious adverse events occurred. One patient (2 %) in the iodixanol group and one patient (2 %) in the iohexol group experienced a transient reddening at the neck and lower neck-line, respectively. Both contrast agents were well tolerated. One patient (2 %) in the iodixanol group and two patients (4 %) in the iohexol group experienced a sensation of warmth (discomfort) in connection with the injection. No difference between the two contrast media were noted radiographically. This comparison between iodixanol and iohexol showed both contrast media to be safe, well-tolerated and efficacious for use in cerebral CT.
Adult↗
Carotid endarterectomy and intracranial thrombolysis: simultaneous and staged procedures in ischemic stroke.
PURPOSE: The feasibility and safety of combining carotid surgery and thrombolysis for occlusions of the internal carotid artery (ICA) and the middle cerebral artery (MCA), either as a simultaneous or as a staged procedure in acute ischemic strokes, was studied. METHODS: A nonrandomized clinical pilot study, which included patients who had severe hemispheric carotid-related ischemic strokes and acute occlusions of the MCA, was performed between January 1994 and January 1998. Exclusion criteria were cerebral coma and major infarction established by means of cerebral computed tomography scan. Clinical outcome was assessed with the modified Rankin scale. RESULTS: Carotid reconstruction and thrombolysis was performed in 14 of 845 patients (1.7%). The ICA was occluded in 11 patients; occlusions of the MCA (mainstem/major branches/distal branch) or the anterior cerebral artery (ACA) were found in 14 patients. In three of the 14 patients, thrombolysis was performed first, followed by carotid enarterectomy (CEA) after clinical improvement (6 to 21 days). In 11 of 14 patients, 0.15 to 1 mIU urokinase was administered intraoperatively, ie, emergency CEA for acute ischemic stroke (n = 5) or surgical reexploration after elective CEA complicated by perioperative intracerebral embolism (n = 6). Thirteen of 14 intracranial embolic occlusions and 10 of 11 ICA occlusions were recanalized successfully (confirmed with angiography or transcranial Doppler studies). Four patients recovered completely (Rankin 0), six patients sustained a minor stroke (Rankin 2/3), two patients had a major stroke (Rankin 4/5), and two patients died. In one patient, hemorrhagic transformation of an ischemic infarction was detectable postoperatively. CONCLUSION: Combining carotid surgery with thrombolysis (simultaneous or staged procedure) offers a new therapeutic approach in the emergency management of an acute carotid-related stroke. Its efficacy should be evaluated in interdisciplinary studies.
Acute Disease↗
[Pulse synchronous tinnitus as the only symptom of fibromuscular dysplasia of cervical arteries].
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Aneurysm↗
Relative value of MR imaging as compared with CT in the diagnosis of inflammatory paranasal sinus disease.
PURPOSE: To evaluate the relative value of magnetic resonance (MR) imaging versus computed tomography (CT) in the diagnosis of inflammatory paranasal sinus disease. MATERIALS AND METHODS: In 30 patients suspected of having or known to have inflammation of the paranasal sinuses, both coronal CT and coronal T1-weighted, three-dimensional, gradient-echo MR imaging of the paranasal sinuses were performed. Visualization of anatomic details, kind and extent of inflammatory disease, and artifacts from dental work were scored. The scores were compared by using the Wilcoxon matched pairs signed rank test. Interexamination agreement between the two methods was calculated by using a kappa analysis. RESULTS: Most bone structures of the infundibular complex were significantly better visualized at CT than at MR imaging. Orbital and brain anatomy were visualized better at MR imaging than at CT. No artifacts from dental work occurred in diagnostically relevant regions at MR imaging. There was a substantial to almost perfect agreement between CT and MR imaging for every kind and extent of the disease except for mucosal thickening in the maxillary and frontal sinuses, in the nasal cavity, and in the infundibulum. CONCLUSION: CT is superior to MR imaging in the depiction of fine bony details and anatomic variants and thus is superior to MR imaging in helping plan functional endoscopic sinus surgery. However, there are patient groups in which MR imaging can be used as a primary tool in screening for sinusitis.
Adult↗
Decompressive craniectomy, reperfusion, or a combination for early treatment of acute "malignant" cerebral hemispheric stroke in rats? Potential mechanisms studied by MRI.
BACKGROUND AND PURPOSE: Both early reperfusion and decompressive craniectomy have proved beneficial in the treatment of large space-occupying "malignant" hemispheric stroke. The aim of this study was to directly compare the benefit of reperfusion with that of craniectomy and to study the effects of combined treatment in a rat model of focal cerebral ischemia. METHODS: Cerebral ischemia was introduced in 28 rats. Four groups were investigated: (1) no treatment, (2) decompressive craniectomy, (3) reperfusion, and (4) reperfusion and craniectomy as treatment at 1 hour after middle cerebral artery occlusion. Perfusion- and diffusion-weighted MRI were performed serially from 0.5 to 6 hours after middle cerebral artery occlusion. RESULTS: The 6-hour DWI-derived hemispheric lesion volumes in the reperfusion group (10.2+/-3.9%), the craniectomy group (23.0+/-6.4%), and the combination group (21.8+/-12.4) were significantly smaller than that in the control group (44.1+/-5.4%) (P<0.05). Reperfusion, craniectomy, and combined treatment led to higher perfusion in the cortex compared with the control group, whereas only reperfused animals achieved significantly higher perfusion in the basal ganglia. In 5 animals, combined reperfusion and decompressive craniectomy resulted in an early contrast media enhancement. CONCLUSIONS: Early reperfusion and craniectomy were shown to be effective in decreasing infarction volume by improving cerebral perfusion. Reperfusion remains the best therapy in malignant hemispheric stroke. Combined treatment yields no additional benefit compared with single treatment, probably because of early blood-brain barrier breakdown.
Acute Disease↗
[Endovascular therapy of cerebral aneurysms and vasospasm].
Major improvements have been achieved in endovascular treatment of cerebral aneurysms during the last twenty years. Initial techniques of selective balloon occlusion were progressively replaced by controlled packing of the aneurysmal sac with soft detachable platinum-coils (GDC). In some patients with large or giant aneurysms of the cavernous portion of the internal carotid artery endovascular parent vessel occlusion therapy with balloons is still necessary. In aneurysms of the proximal paraclinoidal segment of the internal carotid artery a combined endovascular and microneurosurgical approach, the "evacuation-trapping"-technique might be helpful. In patients with symptomatic cerebral vasospasm in whom conservative therapy has failed or is not possible balloon angioplasty and or the intra-arterial infusion of papaverine has become a valuable therapeutic alternative. Further follow-up studies are necessary to assess the value and long-term results of endovascular strategies.
Angioplasty, Balloon↗
Pericallosal artery aneurysm originating from a "supreme anterior communicating artery".
Report on the rare case of a ruptured pericallosal aneurysm originating from an atypic communicating segment between both distal A2 arteries, called the 'supreme anterior communicating artery'. The neurosurgeon should be aware of this rare vascular anomaly that might be angiographically occult and raise unexpected intraoperative difficulties.
Adolescent↗
Diagnostic and therapeutic consequences of repeat brain imaging and follow-up vascular imaging in stroke patients.
BACKGROUND AND PURPOSE: Recently, the diagnostic and therapeutic importance of repeat radiologic imaging in stroke patients has been questioned. The aim of this study was to show the therapeutic and diagnostic consequences of both repeat brain imaging and follow-up vascular imaging in this group of patients. METHODS: Neuroradiologic images and reports as well as clinical records of 317 patients (209 men and 108 women; mean age, 63 years) were reviewed retrospectively to determine the number of modifications made to the diagnosis and therapeutic regimen and to the classification of neuroradiologic findings. RESULTS: Two hundred thirty-eight repeat imaging procedures were performed in 171 patients. Of these, 76 were vascular imaging examinations (11 CT angiograms, 13 MR angiograms, 52 digital subtraction angiograms) and 162 were cross-sectional brain imaging studies (54 MR images, 108 CT scans). Forty of the 76 vascular imaging procedures and 77 of the 162 repeat cross-sectional brain imaging studies led to important diagnostic modifications with consequences for the patients' therapy and prognosis. CONCLUSION: Our study establishes that vascular imaging methods as well as cross-sectional brain imaging used as repeat imaging procedures in stroke patients can have important diagnostic and therapeutic consequences. We believe that repeat imaging in selected subgroups will be cost-effective.
Angiography, Digital Subtraction↗
[Effect of brain edema on the recurrence pattern of malignant gliomas].
PURPOSE: To assess the influence of initial preoperative brain edema in malignant gliomas on regrowth patterns. SUBJECTS AND METHODS: 79 patients with histologically verified supratentorial malignant glioma were prospectively studied by magnetic resonance imaging (MRI) before and every 2-3 months after surgery. The median follow-up time was 11 months. We correlated the configuration of the initial vasogenic edema on T2-weighted images with tumor regrowth patterns on contrast-enhanced T1-weighted images. RESULTS: 35/47 tumor regrowths (75%) imitated the initial edema configuration, while 11/47 occurred within the initial tumor bed; in one case tumor recurrence was multilocal. CONCLUSION: In glioblastoma, tumor regrowth patterns correlate positively with the configuration of the initial vasogenic brain edema. The initial, "presurgical" peritumoral edema should thus be considered when planning further treatment.
Adult↗