Introduction
Symptomatic intracerebral hemorrhage (sICH) following systemic thrombolysis for ischemic stroke is often devastating, and open surgical evacuation is considered dangerous due to the ...increased risk of perioperative bleeding, and stereotactic placement of a catheter is too time-consuming. We therefore evaluated the feasibility of a free-hand bedside catheter technique for emergency hematoma evacuation.
Methods
Patients who had a supratentorial sICH after thrombolysis, a hematoma volume > 30 ml, and an ensuing reduction in vigilance were consecutively treated with acute minimally invasive catheter hematoma evacuation. Catheter insertion and trajectory were planned via 3D-reconstructed computed tomography (CT) scan, and free-hand insertion of an external ventricular catheter into the core of the hematoma was performed bedside, followed by careful blood aspiration. Cranial CT was used to verify catheter position and residual hematoma volume. In cases, where the residual volume exceeded 15 ml, urokinase (5000 IE) was administered into the clot every 6 h until the volume decreased to < 15 ml.
Results
In all six patients, catheter aspiration immediately reduced hematoma volume by 77%, from 73 ± 20 ml to 17 ± 16 ml (
p
= 0.028). In four patients, the hematoma was almost completely removed (< 10 ml) by singular aspiration. In the remaining two patients with a residual hematoma size > 15 ml, consecutive urokinase application resulted in a further reduction to 1 ml and 15 ml, respectively, after 30 h. The median National Institues of Health Stroke Scale/Score after sICH was 19.5 points, rapidly decreasing to 11 after catheter aspiration (
p
= 0.027), and further improving to 4 at discharge. No procedure-related complications were observed.
Conclusions
Emergency free-hand bedside catheter aspiration is a reasonable option for hematoma evacuation in large thrombolysis-associated sICH when performed by experienced neurosurgeons. Larger studies would help in determining the generalizability of our findings to other centers and assessing their impact on functional outcome.
Background
Hemodynamic alterations of extracranial veins are considered an etiologic factor in multiple sclerosis (MS). However, ultrasound and MRI studies could not confirm a pathophysiological ...link. Because of technical challenges using standard diagnostics, information about the involvement of superficial intracranial veins in proximity to the affected brain in MS is scarce.
Purpose
To comprehensively investigate the hemodynamics of intracranial veins and of the venous outflow tract in MS patients and controls.
Study Type
Prospective.
Population
Twenty‐eight patients with relapsing‐remitting MS (EDSS1.9 ± 1.1; range 0–3) and 41 healthy controls.
Field Strength/Sequence
3T/2D phase‐contrast and time‐resolved 4D flow MRI, extra‐ and transcranial sonography.
Assessment
Hemodynamics within the superficial and deep intracranial venous system and outflow tract including the internal, basal, and great cerebral vein, straight, superior sagittal, and transverse sinuses, internal jugular and vertebral veins. Sonography adhered to the chronic cerebrospinal venous insufficiency (CCSVI) criteria.
Statistical Tests
Multivariate repeated measure analysis of variance, Student's two‐sample t‐test, chi‐square, Fisher's exact test; separate analysis of the entire cohort and 32 age‐ and sex‐matched participants.
Results
Multi‐ and univariate main effects of the factor group (MS patient vs. control) and its interactions with the factor vessel position (lower flow within dorsal superior sagittal sinus in MS, 3 ± 1 ml/s vs. 3.8 ± 1 ml/s; P < 0.05) in the uncontrolled cohort were attributable to age‐related differences. Age‐ and sex‐matched pairs showed a different velocity gradient in a single segment within the deep cerebral veins (great cerebral vein, vena cerebri magna VCM 7.6 ± 1.7 cm/s; straight sinus StS 10.5 ± 2.2 cm/s vs. volunteers: VCM 9.2 ± 2.3 cm/s; StS 10.2 ± 2.3 cm/s; P = 0.01), reaching comparable velocities instantaneously downstream. Sonography was not statistically different between groups.
Data Conclusion
Consistent with previous studies focusing on extracranial hemodynamics, our comprehensive analysis of intracerebral venous blood flow did not reveal relevant differences between MS patients and controls.
Level of Evidence 1.
Technical Efficacy Stage 3. J. Magn. Reson. Imaging 2020;51:205–217.
Background
The tourniquet ischemia test (IT) is a hitherto rarely used tool for the diagnostic work‐up of patients with suspected complex regional pain syndrome (CRPS). This analysis aims to ...determine the sensitivity and specificity of this test, and elucidate factors that can influence the test result.
Methods
Consecutive data on clinical presentation, results of the IT and other diagnostic tests, and clinical characteristics were analyzed from patients presenting at our autonomic laboratory between 2000 and 2011. IT results were compared with the final clinical diagnosis at discharge, and statistical analysis was performed to determine specificity, sensitivity, and positive and negative predictive values of the IT.
Results
A total of 78 patients were assessed. IT results were positive (≥50% reduction in pain during ischemia) in 26 cases and negative in 52 cases. CRPS was the final diagnosis in 45 cases, and in 33 cases, a different diagnosis was made. This results in a test sensitivity of 49% and a specificity of 88%, with a positive predictive value of 85% and a negative predictive value of 56%. Age, sex, the type and stage of CRPS, and the affected extremity did not influence the test result in a statistically significant manner. Specificity worsened to 76% if any pain reduction was rated as a positive test result.
Conclusions
A positive tourniquet IT has a high positive predictive value for the diagnosis of CRPS. It is thus useful as a confirmatory assay in patients with suspected CRPS. Low sensitivity rules out its use as a screening test.
Significance
This study retrospectively analyzed the clinical significance of the tourniquet IT that was routinely used in patients with suspected CRPS. It showed that a positive IT result is useful as a confirmatory assay in patients fulfilling the clinical criteria.
The optimal surgical approach to treat neurogenic thoracic outlet syndrome (nTOS) depends on the individual patient's anatomy as well as the surgeon's experience. The authors present a minimally ...invasive posterior approach for the resection of a prominent transverse process to reduce local muscular trauma.
A 19-year-old female presented with painful sensations in the right arm and severe fine-motor skill dysfunction in the right hand, each of which had been present for several years. Further examination confirmed affected C8 and T1 areas, and imaging showed an elongated C7 transverse process displacing the lower trunk of the brachial plexus. Decompression of the plexus structures by resection of the C7 transverse process was indicated, owing to persistent neurological effects. Surgery was performed using a minimally invasive posterior approach in which the nuchal soft tissue was bluntly dissected by dilatators and resection of the transverse process was done microscopically through a tubular retractor. The postoperative course showed a sufficient reduction of pain and paresthesia.
The authors describe a minimally invasive posterior approach for the treatment of nTOS with the aim of providing indirect relief of strain on brachial plexus structures. The advantages of this technique include a small skin incision and minor soft tissue damage.
Background
Clinical observations indicated that vaccine-induced immune thrombosis with thrombocytopenia (VITT)-associated cerebral venous sinus thrombosis (CVST) often has a space-occupying effect ...and thus necessitates decompressive surgery (DS). While comparing with non-VITT CVST, this study explored whether VITT-associated CVST exhibits a more fulminant clinical course, different perioperative and intensive care unit management, and worse long-term outcome.
Methods
This multicenter, retrospective cohort study collected patient data from 12 tertiary centers to address priorly formulated hypotheses concerning the clinical course, the perioperative management with related complications, extracerebral complications, and the functional outcome (modified Rankin Scale) in patients with VITT-associated and non-VITT CVST, both with DS.
Results
Both groups, each with 16 patients, were balanced regarding demographics, kind of clinical symptoms, and radiological findings at hospital admission. Severity of neurological symptoms, assessed with the National Institute of Health Stroke Scale, was similar between groups at admission and before surgery, whereas more patients with VITT-associated CVST showed a relevant midline shift (≥ 4 mm) before surgery (100% vs. 68.8%,
p
= 0.043). Patients with VITT-associated CVST tended to undergo DS early, i.e., ≤ 24 h after hospital admission (
p
= 0.077). Patients with VITT-associated CVST more frequently received platelet transfusion, tranexamic acid, and fibrinogen perioperatively. The postoperative management was comparable, and complications were evenly distributed. More patients with VITT-associated CVST achieved a favorable outcome (modified Rankin Scale ≤ 3) at 3 months (
p
= 0.043).
Conclusions
Although the prediction of individual courses remains challenging, DS should be considered early in VITT-associated CVST because an overall favorable outcome appears achievable in these patients.
The Harlequin syndrome may occur in patients treated with venoarterial extracorporal membrane oxygenation (VA-ECMO), in whom blood from the left ventricle and the ECMO system supply different parts ...of the body with different paCO2-levels. The purpose of this study was to compare two variants of paCO2-analysis to account for the Harlequin syndrome during apnea testing (AT) in brain death (BD) determination.
Twenty-seven patients (median age 48 years, 26–76 years; male n = 19) with VA-ECMO treatment were included who underwent BD determination. In variant 1, simultaneous arterial blood gas (ABG) samples were drawn from the right and the left radial artery. In variant 2, simultaneous ABG samples were drawn from the right radial artery and the postoxygenator ECMO circuit. Differences in paCO2-levels were analysed for both variants.
At the start of AT, median paCO2-difference between right and left radial artery (variant 1) was 0.90 mmHg (95%-confidence intervall CI: 0.7–1.3 mmHg). Median paCO2-difference between right radial artery and postoxygenator ECMO circuit (variant 2) was 3.3 mmHg (95%-CI: 1.5–6.0 mmHg) and thereby significantly higher compared to variant 1 (p = 0.001). At the end of AT, paCO2-difference according to variant 1 remained unchanged with 1.1 mmHg (95%-CI: 0.9–1.8 mmHg). In contrast, paCO2-difference according to variant 2 increased to 9.9 mmHg (95%-CI: 3.5–19.2 mmHg; p = 0.002).
Simultaneous paCO2-analysis from right and left distal arterial lines is the method of choice to reduce the risk of adverse effects (e.g. severe respiratory acidosis) while performing AT in VA-ECMO patients during BD determination.
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