Treatment issues in spontaneous cervicocephalic artery dissections

The management of cervicocephalic arterial dissections raises many unsolved issues such as: how to best acutely treat patients who present with ischemic stroke or occasionally with sub-arachnoid hemorrhage? How to best prevent ischemic stroke in patients who present with purely local signs such as headache, painful Horner Syndrome or neck pain? How long and how should patients be treated after cervicocephalic arterial dissections? Can patients resume their sports activities and when? The consensus is that, given the well-established initial thromboembolic risk, an urgent antithrombotic treatment is required in patients with a recent nonhemorrhagic cervicocephalic arterial dissection, but the type of antithrombotic treatment - anticoagulants or aspirin - as well as the indication for a local arterial treatment such as angioplasty/stenting remain debated. Evidence from a randomized clinical trial would be welcome but such a trial raises major issues of methodology, feasibility and funding. Meanwhile, cervicocephalic arterial dissection remains a situation when a bedside clinician should use, on a case-by-case basis, best clinical judgment and adopt a stepped care approach in the minority of patients who deteriorate despite initial treatment.

Percutaneous and Open Retrograde Endovascular Stenting of Symptomatic High-Grade Innominate Artery Stenosis: Technique and Follow-Up

Angioplasty and stenting of the IA have been reported with high technical and clinical success rates, low complication rates and good mid-term patency rates. Different antegrade or retrograde endovascular catheter-based approaches and combinations with surgical exposure of the CCA are used. The purpose of this study was to determine safety, efficacy and mid-term clinical and radiological outcome of the stent-assisted treatment of atherosclerotic stenotic disease of the IA with special focus on the different technical approaches.

Patterns of frontobasal and frontosinal fractures in children and teenagers relative to developmental stage of the facial skeleton

To clarify the patterns of frontobasal and frontosinal fractures in children and teenagers and to analyze whether the patterns relate to developmental stage of the facial skeleton.

Diffusion-Weighted MRI Helps Predict Outcome in Basilar Artery Occlusion Patients Treated with Intra-Arterial Thrombolysis

Intra-arterial thrombolysis (IAT) can improve clinical outcome in patients with acute basilar artery occlusion (BAO). The purpose of this study was to determine whether the severity of neurological symptoms, the extent of early ischemic damage on pretreatment diffusion-weighted MRI (DWI), and the lesion progression or regression on post-treatment MRI can predict functional outcome in patients with BAO treated with IAT.

Traumatic subarachnoid hemorrhage, basal ganglia hematoma and ischemic stroke caused by a torn lenticulostriate artery

Subarachnoid hemorrhage (SAH), basal ganglia hematoma (BGH) and ischemic stroke are common diseases with diverging therapies. The simultaneous occurrence of these diseases is rare and complicates the therapy. We report the case of a 30-year-old man with a ruptured lenticulostriate artery after traumatic brain injury that caused the combination of SAH, BGH and ischemic stroke and subsequent cerebral vasospasm. This rupture mimicked the pathophysiology and imaging appearance of aneurysmal SAH. The site of rupture was not secured by any treatment; however, hyperdynamic therapy and percutaneous transluminal angioplasty were feasible in this setting to prevent additional delayed neurological deficit.

A two-centre study on facial morphology in patients with complete bilateral cleft lip and palate at nine years of age

The aim of this study was to compare craniofacial morphology and soft tissue profiles in patients with complete bilateral cleft lip and palate at 9 years of age, treated in two European cleft centres with delayed hard palate closure but different treatment protocols. The cephalometric data of 83 consecutively treated patients were compared (Gothenburg, N=44; Nijmegen, N=39). In total, 18 hard tissue and 10 soft tissue landmarks were digitized by one operator. To determine the intra-observer reliability 20 cephalograms were digitized twice with a monthly interval. Paired t-test, Pearson correlation coefficients and multiple regression models were applied for statistical analysis. Hard and soft tissue data were superimposed using the Generalized Procrustes Analysis. In Nijmegen, the maxilla was protrusive for hard and soft tissue values (P=0.001, P=0.030, respectively) and the maxillary incisors were retroclined (P<0.001), influencing the nasolabial angle, which was increased in comparison with Gothenburg (P=0.004). In conclusion, both centres showed a favourable craniofacial form at 9-10 years of age, although there were significant differences in the maxillary prominence, the incisor inclination and soft tissue cephalometric values. Follow-up of these patients until facial growth has ceased, may elucidate components for outcome improvement.

Thickness of the anterior maxillary facial bone wall-a retrospective radiographic study using cone beam computed tomography

The purpose of this retrospective radiographic study was to analyze the thickness of the facial bone wall at teeth in the anterior maxilla based on cone beam computed tomography (CBCT) images, since this anatomical structure is important for the selection of an appropriate treatment approach in patients undergoing postextraction implant placement. A total of 125 CBCT scans met the inclusion criteria, resulting in a sample size of 498 teeth. The thickness of the facial bone wall in the respective sagittal scans was measured perpendicular to the long axis of the tooth at two locations: at the crest level (4 mm apical to the cementoenamel junction; MP1) and at the middle of the root (MP2). No existing bone wall was found in 25.7% of all teeth at MP1 and in 10.0% at MP2. The majority of the examined teeth exhibited a thin facial bone wall (< 1 mm; 62.9% at MP1, 80.1% at MP2). A thick bone wall (? 1 mm) was found in only 11.4% of all examined teeth at MP1 and 9.8% at MP2. There was a statistically significant decrease in facial bone wall thickness from the first premolars to the central incisors. The facial bone wall in the crestal area of teeth in the anterior maxilla was either missing or thin in roughly 90.0% of patients. Both a missing and thin facial wall require simultaneous contour augmentation at implant placement because of the well-documented bone resorption that occurs at a thin facial bone wall following tooth extraction. Consequently, radiographic analysis of the facial bone wall using CBCT prior to extraction is recommended for selection of the appropriate treatment approach.

Basilar artery occlusion

The clinical presentation of basilar artery occlusion (BAO) ranges from mild transient symptoms to devastating strokes with high fatality and morbidity. Often, non-specific prodromal symptoms such as vertigo or headaches are indicative of BAO, and are followed by the hallmarks of BAO, including decreased consciousness, quadriparesis, pupillary and oculomotor abnormalities, dysarthria, and dysphagia. When clinical findings suggest an acute brainstem disorder, BAO has to be confirmed or ruled out as a matter of urgency. If BAO is recognised early and confirmed with multimodal CT or MRI, intravenous thrombolysis or endovascular treatment can be undertaken. The goal of thrombolysis is to restore blood flow in the occluded artery and salvage brain tissue; however, the best treatment approach to improve clinical outcome still needs to be ascertained.

Increasing echogenicity of diffuse circumferential thickening ("macaroni sign") of the carotid artery wall with decreasing inflammatory activity of takayasu arteritis

We report a case of sonographic follow-up showing brightening of the diffuse circumferential thickening (halo) of the carotid artery wall (the so-called "macaroni sign") in a patient with decreasing inflammatory activity of Takayasu arteritis over a 6-month period. Sonographic follow-up in patients with Takayasu arteritis may be a useful complementary tool for evaluation of inflammatory activity. Besides a reduction of halo diameter, an increase in wall echogenicity appears to be a sign of decreasing inflammation.

Impact of coronary artery disease and percutaneous coronary intervention on outcomes in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation

Coronary artery disease (CAD) is frequently present in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI). While revascularisation affects peri-operative outcome in patients undergoing surgical aortic valve replacement, the impact of percutaneous coronary intervention (PCI) in patients undergoing TAVI is not well established.