In medically refractory patients with high-grade intracranial atherosclerotic stenoses, a new treatment paradigm involving predilation with an undersized Gateway percutaneous transluminal angioplasty balloon catheter and placement of a self-expanding Wingspan stent system appears to be safe, may facilitate remodeling, and may contribute to favorable angiographic outcomes.

Perfusion MRI is predictive in distinguishing glioblastomas from metastases, CNS lymphomas and other gliomas vs MRI and magnetic resonance spectroscopy.

Background and Purpose-The ABC/2 formula is a reliable estimation technique of intracerebral hematoma volume.However, oral anticoagulant therapy (OAT)-related intracerebral hemorrhage (ICH) compared with primary ICH is based on a different pathophysiological mechanism, and various shapes of hematomas are more likely to occur. Our objective was to validate the ABC/2 technique based on analyses of the hematoma shapes in OAT-related ICH. Methods-We reviewed the computed tomography scans of 83 patients with OAT-associated intraparenchymal ICH.Location was divided into deep, lobar, cerebellar, and brain stem hemorrhage. Shape of the ICH was divided into (A) round-to-ellipsoid, (B) irregular with frayed margins, and (C) multinodular to separated. The ABC/2 technique was compared with computer-assisted planimetric analyses with regard to hematoma site and shape. Results-The mean hematoma volume was 40.83Ϯ3.9 cm 3 (ABC/2) versus 36.6Ϯ3.5 cm 3 (planimetric analysis). Bland-Altman plots suggested equivalence of both estimation techniques, especially for smaller ICH volumes. The most frequent location was a deep hemorrhage (54%), followed by lobar (21%), cerebellar (14%) and brain stem hemorrhage (11%). The most common shape was round-to-ellipsoid (44%), followed by irregular ICH (31%) and separated and multinodular shapes (25%). In the latter, ABC/2 formula significantly overestimated volume by ϩ32.1% (round shapes by ϩ6.7%; irregular shapes by ϩ14.9%; P ANOVA Ͻ0.01). Variation of the denominator toward ABC/3 in cases of irregularly and separately shaped hematomas revealed more a precise volume estimation with a deviation of Ϫ10.3% in irregular and ϩ5.6% in separately shaped hematomas. Conclusions-In patients with OAT-related ICH, Ͼ50% of bleedings are irregularly shaped. In these cases, hematoma volume is significantly overestimated by the ABC/2 formula. Modification of the denominator to 3 (ie, ABC/3) measured ICH volume more accurately in these patients potentially facilitating treatment decisions. (Stroke. 2006;37:404-408.)

Background and Purpose-Diffusion-weighted MRI (DWI) has become a commonly used imaging modality in stroke centers. The value of this method as a routine procedure is still being discussed. In previous studies, CT was always performed before DWI. Therefore, infarct progression could be a reason for the better result in DWI. Methods-All hyperacute (Ͻ6 hours) stroke patients admitted to our emergency department with a National Institutes of Health Stroke Scale (NIHSS) score Ͼ3 were prospectively randomized for the order in which CT and MRI were performed. Five stroke experts and 4 residents blinded to clinical data judged stroke signs and lesion size on the images. To determine the interrater variability, we calculated values for both rating groups. Results-A total of 50 patients with ischemic stroke and 4 patients with transient symptoms of acute stroke (median NIHSS score, 11; range, 3 to 27) were analyzed. Of the 50 patients, 55% were examined with DWI first. The mean delay from symptom onset until CT was 180 minutes; that from symptom onset until DWI was 189 minutes. The mean delay between DWI and CT was 30 minutes. The sensitivity of infarct detection by the experts was significantly better when based on DWI (CT/DWI, 61/91%). Accuracy was 91% when based on DWI (CT, 61%). Interrater variability of lesion detection was also significantly better for DWI (CT/DWI, ϭ0.51/0.84). The assessment of lesion extent was less homogeneous on CT (CT/DWI, ϭ0.38/0.62). The differences between the 2 modalities were stronger in the residents' ratings (CT/DWI: sensitivity, 46/81%; ϭ0.38/0.76). Conclusions-CT and DWI performed with the same delay after onset of ischemic stroke resulted in significant differences in diagnostic accuracy. DWI gives good interrater homogeneity and has a substantially better sensitivity and accuracy than CT even if the raters have limited experience.

BACKGROUND AND PURPOSE:Incomplete occlusion and recanalization of large and wide-neck brain aneurysms treated by endovascular therapy remains a challenge. We present preliminary clinical and angiographic results of an experimentally optimized Surpass flow diverter for treatment of intracranial aneurysms in a prospective, multicenter, nonrandomized, single-arm study.

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Background and Purpose-Serum levels of the cytokine interleukin-6 (IL-6) rise markedly in stroke. IL-6 is a key regulator of inflammatory mechanisms that play an important part in stroke pathophysiology. The action of IL-6 is modified by its soluble receptor subunits sgp130 and sIL-6R. The purpose of this study was to investigate whether serum levels of the receptor subunits are changed after ischemic stroke and to define the role of genetic influences on IL-6 expression in acute stroke. Methods-In 48 patients with acute stroke and 48 age-and sex-matched control subjects, serum concentrations of IL-6, sgp130, and sIL-6R were measured by enzyme-linked immunosorbent assay. Furthermore, IL-6 promoter haplotypes comprising 4 different polymorphisms (Ϫ597G3 A, Ϫ572G3 C, Ϫ373A(n)T(n), Ϫ174G3 C) were determined by DNA sequencing and allele-specific oligonucleotide polymerase chain reaction. The effect of the common haplotypes on IL-6 gene transcription was tested by transfecting reporter fusion genes in the astrocytelike cell line U373. Results-Whereas serum concentrations of IL-6 significantly rose (PϽ0.001), sgp130 levels were transiently reduced after stroke (PϽ0.05), and sIL-6R levels remained unchanged. IL-6 levels depended on the infarct size and the haplotype of the promoter region. The common haplotype A-G-8/12-C was associated with low IL-6 levels after stroke and a reduced induction of IL-6 transcription on stimulation with an adenosine analog in vitro. Conclusions-The data demonstrate genetic variation in the expression of IL-6 in stroke. Induction of the inflammatory response by IL-6 might be enhanced by a transient downregulation of the potential IL-6 antagonist sgp130. (Stroke.

Background and Purpose-Intracerebral hemorrhage (ICH) is the most serious and potentially fatal complication of oral anticoagulant therapy (OAT). Still, there are no universally accepted treatment regimens for patients with OAT-ICH, and randomized controlled trials do not exist. The aim of the present study was to compare the acute treatment strategies of OAT-associated ICH using vitamin K (VAK), fresh frozen plasma (FFP), and prothrombin complex concentrates (PCCs) with regard to hematoma growth and outcome. Methods-In this retrospective study, a total of 55 treated patients were analyzed. Three groups were compared by reviewing the clinical, laboratory, and neuroradiological parameters: (1) patients who received PCCs alone or in combination with FFP or VAK (nϭ31), (2) patients treated with FFP alone or in combination with VAK (nϭ18), and (3) patients who received VAK as a monotherapy (nϭ6). The end points of early hematoma growth and outcome after 12 months were analyzed including multivariate analysis. Results-Hematoma growth within 24 hours occurred in 27% of patients. Incidence and extent of hematoma growth were significantly lower in patients receiving PCCs (19%/44%) compared with FFP (33%/54%) and VAK (50%/59%). However, this effect was no longer seen between PCC-and FFP-treated patients if international normalized ratio (INR) was completely reversed within 2 hours after admission. The overall outcome was poor (modified Rankin scale 4 to 6 in 77%). Predictors for hematoma growth were an increased INR after 2 hours, whereas administration of PCCs was significantly protective in multivariate analyses. Predictors for a poor outcome were age, baseline hematoma volume, and occurrence of hematoma growth. Conclusions-Overall, PCC was associated with a reduced incidence and extent of hematoma growth compared with FFP and VAK. This effect seems to be related to a more rapid INR reversal. Randomized controlled trials are needed to identify the most effective acute treatment regimen for lasting INR reversal because increased levels of INR were predisposing for hematoma enlargement.