IntroductionThe purpose of this study was to evaluate the safety and efficacy of the recently available flow diverter “pipeline embolization device” (PED) for the treatment of intracranial aneurysms and dissections.MethodsEighty-eight consecutive patients underwent an endovascular treatment of 101 intracranial aneurysms or dissections using the PED between September 2009 and January 2011. The targeted vessels include 79 (78%) in the anterior circulation and 22 (22%) in the posterior circulation. We treated 96 aneurysms and 5 vessel dissections. Multiple devices were implanted in 67 lesions (66%).ResultsOne technical failure of the procedure was encountered. Immediate exclusion of the target lesion was not observed. Angiographic follow-up examinations were carried out in 80 patients (91%) with 90 lesions and revealed complete cure of the target lesion(s) in 47 (52%), morphological improvement in 32 lesions (36%), and no improvement in 11 lesions (12%). Six major complications were encountered: one fatal aneurysm rupture, one acute and one delayed PED thrombosis, and three hemorrhages in the dependent brain parenchyma.ConclusionOur experience reveals that the PED procedure is technically straightforward for the treatment of selected wide-necked saccular aneurysms, fusiform aneurysms, remnants of aneurysms, aneurysms with a high likelihood of failure with conventional endovascular techniques, and dissected vessels. While vessel reconstruction, performed after dissection, is achieved within days, remodeling of aneurysmal dilatations may take several months. Dual platelet inhibition is obligatory. Parenchymal bleeding into brain areas dependent on the target vessel is uncommon.

ETV is most effective in treating uncomplicated occlusive hydrocephalus caused by aqueductal stenosis and space-occupying lesions. ETV is still effective in two-thirds of the patients with previous infections or intraventricular bleeding. Patients who have previously undergone shunting and who have occlusive hydrocephalus should undergo ETV at the time of shunt failure, with immediate ligation or removal of the shunt device. In selected cases of distorted anatomy or impaired visual conditions, stereotactic guidance is helpful.

Emotional facial paresis is characterized by impaired activation of face muscles with emotion but normal voluntary activation. We report seven patients with this sign. Their lesions involved the frontal lobe white matter, the striatocapsular territory, the anterolateral thalamus and insula, the posterior thalamus and operculum, and the mesial temporal lobe and insula each in one patient, and the posterior thalamus in two patients. Volitional facial paresis affects facial movements with voluntary effort, sparing activation on emotion. We report four such patients, with lesions involving the motor cortex in one and the pyramidal tract in the cerebral hemisphere in three.

Purpose: To determine if the diffusion tensor imaging (DTI) parameters fractional anisotropy (FA) and mean diffusivity (MD) can differentiate between accompanying edema and tumor cell infiltration of white matter (WM) beyond the tumor edge as defined from conventional MRI in low-and high-grade gliomas. Materials and Methods:We examined 12 patients with high-grade gliomas/glioblastomas and eight patients with low-grade gliomas and compared them to 10 patients with meningiomas, in which no tumor infiltration is expected. The tumor was defined as the enhancing area in glioblastomas and meningiomas and as the area of increased T2-signal in low-grade gliomas. FA and MD were measured in the center of the tumor and in the adjacent WM. The contralateral WM and internal capsule were used as an internal standard. Results:Comparing the WM areas of increased T2-signal adjacent to meningiomas and glioblastomas, we saw a trend (without significance) towards a reduction of FA, but not of MD, in glioblastomas. We found no changes of FA and MD in the WM adjacent to low-grade gliomas (without T2-signal increase) compared to the WM of the contralateral hemisphere. In meningiomas and high-grade gliomas/ glioblastomas, a narrow rim of significantly (P Ͻ 0.01) increased FA and decreased MD values around the enhancing tumor area was seen, whereas in low-grade gliomas, such a rim could not be defined. There was no contribution of FA or MD to grading of gliomas. Conclusion:In glioblastomas, a reduction of FA in the edematous area surrounding the tumor may indicate tumor cell infiltration, but a reliable differentiation between infiltration and vasogenic edema is not yet possible on the basis of DTI. The additional finding of a narrow rim of increased FA and decreased MD at the edge of glioblastomas (as well as in meningiomas) may be caused by compressed WM fibers and/or increased vascularity, but does not contribute to exclude peripheral cellular infiltration.

The overall success rate of a single ETV was 71.3 % and including successful re-ETV 76.7 %. Best results were observed in adults and children older than 1 year. Infants demonstrated significantly worser outcomes. Patients with benign aqueductal stenosis and tumor compressing the aqueduct had the greatest profit from the ETV. The stereotactic guidance had no influence on the outcome and the number of severe complications. Complications were one arterial bleeding, three venous bleedings, and one ICB, all without permanent deficit, except one permanent hemiparesis. No mortality was observed.