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Previous studies have indicated that glabellar botulinum toxin (BTX) injections may lead to a sustained alleviation of depression. This may be accomplished by the disruption of a facial feedback loop, which potentially mitigates the experience of negative emotions. Accordingly, glabellar BTX injection can attenuate amygdala activity in response to emotional stimuli. A prototypic condition with an excess of negative emotionality and impulsivity accompanied by elevated amygdala reactivity to emotional stimuli is borderline personality disorder (BPD). In order to improve the understanding of how glabellar BTX may affect the processing of emotional stimuli and impulsivity, we conducted a functional magnetic resonance imaging (fMRI) study. Our hypotheses were (1) glabellar BTX leads to increased activation in prefrontal areas during inhibition performance and (2) BTX decreases amygdala activity during the processing of emotional stimuli in general. Using an emotional go-/no-go paradigm during fMRI, the interference of emotion processing and impulsivity in a sample of n = 45 women with BPD was assessed. Subjects were randomly assigned to BTX treatment or serial acupuncture (ACU) of the head. After 4 weeks, both treatments led to a reduction in the symptoms of BPD. However, BTX treatment was specifically associated with improved inhibition performance and increased activity in the motor cortex. In addition, the processing of negative emotional faces was accompanied by a reduction in right amygdala activity. This study provides the first evidence that glabellar BTX injections may modify central neurobiological and behavioural aspects of BPD. Since the control treatment produced similar clinical effects, these neurobiological findings may be specific to BTX and not a general correlate of symptomatic improvement.

Contemporary theories of motor control assume that motor actions underlie a supervisory control system which utilizes reafferent sensory feedbacks of actions for comparison with the original motor programs. The functional network of visuomotor action monitoring is considered to include inferior parietal, lateral and medial prefrontal cortices. To study both sustained monitoring for visuomotor incongruence and the actual detection of incongruence, we used a hybrid fMRI epoch-/event-related design. The basic experimental task was a continuous motor task, comprising a simple racing game. Within certain blocks of this task, incongruence was artificially generated by intermittent takeover of control over the car by the computer. Fifteen male subjects were instructed to monitor for incongruence between their own and the observed actions in order to abstain from their own action whenever the computer took over control. As a result of both sustained monitoring and actual detection of visuomotor incongruence, the rostral inferior parietal lobule displayed a BOLD signal increase. In contrast, the prefrontal cortex (PFC) exhibited two different activation patterns. Dorsolateral (BA 9/46) and medial/cingulate (BA 8, BA 32) areas of the PFC displayed a greater increase of activation in sustained monitoring, while ventrolateral PFC showed greater event-related activation for the actual detection of visuomotor incongruence. Our results suggest that the rostral inferior parietal lobule is specifically involved in the reafferent comparison of the test subjects’ own actions and visually perceived actions. Different activation patterns of the PFC may reflect different frontoparietal networks for sustained action monitoring and actual detection of reafferent incongruence.

IntroductionSubarachnoid haemorrhage (SAH) can result in cerebral vasospasms and delayed cerebral ischemia, which contribute significantly to morbidity and mortality. The effectiveness of endovascular treatment for this condition is still a subject of debate. However, the adjustable neck-bridging device Comaneci (Rapid Medical, Yokneam, Israel) may offer a safe and effective alternative to balloon angioplasty.Aim of StudyThe Comaneci Registry Trial is the first multicentre registry designed to evaluate the clinical and radiologic safety and efficacy of Comaneci in angioplasty of cerebral vasospasm in a standardized manner in patients with severe cerebral vasospasm after SAH.MethodsAll patients with severe vasospasm (>50%) in digital subtraction angiography (DSA) after aneurysmatic SAH treated with the Comaneci device as first-line therapy are included and evaluated through an angiographic vessel-by-vessel analysis using a 4-level scale as primary endpoint. All vessel-segments in anterior and posterior circulation up to M3-,A3- and P2-level are eligible for angioplasty with Comaneci. Clinical outcome is assessed with National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale mRS.ResultsAlthough the study is still ongoing, the preliminary findings have demonstrated the safety and effectiveness of the treatment for vasospasm with Comaneci as a first-line angioplasty device.ConclusionThe Comaneci device has the potential to serve as a first-line device for providing therapeutic benefit to patients with SAH and vasospasm. However, future prospective trials are required.Disclosure of InterestNothing to disclose

The purpose of this study was to investigate the possibility to discriminate the representation sites of lip and tongue movement in the primary motor cortex (PMC). In contrast to preceding studies this research was particularly focused on single subject analysis. Six healthy right-handed volunteers underwent functional magnetic resonance imaging (fMRI) by means of a 1.5 tesla scanner. Using a block design the subjects had to perform two different motor tasks: horizontal tongue movement and symmetrical lip pursing. To ensure that only the functional selective cortical representations for each particular motor task were determined, the approach of contrasting both motor paradigms was followed during data analysis. Selective cortex activations for both motor tasks were detectable in the motor strips and could be spatially discriminated for the whole group and for the majority of the single subjects in both hemispheres. Furthermore, expanded regions responsive to both motor tasks were found bilaterally. The individually proven possibility to differentiate the cortical representation sites of tongue and lip movements opens the chance to monitor therapeutic cortical effects after neuro-reconstructive surgery, e. g. hypoglossal-facial nerve anastomosis (HFA).

Background Patients with aneurysmal subarachnoid hemorrhage (aSAH) require close treatment in neuro intensive care units (NICUs). The treatments available to counteract secondary deterioration and delayed ischemic events remain restricted; moreover, available neuro-monitoring of comatose patients is undependable. In comatose patients, clinical signs are hidden, and timing interventions to prevent the evolution of a perfusion disorder in response to fixed ischemic brain damage remain a challenge for NICU teams. Consequently, comatose patients often suffer secondary brain infarctions. The outcomes for long-term intubated patients w/wo pupil dilatation are the worst, with only 10% surviving. We previously added two nitroxide (NO) donors to the standard treatment: continuous intravenous administration of Molsidomine in patients with mild-to-moderate aSAH and, if required as a supplement, intraventricular boluses of sodium nitroprusside (SNP) in high-risk patients to overcome the so-called NO-sink effect, which leads to vasospasm and perfusion disorders. NO boluses were guided by clinical status and promptly reversed recurrent episodes of delayed ischemic neurological deficit. In this study, we tried to translate this concept, the initiation of intraventricular NO application on top of continuous Molsidomine infusion, from awake to comatose patients who lack neurological–clinical monitoring but are primarily monitored using frequently applied transcranial Doppler (TCD). Methods In this observational, retrospective, nonrandomized feasibility study, 18 consecutive aSAH comatose/intubated patients (Hunt and Hess IV/V with/without pupil dilatation) whose poor clinical status precluded clinical monitoring received standard neuro-intensive care, frequent TCD monitoring, continuous intravenous Molsidomine plus intraventricular SNP boluses after TCD-confirmed macrospasm during the daytime and on a fixed nighttime schedule. Results Very likely associated with the application of SNP, which is a matter of further investigation, vasospasm-related TCD findings promptly and reliably reversed or substantially weakened ( p  < 0.0001) afterward. Delayed cerebral ischemia (DCI) occurred only during loose, low-dose or interrupted treatment (17% vs. an estimated 65% with secondary infarctions) in 17 responders. However, despite their worse initial condition, 29.4% of the responders survived (expected 10%) and four achieved Glasgow Outcome Scale Extended (GOSE) 8–6, modified Rankin Scale (mRS) 0–1 or National Institutes of Health Stroke Scale (NIHSS) 0–2. Conclusions Even in comatose/intubated patients, TCD-guided dual-compartment administration of NO donors probably could reverse macrospasm and seems to be feasible. The number of DCI was much lower than expected in this specific subgroup, indicating that this treatment possibly provides a positive impact on outcomes. A randomized trial should verify or falsify our results.

Purpose Identification of independent treatment factors associated with high radiation exposure during endovascular mechanical thrombectomy (EMT) in acute ischemic stroke. Methods This retrospective analysis included all patients treated by means of EMT during the 2‑year period 2017–2018 in a comprehensive stroke center. The EMT were performed by four internal and three external certified neuroradiologists in a clinic overlapping on call system. Radiation exposure as the dependent variable (dose area product DAP, Gy ⋅ cm 2 ) was dichotomized in < 100 Gy ⋅ cm 2 and ≥ 100 Gy ⋅ cm 2 . Independent variables were age (< 75 years vs. ≥ 75 years), time of intervention (during vs. beyond workday), treating neuroradiologist (internal vs. external), occlusion type (“mono” vs. “tandem”), reperfusion success (TICI 0–2A vs. TICI 2B/3), recanalization attempts (≤ 2 vs. > 2) and dose protocol (normal dose in 2017 vs. low dose in 2018). Results The EMT treatment of 208 patients (111 female, 97 male, mean age 71.6 years) was analyzed. Median DAP was 86.6 Gy ⋅ cm 2 and could be reduced from 104.8 Gy ⋅ cm 2 ( N  = 105 in 2017) to 73.3 Gy ⋅ cm 2 ( N  = 103 in 2018) with LD program. Univariable and multivariable binary logistic regression analysis revealed a significantly increased radiation exposure (≥ 100 Gy ⋅ cm 2 ) in tandem occlusion type ( P  < 0.001), > 2 recanalization attempts ( P  < 0.001) and normal dose protocol ( P  = 0.002). Conclusion Low dose programs can significantly reduce the radiation exposure in EMT. High radiation exposure is significantly associated with more than two recanalization attempts and in cases of tandem occlusions.

We report on an isolated enlargement of the fourth ventricle in a patient with neurosarcoidosis which developed 3 years after the insertion of a ventriculo-atrial shunt. Repeated MRI images were obtained in a patient with known neurosarcoidosis between 1995 and 2000. Imaging findings were correlated to the medical course of the patient, who developed a hydrocephalus and a trapped fourth ventricle consecutively. The isolation was presumably due to granulomatous inflammation of the ependyma surrounding the fourth ventricular outlets. The isolated fourth ventricle was responsible for a deterioration of neurological status. Neurosarcoidosis is a severe complication in sarcoidosis patients. An isolated enlargement of the fourth ventricle is a rare complication in clinically deteriorated patients with neurosarcoidosis and ventricular drainage, which may require neurosurgical treatment.

Introduction SWI can help to identify high-grade gliomas (HGG). The objective of this study was to analyse SWI and CE-SWI characteristics, i.e. the relationship between contrast-induced phase shifts (CIPS) and intratumoral susceptibility signals (ITSS) and their association with tumour volume in patients with glioblastoma multiforme (GBM). Materials and methods MRI studies of 29 patients were performed to evaluate distinct susceptibility signals comparing SWI and CE-SWI characteristics. The relationship between these susceptibility signals and CE-T1w tumour volume was analysed by using Spearman’s rank correlation coefficient and Kruskal-Wallis-test. Tumour biopsies of different susceptibility signals were performed in one patient. Results Comparison of SWI and CE-SWI demonstrated different susceptibility signals. Susceptibility signals visible on SWI images are consistent with ITSS; those only seen on CE-SWI were identified as CIPS. Correlation with CE-T1w tumour volume revealed that CIPS were especially present in small or medium-sized GBM (Spearman’s rho r  = 0.843, P  < 0.001). Histology identified the area with CIPS as the tumour invasion zone, while the area with ITSS represented micro-haemorrhage, highly pathological vessels and necrosis. Conclusion CE-SWI adds information to the evaluation of GBM before therapy. It might have the potential to non-invasively identify the tumour invasion zone as demonstrated by biopsies in one case. Key Points • MRI is used to help differentiate between low- and high-grade gliomas. • Contrast-enhanced susceptibility-weighted MRI (CE-SWI) helps to identify patients with glioblastoma multiforme. • CE-SWI delineates the susceptibility signal (CIPS and ITSS) more than the native SWI. • CE-SWI might have the potential to non-invasively identify the tumour invasion zone.

Purpose. To evaluate stent lumen visibility of a large sample of different peripheral arterial (iliac, renal, carotid) stents using magnetic resonance angiography in vitro. Materials and Methods. 21 different stents and one stentgraft (10 nitinol, 7 316L, 2 tantalum, 1 cobalt superalloy, 1 PET + cobalt superalloy, and 1 platinum alloy) were examined in a vessel phantom (vessel diameters ranging from 5 to 13 mm) filled with a solution of Gd-DTPA. Stents were imaged at 1.5 Tesla using a T1-weighted 3D spoiled gradient-echo sequence. Image analysis was performed measuring three categories: Signal intensity in the stent lumen, lumen visibility of the stented lumen, and homogeneity of the stented lumen. The results were classified using a 3-point scale (good, intermediate, and poor results). Results. 7 stents showed good MR lumen visibility (4x nitinol, 2x tantalum, and 1x cobalt superalloy). 9 stents showed intermediate results (5x nitinol, 2x 316L, 1x PET + cobalt superalloy, and 1x platinum alloy) and 6 stents showed poor results (1x nitinol, and 5x 316L). Conclusion. Stent lumen visibility varies depending on the stent material and type. Some products show good lumen visibility which may allow the detection of stenoses inside the lumen, while other products cause artifacts which prevent reliable evaluation of the stent lumen with this technique.