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Background Asymptomatic carotid artery stenosis (ACS) has a low risk of stroke. To achieve an advantage over noninterventional best medical treatment (BMT), carotid endarterectomy (CEA) or carotid artery stenting (CAS) must be performed with the lowest possible risk of stroke. Therefore, an analysis of risk-elevating factors is essential. Grade of ipsilateral and contralateral stenosis as well as plaque morphology are known risk factors in ACS. Methods The randomized, controlled, multicenter SPACE-2 trial had to be stopped prematurely after recruiting 513 patients. 203 patients were randomized to CEA, 197 to CAS, and 113 to BMT. Within one year, risk factors such as grade of stenosis and plaque morphology were analyzed. Results Grade of contralateral stenosis (GCS) was higher in patients with any stroke (50%ECST vs. 20%ECST; p=0.012). Echolucent plaque morphology was associated with any stroke on the day of intervention (OR 5.23; p=0.041). In the periprocedural period, any stroke was correlated with GCS in the CEA group (70%ECST vs. 20%ECST; p=0.026) and with echolucent plaque morphology in the CAS group (6% vs. 1%; p=0.048). In multivariate analysis, occlusion of the contralateral carotid artery (CCO) was associated with risk of any stroke (OR 7.00; p=0.006), without heterogeneity between CEA and CAS. Conclusion In patients with asymptomatic carotid artery stenosis, GCS, CCO, as well as echolucent plaque morphology were associated with a higher risk of cerebrovascular events. The risk of stroke in the periprocedural period was increased by GCS in CEA and by echolucent plaque in CAS. Due to small sample size, results must be interpreted carefully.

Die hamodynamische Variante der Amaurosis fugax wird nicht durch einen passageren vollstandigen Verschluss sondern durch eine kritische Minderperfusion der A. centralis retinae verursacht. Ausloser sind meist hochgradige Stenosen der proximalen A. carotis interna. Der dargestellte Fall zeigt als eine weitere, seltene Differenzialdiagnose eine symptomatische hochgradige, hamodynamisch relevante potentiell embolisch bedingte, nicht vaskulitische Stenose der distalen Zentralarterie als Ursache fluktuierender monokularer Sehstorungen. Die orbitale Farbduplexsonografie von retrobulbaren Arterien ermoglicht durch multimodale Gefasbeurteilung eine prazise, reliable und zum therapeutischen Monitoring einfach reproduzierbare Darstellung einer symptomatischen Zentralarterienstenose. Unter individueller Behandlung auf Grundlage der vaskularen Ultraschallbefunde mit anfangs toleriertem Erfordernishochdruck zur Sicherung einer hamodynamisch ausreichenden retinalen Blutversorgung und sekundarprophylaktischer einfacher Thrombozytenfunktionshemmung traten keine weiteren Sehstorungen mehr auf. Die hamodynamisch relevante Zentralarterienstenose bildete sich im Sinne einer vollstandigen Rekanalisation innerhalb von 4 Wochen anhaltend und vollstandig zuruck. Evidenzbasierte Therapien einer symptomatischen Zentralarterienstenose liegen bislang wie auch beim embolisch verursachten Zentralarterienverschluss nicht vor, so dass prospektive Studien zur Evaluation einer standardisierten Behandlung dieses vaskularen Notfalls erforderlich sein werden.

Zur Pravention zerebraler Ischamien sollte ein von Karotisstenosen oder Plaques ausgehendes Schlaganfallrisiko fruhzeitig erkannt werden. Das Standardverfahren fur die Diagnostik der Halsarterien ist die Duplexsonographie. Die Diagnostik unter Verwendung der neuen standardisierten DEGUM-Kriterien (Deutsche Gesellschaft fur Ultraschall in der Medizin) erlaubt eine verlassliche Graduierung von Karotisstenosen und die Erkennung einer Stenoseprogression im Verlauf. Alle aktuellen Leitlinien empfehlen die Duplexsonographie als Standardverfahren. Therapeutische Konsequenzen beim Nachweis von Atherosklerose sind die intensivierte Kontrolle und Therapie vaskularer Risikofaktoren. Bei rasch progredienter und sehr hochgradiger Stenose sind im Einzelfall Operation oder Stenting indiziert. Der Nachweis einer Atheromatose ist unkompliziert und methodisch nicht anspruchsvoll. Zur Erkennung einer Karotisstenose mit hohem Schlaganfallrisiko ist die exakte Graduierung des Stenosebefundes durch einen erfahrenen Untersucher erforderlich. Das Screening wird empfohlen fur Patienten mit vaskularen Risikofaktoren, nicht fur die Allgemeinbevolkerung. Bei Nachweis einer Karotisstenose sollte eine genaue Quantifizierung der Stenose durch einen erfahrenen Anwender erfolgen.

Die Riesenzellarteriitis (RZA) kann durch Manifestation an hirnversorgenden Arterien zerebrale Ischamien verursachen und ist eine wichtige Differenzialdiagnose der zerebralen Makroangiopathie. Bevorzugt betroffen sind die extrakraniellen Abschnitte der Vertebralarterien. Wir berichten uber 3 Patienten, bei denen sich eine RZA mit hochgradigen intrakraniellen Vertebralisstenosen und Kleinhirninfarkten manifestierte. Nur bei einer Patientin war eine Polymyalgia rheumatica assoziiert, ansonsten lagen keine Symptome vor, die die klinische Diagnose einer Arteriitis cranialis erlaubt hatten, insbesondere initial keine Kopfschmerzen. Die Diagnose konnte bei allen Patienten durch sonografischen Nachweis des Halo-Zeichens an den Vertebral- und Temporalarterien gestellt werden. Die Stenosebefunde bildeten sich unter Behandlung mit Prednisolon bei 2 Patienten kontinuierlich zuruck, bei einem bestanden sie fort. Eine Manifestation der RZA im intrakraniellen Abschnitt der A. vertebralis gilt als seltener Befund. Da die Arterie langstreckig durch die Vaskulitis betroffen ist, konnte die Diagnose in den von uns beobachteten Fallen durch extrakranielle Farbduplexsonografie gestellt werden. Die Untersuchung ist technisch einfach, erfordert aber Erfahrung des Untersuchers. In unklaren Fallen konnen erganzend PET bzw. PET-CT oder spezielle Sequenzen einer kontrastgestutzten MRT, moglichst mit 3 Tesla-System, zur Diagnosesicherung eingesetzt werden. Wichtig ist die Sonografie – zusammen mit klinischen und laborchemischen Verlaufsparametern – fur das Monitoring von Gefasbefunden zur Optimierung der immunsuppressiven und thrombozytenaggregationshemmenden Therapie.

Die zerebrovaskulare Beteiligung ist eine fur die Prognose der bakteriellen Meningitis relevante Komplikation. Wir berichten uber eine Patientin mit Pneumokokkenmeningitis, die unter laufender Therapie mit Antibiotika und Dexamethason eine Dysphasie entwickelte. Die zerebrale Kernspintomografie einschlieslich time-of-flight-Angiografie blieb unauffallig. Mittels transkranieller Farbduplexsonografie konnten jedoch hochgradige Stenosen der Arteria cerebri media beidseits nachgewiesen werden, deren vollstandige Ruckbildung innerhalb von 14 Tagen macht Vasospasmen als Ursache der Stenosen wahrscheinlich. Unter Tripel-H-Therapie war die Dysphasie vollstandig rucklaufig. Der Fall zeigt die klinische Relevanz der Erkennung zerebraler Vasospasmen als wichtigen prognostischen Faktor bei bakterieller Meningitis. Spatestens mit Auftreten neurologischer Fokalsymptome sollte die transkranielle Farbduplexsonografie erganzend eingesetzt werden, damit Risikopatienten vor Auftreten hamodynamischer Hirninfarkte identifiziert und der Verlauf der Vasospasmen kontrolliert werden konnen. Diagnostische und therapeutische Konsequenzen waren ein vaskulares Monitoring mit konsequenter hypotonievermeidender Kreislaufstabilisierung.

Die idiopathische intrakranielle Hypertension (IIH) kann zu irreversiblen Gesichtsfelddefekten fuhren. Als mogliche Ursachen kommen eine Liquordruckerhohung im subarachnoidalen Kompartiment der Sehnervenscheide und des Sehnervenkopfes mit chronischer Ischamie des Nervus opticus und eine unzureichende Autoregulation der retinalen Perfusion in Betracht, die zu einer erhohten Pulsatilitat der A. centralis retinae fuhren konnen. Deshalb ist ein sorgfaltiges Monitoring des Liquordrucks unter Therapie erforderlich. Wahrend die Druckmessung mittels Lumbalpunktion ein invasives Verfahrens darstellt, ist die transbulbare sonografische Beurteilung des Sehnervenscheidendurchmessers eine valide Moglichkeit, erhohten Hirndruck nichtinvasiv zu kontrollieren. Wir konnten erstmals kasuistisch dokumentieren, dass sich – passend zum Charakter eines Kompartmentsyndroms der Sehnervenscheide – zusatzlich auch die duplexsonografisch darstellbare Hamodynamik der A. centralis retinae bei einer Patientin mit IIH in Abhangigkeit vom Liquordruck verandert: Die bei erhohtem Liquordruck pathologisch erhohte Pulsatilitat der Strompulskurve normalisiert sich zeitnah nach lumbaler Entlastungspunktion. Sollte sich die Validitat dieses neuen gefassonografischen Parameters zum Monitoring pathologischer Druckverhaltnisse des Sehnervenkompartiments an groseren Patientenkollektiven prospektiv bestatigen lassen, ergabe sich neben der etablierten B-Bild Sonografie des Optikusscheidendurchmessers ein weiteres sonografisches Instrument zum Therapiemonitoring bei idiopathischer intrakranieller Hypertension.

Since 1986, German ultrasound criteria for grading carotid stenosis have followed the local diameter reduction percentage consistent with the definition used in the European Carotid Surgery Trial (ECST) definition. To overcome the confusion caused by the coexisting grading method used in the North American Symptomatic Carotid Endarterectomy Trial (NASCET), a German interdisciplinary council on carotid artery stenosis has recommended the implementation of the NASCET grading system (distal diameter reduction percentage) as the standard. The multi-parametric German "DEGUM ultrasound criteria" consisting of combined Doppler and imaging criteria have consequently been revised and transferred to the NASCET definition. In addition, a novel differentiation between main (primary) and additional (secondary) criteria has been proposed. When these ultrasound criteria are combined, vascular sonography allows reliable grading of carotid disease.

Die bildgebende Diagnostik der Gefase ermoglicht heute neben der Darstellung des Gefaslumens und der Perfusion auch die Beurteilung der Gefaswand: Dadurch lassen sich nicht nur stenosierende Gefaserkrankungen erkennen, sondern auch solche, die vorwiegend die auseren Gefaswandschichten betreffen. Von den verfugbaren bildgebenden Verfahren, die zur Diagnostik an den Halsarterien eingesetzt werden, hat die Sonografie die hochste raumliche Auflosung und ist deshalb fur die Diagnostik nicht atheromatoser Pathologien besonders geeignet. Eine besondere Gefaspathologie erfordert meist eine spezifische Behandlung, deshalb hat ihr Nachweis erhebliche Relevanz. Voraussetzung fur eine erfolgreiche Diagnostik ist immer die Kenntnis der klinischen Symptomatologie: Die Bildgebung sollte bereits mit einer konkreten Verdachtsdiagnose erfolgen, damit die Untersuchungstechnik differenziert eingesetzt werden kann. Bei routinemasiger Untersuchung der hirnversorgenden Arterien konnen besondere Pathologien leicht ubersehen werden. Dissektion !

PURPOSE To evaluate duplex ultrasonography of external carotid artery branches for the non-invasive diagnosis of dural AV fistulae (DAVFs). MATERIALS AND METHODS A total of 126 patients suffering from pulsatile tinnitus underwent duplex ultrasonography of the cervicocephalic vasculature including external carotid artery branches. DAVFs were identified by increased flow velocity and reduced pulsatility. Patients with ultrasound findings of DAVFs were considered for selective angiography. RESULTS Of the 23 patients that fulfilled the ultrasound criteria of AV fistula, 5 did not undergo angiography and were excluded from the study. The ultrasound findings of AV fistula were confirmed in all remaining patients (17 DAVFs, 1 extracranial AV fistula). Duplex ultrasound detected a DAVF of the common carotid artery in 29 %, of the external carotid artery in 65 % and of the external carotid artery branches in 100 % of the cases. CONCLUSION Duplex ultrasonography of external carotid artery branches improves the non-invasive detection of DAVFs. For the evaluation of the venous drainage, however, selective angiography is necessary.

Die Bestimmung des Stenosegrades und die Beurteilung der Stenosemorphologie sind wichtig fur die Planung einer Operation oder einer Stentimplantation. Der Gefasultraschall ist normalerweise das Verfahren der ersten Wahl zur Bewertung von Karotisstenosen.

Purpose: Physical and technical artefacts of the colour Doppler method are examined with regard to their diagnostic relevance for the carotid artery. Materials and methods: After recording all diagnostic problems arising from physical and technical artefacts in 30,000 consecutively carotid arteries, the quantitative significance of relevant artefacts was determined in minor subgroups of the collective. Results: Acoustic shadowing causes diagnostic problems in morphological and haemodynamic evaluation of stenoses. Mirror image artefacts simulate flow in cases of actual vessel occlusion or mimic vessel wall ulceration in carotid plaques and stenoses. Insonation angle artefacts inhibit detection of flow or mimic flow reversal. Problems of spatial resolution lead to incorrect demonstration of the vessel lumen in stenotic findings. Aliasing, perivascular colour artefacts, and ghosting do not cause any diagnostic problems. Relevant shadowing artefacts occurred in 14.7%, and relevant mirror image artefacts in 2.5% of the pathological cases. Insonation angle artefacts occurred in 17.3% of the cases (when using standard apparatus setting). However, with an exact knowledge of the artefact phenomena, insonation angle artefacts could be eliminated and mirror image artefacts were recognized in all cases. Resolution artefacts resulted in underestimation of carotid stenoses by on average 13.3% of the degree of stenosis. Conclusion: In principle, four artefact phenomena give rise to diagnostic problems; however, with a good knowledge of the phenomena, only artefacts due to acoustic shadowing and limited spatial resolution are of diagnostic significance.

UNLABELLED Therapeutic decisions in cases of arteriosclerotic stenosis of the internal carotid artery usually depend mainly on the degree of stenosis. However, the recommendations with regard to suitable ultrasonographic criteria are so controversial that even authors of repute describe "confusion" and "chaos in methodology". AIM The aim of this study is to assess which of the most frequently recommended sonographic criteria for stenosis best fulfill the requirements of an exact quantification of stenoses of the internal carotid artery. METHOD In 42 consecutive cases the preoperative ultrasound findings were compared with the degree of stenosis in surgically removed specimens. The sonographic technique employed consisted of the analysis of 2 direct and 3 indirect hemodynamic criteria of stenosis. In 34 of these cases planimetry was performed, too. The specimens were obtained by eversion thrombendarteriectomy or arteriotomy; for determination of the degree of stenosis a Paladur molded cylinder was prepared and measured. RESULTS Quantification of the haemodynamic criteria carries provided well with the endarterectomy specimens. Only in two cases there was a deviation of more than 10 %; however, in these two cases a change with time in the degree of stenosis was probably responsible for the discrepancy. In contrast, planimetry usually underestimated the degree of stenosis: In 61 % of the findings the ultrasonographic results differed by more than 10 % from the reference standard. CONCLUSION Quantification of stenosis of the internal carotid artery should be made using a combination of direct and indirect haemodynamic ultrasonographic criteria.

UNLABELLED Perivascular tissue vibrations, an artefact of the colour Doppler method, are already known to be a sonographic sign of stenosis but have not yet been investigated systematically in the examination of the internal carotid artery. AIM The present study is intended to assess the value of this artefact in the diagnosis of stenosis of the internal carotid artery. METHOD A total of 167 consecutive cases including a stenosis of the internal carotid artery of at least 50% were diagnosed according to the usual haemodynamic criteria using Doppler and duplex sonography and classified into 10% categories. Intermediate groups were formed for findings that could not be assigned unambiguously. By means of suitable apparatus settings each finding was examined to test whether a perivascular colour artefact was detectable. RESULTS In the stenosis categories of 50% to 70% no perivascular colour artefact was found, whereas in the stenosis categories of 80% to 90% this was the case in 80% of the findings, and in the intermediate 75% category in 42% of the findings. The perivascular colour artefact was recognizable even under poor sonographic conditions. CONCLUSION When a perivascular colour artefact is seen the diagnosis of a high-degree stenosis (or an AV fistula) is certain. The phenomenon is particularly valuable as a supplementary criterion of stenosis in cases of unfavourable sonographic conditions. However, the perivascular colour artefact may only be used to confirm, but never to exclude, a high-degree stenosis.

Craniofacial pain may lead to an extensive differential diagnosis. A rare cause is Eagle's syndrome, which was first described in 1937. It is characterised by cranial and facial pain associated with the sensation of a foreign body in the pharynx. Typically, these complaints can be elicited by speaking, swallowing or cervical rotation. The symptoms, which may vary between individual patients, may be evoked by an abnormal length of the styloid process or calcification of the stylohyoid ligament. Due to their close anatomic relationship, they irritate the mandibular branch of the fifth cranial nerve and / or the intermediate nerve or even the caudal cranial nerves, respectively. Only a small number of patients with an abnormally prolonged styloid process develop Eagle's syndrome. In some of these cases the syndrome occurs spontaneously, in other cases it follows a local surgical or external trauma, probably due to individually different anatomic anomalies. In most of these symptomatic cases, the manifestation of Eagle's syndrome has been elicited by tonsillectomy. The case report presented here documents an Eagle syndrome following ipsilateral carotid endarterectomy. We discuss diagnostic criteria and therapeutic options for Eagle syndrome's, which may be underestimated as a reason for craniocervical neuralgic pain, since the symptoms of this entity are variable and non-specific at the first manifestation.

Bilateral embolic infarction of the thalamus is an uncommon manifestation of stroke. If ventromedial hypothalamic areas are affected additionally due to their common arterial supply, a long-lasting tendency to hypoglycaemia may occur as a rare but relevant complication. Because corticotropin-releasing factor receptors within the ventromedial hypothalamus regulate the hypoglycaemia-induced hormonal counterregulation, ischaemic damage to these areas also impairs the neuroendocrine response to hypoglycaemia. The following case report demonstrates a patient with a cardioembolic bilateral thalamic and hypothalamic infarction, which became evident by this uncommon clinical feature. Any other reasons for the complicating long-lasting tendency to hypoglycaemia seen in our case could be excluded.

Cranial dural fistulae are rare; when they occur, it is usually difficult to detect them at an early stage. With a view to the question of possible progress in diagnosis we now report on seven patients with lateral dural fistulae fed by branches of the external carotid artery. The examination was carried out before selective arteriography using cw-Doppler sonography and colour coded duplex sonography in combination. Sonographic criteria for detection of hyperperfusion take account of flow velocity as well as pulsatility. In all cases hyperperfusion of the external carotid artery was detected. In most of these cases pathologic findings were also observed at the occipital artery, and more rarely in the contralateral external carotid artery or the ipsilateral vertebral artery, in addition. A possible source of error arising from confusion of blood vessels was present with the cw-Doppler sonography, but not for colour coded duplex sonography. Therefore, cranial dural fistulae characterized by a high shunt volume can be diagnosed correctly by indirect Doppler sonographic criteria using cw-Doppler and duplex sonography. Direct visualization of the fistula and its nidus requires additional selective arteriography, in the course of which endovascular embolization may be performed.

Eine 51-jahrige Frau erlitt wahrend eines Urlaubs plotzlich heftigen und anhaltenden Schwindel mit Ubelkeit und Erbrechen. Aus der Vorgeschichte war kein Trauma zu eruieren, auch keine arztliche Behandlung oder Manualtherapie; die Patientin berichtete allein uber Nacken-Hinterkopfschmerzen, die wenige Tage zuvor nach einem Friseurbesuch (und Haarwasche mit stark rekliniertem Kopf) aufgetreten waren. Die Schwindelsymptomatik besserte sich im Verlauf, war aber nach einer Woche noch nicht abgeklungen. Die Patientin wurde daraufhin in unserer Gefasambulanz vorgestellt. Das kraniale MRT wies einen territorialen, wahrscheinlich durch Embolie entstandenen Kleinhirninfarkt rechts nach. Wir fuhrten eine Duplexsonographie der hirnversorgenden Arterien durch, verwendeten dazu das System Siemens Elegra (Siemens AG, Erlangen) mit Linearschallkopfen 7.5L40 und 5.0L40. Folgende Arterien wurden jeweils beidseits untersucht: A. carotis communis, A. carotis interna und A. carotis externa, A. vertebralis sowie A. subclavia. Die Darstellung der A. vertebralis erfolgte in den Segmenten V1 bis V3. Mit Untersuchung der A. subclavia wurden auch die Abgange ihrer Aste am Subklaviabogen dargestellt. Erganzend wurde mit cw-Dopplersonographie die A. supratrochlearis bds. untersucht. Mittels transkranieller Doppler-Sonographie wurden die A. cerebri media, A. cerebri anterior, A. cerebri posterior, A. carotis interna und A. vertebralis jeweils bds. sowie die A. basilaris untersucht. Die A. carotis war in allen untersuchten Abschnitten und Asten (extraund intrakraniell) unauffallig. Die A. subKasuistiken /Case reports VASA 2005; 34:50–52

The aim was to identify the risk of impending stroke originating from diseases of the carotid artery.Duplex scanning is the standard method for clinical examination of carotid arteries.By implementing the new standardized German Society for Ultrasound in Medicine (DEGUM) criteria, ultrasound examination enables reliable grading of carotid artery disease and identification of the progression of stenosis.Current guidelines recommend duplex scanning as the standard method. In consequence of finding atherosclerosis, intensive monitoring and therapy of cardiovascular risk factors is mandatory. In cases showing rapid progression of stenosis or a very high degree of stenosis indicating increased risk of stroke, carotid endarterectomy or stenting is warranted.Detection of carotid artery atherosclerosis is uncomplicated and the method is not demanding; however, identification of high-risk carotid disease by exact grading of carotid stenosis requires investigation by an experienced examiner.Screening is recommended for patients exhibiting cardiovascular risk factors but is not recommended for the general population. On detection of carotid stenosis an exact grading of stenosis by an experienced examiner is absolutely essential.

A group of 59 patients with stroke due to acute vertebrobasilar or carotid territory occlusion have been treated by local intra-arterial fibrinolysis (LIF). A high recanalisation rate was accomplished with either urokinase or recombinant tissue plasminogen activator (r-TPA). However, with either substance, even if a high dose was used, recanalisation was a time-consuming process which usually took 120 min. A reasonable explanation for the lack of effectiveness of these plasminogen-activating substances might be a deficit of substrate, e.g. plasminogen, in aged thrombus. LIF was capable of improving clinical outcome in acute vertebrobasilar artery occlusion, reducing mortality to 50% in patients fulfilling inclusion criteria. In the carotid territory multiple occlusions had a poor prognosis while good clinical results could be achieved in occlusions of the proximal middle cerebral artery or single branches.

Since 1986, German ultrasound criteria for grading carotid stenosis have followed the local diameter reduction percentage consistent with the definition used in the European Carotid Surgery Trial (ECST) definition. To overcome the confusion caused by the coexisting grading method used in the North American Symptomatic Carotid Endarterectomy Trial (NASCET), a German interdisciplinary council on carotid artery stenosis has recommended the implementation of the NASCET grading system (distal diameter reduction percentage) as the standard. The multi-parametric German "DEGUM ultrasound criteria" consisting of combined Doppler and imaging criteria have consequently been revised and transferred to the NASCET definition. In addition, a novel differentiation between main (primary) and additional (secondary) criteria has been proposed. When these ultrasound criteria are combined, vascular sonography allows reliable grading of carotid disease.

A 51-year-old woman suffering from vertigo presented to our cerebrovascular laboratory. MRI revealed a right-sided cerebellar infarction. On ultrasound examination, we found a dissection with wall hematoma of the right subclavian artery extending to the first segment of the vertebral artery and to the thyrocervical trunc, as well as a dissection of the left vertebral artery in the cranio-cervical junction. On follow-up evaluation, all stenoses resulting from dissection were recanalized within 2 months and findings of wall hematoma disappeared completely within 7 months. There was no evidence of a traumatic or iatrogenic cause of dissection; an aortic dissection was excluded by MRI. So we diagnosed a spontaneous dissection of the subclavian artery--an extremely rare but apparently existing vascular condition.

To evaluate duplex ultrasonography of external carotid artery branches for the non-invasive diagnosis of dural AV fistulae (DAVFs).A total of 126 patients suffering from pulsatile tinnitus underwent duplex ultrasonography of the cervicocephalic vasculature including external carotid artery branches. DAVFs were identified by increased flow velocity and reduced pulsatility. Patients with ultrasound findings of DAVFs were considered for selective angiography.Of the 23 patients that fulfilled the ultrasound criteria of AV fistula, 5 did not undergo angiography and were excluded from the study. The ultrasound findings of AV fistula were confirmed in all remaining patients (17 DAVFs, 1 extracranial AV fistula). Duplex ultrasound detected a DAVF of the common carotid artery in 29 %, of the external carotid artery in 65 % and of the external carotid artery branches in 100 % of the cases.Duplex ultrasonography of external carotid artery branches improves the non-invasive detection of DAVFs. For the evaluation of the venous drainage, however, selective angiography is necessary.

Prof. Dr. Kurt A. Jager vollendet im September 2013 sein 65. Lebensjahr und wird dann als Direktor der Klinik Angiologie am Universitatsspital Basel in den Ruhestand treten. Er hat entschieden, sich gleichzeitig aus dem Editorial Board von Ultraschall in der Medizin/European Journal of Ultrasound zuruckzuziehen. Im Namen der Zeitschrift, ihrer Leser und Autoren mochten wir ihm fur die langjahrige engagierte Arbeit als Herausgeber herzlich danken. Seit 30 Jahren ist Prof. Jager ein herausragender Experte fur die Anwendung des Gefas-Ultraschalls, ein wahrer Leuchtturm! Stets international orientiert und engagiert, war er 1984 Grundungsmitglied des DEGUM-Arbeitskreises Gefasdiagnostik; der Arbeitskreis profitierte immer sehr von seiner Mitarbeit und seiner Expertise. Wahrend die DEGUM-Spezialisten damals noch sehr mit der cw-Doppler-Sonografie beschaftigt waren, wendete Kurt Jager nach einem Forschungsaufenthalt in Seattle bei Prof. D. E. Strandness jr. bereits systematisch die Duplex-Sonografie an. Er interessierte sich fruh fur das Farbdoppler-Verfahren und faszinierte die Gefas-Ultraschall-Experten auf dem Hamburger Dreilandertreffen 1989 mit einem eindrucksvollen Referat uber diese neue Technik. Beim Dreilandertreffen 1994 in Basel, das er als Tagungsprasident organisierte, war die Farbduplex-Sonografie bereits Themenschwerpunkt. Ein groses Anliegen war ihm, auch in seinen Fortbildungen, immer die genaue Kenntnis und Beachtung physikalischer und technischer Grundlagen der Methode. Bei kontrastmittelgestutzter Sonografie (CEUS) legte er grosen Wert auf ein standardisiertes Vorgehen: Er ist wesentlich an der Entwicklung europaischer Leitlinien zur Anwendung von CEUS beteiligt. 1999 wurde Prof. Jager Mitherausgeber von Ultraschall in der Medizin. Hier konnte er die vertrauensvolle Zusammenarbeit zusammen mit Gert Judmaier und Karlheinz Seitz aus der gemeinsamen Zeit als Prasidenten der SGUM, OGUM und DEGUM fortsetzen. Mit hohem zeitlichen Aufwand und sorgfaltiger Auswahl der Manuskripte hatte er stets die Qualitat der Zeitschrift im Auge. Zusammen mit dem vierten Mitherausgeber, Eberhard Merz, arbeitete das Editorenteam stets einvernehmlich am langsamen Anstieg des Impact Faktors. Um die Ultraschall in der Medizin auch fur hochwertige englischsprachige Publikationen zu offnen, wurde die Zeitschrift schlieslich zweisprachig. Dieser vorausschauenden Entscheidung und Kurt Jagers Einfluss, seiner internationalen Reputation und seinem diplomatischen Geschick in der EFSUMB, der er von 2002 bis 2005 als Prasident vorstand, war es zu verdanken, dass Ultraschall in der Medizin 2004 zum European Journal of Ultrasound, dem offiziellen Organ der EFSUMB wurde. Als weiterhin zweisprachige Zeitschrift wendet sie sich an ihre ursprunglichen Abonnenten. Alle CME-Fortbildungsartikel, Titelbildbeitrage und Editorial sowie alle Abbildungslegenden sind zweisprachig. Originalarbeiten werden inzwischen fast ausschlieslich englischsprachig publiziert. Mit grosem Geschick war Kurt Jager die treibende Kraft fur die Europaisierung der Herausgeber und des Editorial Boards. Die „echte“ Internationalisierung der Zeitschrift wurde so zur Erfolgsgeschichte: Ultraschall in Med/EJU ist mit dem aktuellen Impact Factor (2011) von 2,398 die am hochsten gerankte interdisziplinare Ultraschall-Zeitschrift weltweit. Dieser Weg ware ohne Kurt Jager nicht moglich gewesen. Kurt Jager war langjahrig Vorstandsmitglied der Schweizerischen Gesellschaft fur Ultraschall in der Medizin (SGUM) und der Schweizerischen Gesellschaft fur Angiologie. Er war auch Prasident beider Gesellschaften sowie Prasident der EFSUMB. Er ist Ehrenmitglied der DEGUM und der SGUM und hat zahlreiche weitere Ehrungen erfahren und mehrere wissenschaftliche Preise erhalten. Er war in zahlreichen weiteren Fachgesellschaften und Organisationen und im Editorial Board mehrerer Zeitschriften ehrenamtlich tatig. Wir sind ihm sehr dankbar, dass er sich neben diesen Aufgaben so engagiert fur Ultraschall in Med/EJU eingesetzt hat. Kurt Jager erledigt Aufgaben immer mit vollem Engagement, nie mit halber Kraft. Deshalb ist es folgerichtig und verstandlich, dass er sich mit Eintritt in den Ruhestand aus dem Herausgebergremium der Zeitschrift zuruckzieht, so sehr wir diesen Schritt auch bedauern. Wir danken ihm herzlich fur seine Kollegialitat und Freundschaft und dafur, dass er uns uber so viele Jahre fachlich ein leuchtendes Vorbild war. Lieber Kurt, du wirst uns fehlen! Karlheinz Seitz im Namen aller Herausgeber und Christian Arning.

Determining degree and morphology of stenoses is important for surgical planning or stent implantation. Vascular ultrasound is usually the first modality to evaluate carotid artery stenosis. Due to rapid development various methods of vascular ultrasound are applied including continuous wave (CW) Doppler, duplex Doppler, colour-coded duplex sonography (CCDS), power Doppler and B-flow technique. For quantitative assessment of the degree of stenosis the most frequently used parameters are peak systolic velocity (PSV), end-diastolic velocity (EDV) in the internal carotid artery (ICA), as well as ICA to CCA ratios of PSV and EDV. Different results reported in the literature may reflect differences in defining the degree of stenosis and methodological differences in protocol or imaging techniques. Differences in defining the degree of stenosis, advantages and disadvantages of the different Doppler techniques and future developments are discussed in detail.

Therapeutic decisions in cases of arteriosclerotic stenosis of the internal carotid artery usually depend mainly on the degree of stenosis. However, the recommendations with regard to suitable ultrasonographic criteria are so controversial that even authors of repute describe "confusion" and "chaos in methodology".The aim of this study is to assess which of the most frequently recommended sonographic criteria for stenosis best fulfill the requirements of an exact quantification of stenoses of the internal carotid artery.In 42 consecutive cases the preoperative ultrasound findings were compared with the degree of stenosis in surgically removed specimens. The sonographic technique employed consisted of the analysis of 2 direct and 3 indirect hemodynamic criteria of stenosis. In 34 of these cases planimetry was performed, too. The specimens were obtained by eversion thrombendarteriectomy or arteriotomy; for determination of the degree of stenosis a Paladur molded cylinder was prepared and measured.Quantification of the haemodynamic criteria carries provided well with the endarterectomy specimens. Only in two cases there was a deviation of more than 10 %; however, in these two cases a change with time in the degree of stenosis was probably responsible for the discrepancy. In contrast, planimetry usually underestimated the degree of stenosis: In 61 % of the findings the ultrasonographic results differed by more than 10 % from the reference standard.Quantification of stenosis of the internal carotid artery should be made using a combination of direct and indirect haemodynamic ultrasonographic criteria.

On the basis of morphological and hemodynamic criteria, color-coded duplex sonography enables diagnostic evaluation of non-atheromatous lesions of the cervical arteries. Ultrasonography is the method of first choice for Takayasu's arteritis, radiation angiopathy, and common carotid artery dissections. Internal carotid and vertebral artery dissections are detected in up to 95% and 79%, respectively; in some of these cases, however, ultrasonography delivers unspecific findings so that dissections can only be confirmed when typical clinical symptoms are present, too. Detection of vasospasms of the cranial arteries is extremely difficult, on account of their tendency for rapid regression; however, sonography is in principle a suitable method. In cases of fibromuscular dysplasia ultrasound has furnished less positive results on account of the unfavourable localisation for duplex sonography. As the disease has a relatively good prognosis, only symptomatic cases need to be detected. On the whole, sonography is a suitable method for the diagnosis of nonatherosclerotic diseases of the cervical arteries.

The aim of this study was to assess the current value of extracranial continuous wave (cw) Doppler sonography in routine use as compared to color-coded duplex sonography. For this purpose, 500 carotid and 500 vertebral arteries were examined by a user experienced in both methods. The error rate of Doppler sonography was determined only when the methods allowed a clear decision to be made about the status of the vessel (normal findings including common variants, stenosis, and occlusion). In 85.4% of the carotid arteries and 88% of the vertebral arteries, the Doppler findings fulfilled the diagnostic differentiation unequivocally. For these cases, false findings were obtained in 1.9% of the carotid arteries and 0.2% of the vertebral arteries. Accordingly, a clear Doppler sonographic finding, normal or pathologic, is still of large diagnostic value. However, ambiguous or uncertain findings requiring further diagnostic workup are not uncommon. Thus, the sole use of cw Doppler sonography is no longer sufficient in a stroke center but still retains its utility in the practitioner's office.

The aim of this study was to determine the acute effects of the "Ecstasy" analogue MDE (3,4-methylene dioxyethamphetamine) on cerebral glucose metabolism (rMRGlu) of healthy volunteers and to correlate neurometabolism with acute psychopathology. In a randomized double-blind trial, 15 healthy volunteers without a history of drug abuse were examined with fluorine-18-deoxyglucose (18FDG) positron emission tomography (PET) 110-120 min after oral administration of 2 mg/kg MDE (n = 7) or placebo (n = 8). Two minutes prior to radiotracer injection, constant cognitive stimulation was started and maintained for 32 min using a word repetition paradigm to ensure constant and comparable mental conditions during cerebral glucose uptake. Individual brain anatomy was represented using Tl-weighted 3D flash magnetic resonance imaging (MRI), followed by manual regionalization into 108 regions of interest and PET/MRI overlay. After absolute quantification of rMRGlu and normalization to global metabolism, normalized rMRGlu under MDE was compared to placebo using the Mann-Whitney U-test. Acute psychopathology was assessed using the Positive and Negative Syndrome Scale (PANSS) and rMRGlu was correlated to PANSS scores according to Spearman. MDE subjects showed significantly decreased rMRGlu in the bilateral frontal cortex: left frontal posterior (-7.1%, P0.05) and right prefrontal superior (-4.6%, P0.05). On the other hand, rMRGlu was significantly increased in the bilateral cerebellum (right: +10.1%, P0.05; left: +7.6%, P0.05) and in the right putamen (+6.2%, P0.05). There were positive correlations between rMRGlu in the middle right cingulate and grandiosity (r = 0.87, P0.05), both the right amygdala (r = 0.90, P0.01) and the left posterior cingulate (r = 0.90, P0.01) to difficulties in abstract thinking, and the right frontal inferior (r = 0.85, P0.05), right anterior cingulate (r = 0.93, P0.01), and left anterior cingulate (r = 0.85, P0.05) to attentional deficits. A negative correlation was found between the left frontal operculum (Broca's area) and attentional deficits (r = -0.85, P0.05). The present study revealed acute neurometabolic changes under the "Ecstasy" analogue MDE, indicating a frontostriatocerebellar imbalance paralleling other psychotropic substances or various psychiatric disorders.

Spontaneous or traumatic arteriovenous fistulae between vertebral artery and the surrounding venous plexus may cause vertebrobasilar hypoperfusion by steal effects. We report on a 71-year-old man presenting with vertigo. Duplex sonography revealed a vertebral arteriovenous fistula at the C4/5 level with the typical perivascular color Doppler artifact and hyperperfusion in the supplying arteries and draining veins. Angiography confirmed the findings; the consequently performed endovascular embolization using platin coils and silicon balloon removed the symptoms immediately. Ultrasonographic follow-up examinations within 5 months demonstrated the success of therapy showing only low-flow fistula yet. This case demonstrates that early detection of a vertebral arteriovenous fistula by duplex sonography is highly beneficial because efficient treatment modalities are available.

The aim of the present study was to determine the acute effects of the "Ecstasy" analogue MDE (3, 4-methylendioxyethamphetamine) on the cerebral glucose metabolism (rMRGlu) of healthy volunteers.In a randomised double-blind trial, 16 healthy volunteers without a history of drug abuse were examined with 18-FDG PET 110-120 minutes after oral administration of 2 mg/kg MDE (n = 8) or placebo (n = 8). Beginning two minutes prior to radiotracer injection, a constant cognitive stimulation was maintained for 32 minutes using a word repetition paradigm in order to ensure constant and comparable mental conditions during cerebral 18-FDG uptake. Individual brain anatomy was represented using T1-weighted 3D flash MRI, followed by manual regionalisation into 108 regions-of-interest and PFT/MRI overlay. Absolute quantification of rMRGlu and comparison of glucose metabolism under MDE versus placebo were performed using Mann-Whitney U-test.Absolute global MRGlu was not significantly changed under MDE versus placebo (MDE: 41.8 +/- 11.1 mumol/min/100 g, placebo: 50.1 +/- 18.1 mumol/min/100 g, p = 0.298). The normalised regional metabolic data showed a significantly decreased rMRGlu in the bilateral frontal cortex: left frontal posterior (-7.1%, p0.05) and right prefrontal superior (-4.6%, p0.05). On the other hand, rMRGlu was significantly increased in the bilateral cerebellum (right: +10.1%, p0.05; left +7.6%, p0.05) and in the right putamen (+6.2%, p0.05).The present study revealed acute neurometabolic changes under the "Ecstasy" analogon MDE indicating a fronto-striato-cerebellar dysbalance with parallels to other psychotropic substances and various endogenous psychoses respectively.

A 71-year-old man presented with a pulsating swelling in the lower right neck region. On clinical examination palpation revealed a local thrill and auscultation the typical systolic vascular sounds. On sonography the typical findings for an AV fistula with large widening of the jugular vein and entry of an extremely rapid jet stream into the vein were detected. The entry point was under a venous valve whose movements apparently influenced the jet stream since the inflow was only seen intermittently and only in the systolic phase. The shunt volume of the fistula was apparently small: indirect signs of an arteriovenous short circuit could not be seen on duplex sonography. The low-flow fistula was not demonstrated by arterial DSA. Thus, the arterial sources could not be identified. Sonographic monitoring over 5 years at first showed no changes while at the last follow-up the fistula was no longer detectable. The suspected cause of the arteriovenous fistula was a vascular wall perforation effected some years previously during insertion of a central venous catheter. We further assume that the anticoagulation therapy with Marcumar started at that time had prevented spontaneous closure of the fistula over a period of several years. This case illustrates the value of colour-coded duplex sonography for the differentiation of pulsating tumors in the neck. In individual cases of AV fistulas with low shunt volumes the method is apparently superior even to angiography.

The practical application of colour-coded duplex sonography shows that physico-technical artifacts of colour Doppler imaging may not be obvious in all cases and can lead to misinterpretation. Slice-thickness artifacts are due to restricted transversal resolution, as in the B-mode, and may cause false negative results in vascular occlusions. Specific problems in creating and processing the colour flow image interfere with lateral resolution and lead to errors in the quantification of stenoses from the colour Doppler image. Mirror image artifacts produce phantom pictures that can be easily identified as such in some cases, but may resemble recesses in the arterial wall in other cases. Phenomena of sound shadowing resulting from the same reasons as in B-mode may lead to assume vascular occlusions in cases of long-range stenoses. Artifacts of the sonication angle in case of blood vessel tortuosity may lead to misdiagnosis of a non-existent retrograde flow. The artifacts mentioned do restrict the capacity of colour coded duplex sonography for localising flow in the ultrasound image. Users of the method should therefore be familiar with these artifacts.

Cranial dural fistulae are rare; when they occur, it is usually difficult to detect them at an early stage. With a view to the question of possible progress in diagnosis we now report on seven patients with lateral dural fistulae fed by branches of the external carotid artery. The examination was carried out before selective arteriography using cw-Doppler sonography and colour coded duplex sonography in combination. Sonographic criteria for detection of hyperperfusion take account of flow velocity as well as pulsatility. In all cases hyperperfusion of the external carotid artery was detected. In most of these cases pathologic findings were also observed at the occipital artery, and more rarely in the contralateral external carotid artery or the ipsilateral vertebral artery, in addition. A possible source of error arising from confusion of blood vessels was present with the cw-Doppler sonography, but not for colour coded duplex sonography. Therefore, cranial dural fistulae characterized by a high shunt volume can be diagnosed correctly by indirect Doppler sonographic criteria using cw-Doppler and duplex sonography. Direct visualization of the fistula and its nidus requires additional selective arteriography, in the course of which endovascular embolization may be performed.

At the University Hospital Eppendorf, we have performed local intra- arterial fibrinolytic (LIF) therapy in acute stroke patients with a superselective technique since 1987 [4, 7]. With urokinase a high recanalization rate was achieved, but complete recanalization did not usually occur before 120 min of infusion. Recombinant tissue plasminogen activator (rt-PA) not only has a higher fibrin specificity and less fibrinogen affinity, but it has a much shorter half-life in plasma than urokinase. Even a relatively high dose of rt-PA (20 mg alteplase) in comparison to urokinase (750000/IU) would have less of an influence on systemic hemostasis, but eventually perhaps a better impact on clot lysis. Thus, we have compared the efficacy of rt-PA with urokinase regarding the time to achieve clot resolution in vivo.

Ein Verschlus der A. carotis communis oder interna kann bereits mittels konventioneller cw-Dopplersonographie mit hoher Treffsicherheit nachgewiesen werden. Zur Klarung der Ursache des Gefasverschlusses ist aber der Einsatz bildgebender Verfahren erforderlich. Angiographisch wird eine Differenzierung versucht nach der Form des proximalen S tumpfes: ein zuverlassiger Schlus auf die Ursache der Obliteration ist hieraus aber nicht moglich (2). Die bildgebende Sonographie ermoglicht jedoch eine direkte Darstellung der Obliteration und erlaubt zusatzliche Aussagen uber deren Art und Ursache.