Silk Device for the Treatment of Intracranial Aneurysms. Part 1: Peri-Procedural Results, Technical Aspects and Learning Curve.

AIM: We evaluated the procedural outcomes of intracranial aneurysm treatment with the Silk device and its relation with operator experience. We also detailed some technical points we learned throughout our experience. MATERIAL AND METHODS: One hundred and six consecutive patients with intracranial aneurysms treated using Silk (BaltExtrusion, Montmorency, France) stent between October 2010 and November 2013 were included. Patients were evaluated in terms of age, sex, aneurysm size, location, technical success, and adverse events. RESULTS: There were 106 patients (71 female) undergoing 116 procedures with a mean age of 49.8 (range: 3-78 years). Mean aneurysm size was 10.7±8.0 (range, 2-40 mm). Technical success of the procedures was 96.5%. Adverse event rate was 11.2%. Among adverse events, there were 4 adverse events without complications, 2 mild complications, 7 severe complications, 4 of which resulted with death. The adverse event rate was significantly higher during the first half of the operator's experience. The rate of adverse events seemed to stabilize after around 50 patients. Adverse events, regardless of the presence or absence of a clinical complication, were more frequent in aneurysms larger than 18.5 mm. CONCLUSION: Safety of flow-diverter (FD) placement for intracranial aneurysms increases with operator experience. Training programs in endovascular management of cerebrovascular diseases and relevant fellowship curricula must be adapted to include sufficient flow diverter experience. The learning curve needs to be kept in mind when studies comparing different FD devices or those comparing other treatments to FDS are planned.

Silk Device for the Treatment of Intracranial Aneurysms, Part 2: Factors Related to Clinical and Angiographic Outcome.

AIM: To report patient and procedure-related factors affecting the angiographic and clinical outcome in patients treated with the Silk device. MATERIAL AND METHODS: All patients with intracranial aneurysms in whom treatment was attempted with the Silk flow diverter by our neurovascular team between October 2010 and November 2013 were included consecutively. The data was analyzed by an independent stroke neurologist not involved in the treatment of the patients. RESULTS: A total of 96 patients (64 female) with ages range from 3 to 78 were included in this study. We found that 54 of the patients were asymptomatic and 42 of them symptomatic, while 21 had a prior history of subarachnoid hemorrhage (SAH). Mean aneurysm size was 10.2 mm (range 2 to 40 mm). 2 patients died due to consequences of SAH. 3 patients developed visual decline on the follow-up, 2 of these were procedure-related. Symptomatic thromboembolic events were noted in 7 cases. Patients with aneurysms smaller than 13 mm had significantly less complications and higher occlusion rates. The complication rate was significantly high in patients admitted with symptoms. Adjunctive coiling had no impact on outcome. CONCLUSION: Safety and efficacy of flow diversion in this series was closely related to aneurysm size and presenting symptoms. A size cut-off for safety and efficacy has not been reported before and will be useful not only for future studies but also for patient counseling in daily practice. The futility of adjunctive coiling in this series calls for reappraisal of the current recommendations for this specific device.

Vena Cava Filters are not Superior to Low Molecular Weight Heparin in Venous Thromboembolism Prophylaxis: A Study on Long-Term Immobilized Neurosurgical Patients.

AIM: Deep venous thrombosis (DVT) and pulmonary embolism (PE) are the most frequent surgical problems and associated with high morbidity and mortality. Neurosurgical patients constitute a unique group where prophylaxis with anticoagulant and antiaggregant agents are relatively contraindicated due to the natural course of vascular problems such as aneurysms, hemorrhagic tumors or hematomas or increased vulnerability to complex spinal surgeries and trauma. MATERIAL AND METHODS: We included 67 patients predicted to be immobilized for 2 or more months in this retrospective analysis. A vena cava filter was inserted between the first and seventh postoperative day in 40 patients in a prophylactic manner whereas 27 patients received low dose heparin for the same purpose. The patients were evaluated for symptomatic DVT or PE. RESULTS: Percutaneous insertion was performed for all filters without any complication. DVT occurred in two patients of the filter group and 1 patient of the heparin group. There was no PE recorded in any patient of either group. Patients were followed up for 22 months in the filter and 16 months in the heparin group. CONCLUSION: We conclude that prophylactic filter use in high risk neurosurgical patients is not beneficial and not superior to low-molecular-weight heparin use. Nevertheless, it is reasonable to prevent PE in patients with proven DVT who have no contraindication for anticoagulant drugs.

Preliminary experience with squid: a new liquid embolizing agent for AVM, AV fistulas and tumors.

AIM: The aim of the present study was to analyze our experience with a new liquid embolic agent, Squid, for the treatment of cerebral vascular lesions. MATERIAL AND METHODS: We present 28 patients who were treated with two formulations of Squid (Squid 18 and Squid 12). The lesions included 16 arteriovenous malformation (AVM)s (Spetzler-Martin grade 2 in 8, 3 in 6 and 4 in 2), 9 arteriovenous (AV) fistulas, 2 tumors (glomus tumor and angiofibroma) and 1 AICA aneurysm. Of the 9 patients presenting with hemorrhage, 6 were AVM, 2 were AVF and 1 was aneurysm. RESULTS: The total obliteration rate of the AVMs was 37.5%. Fistulas were closed completely after combined treatment with surgery in 6 out of 9 patients, and one was sent to radiotherapy. There was no mortality. Two reported hemorrhages and thromboembolic complications resulted in permanent deficits in 3 patients. Pathologic examination revealed mild inflammatory reaction with infiltration of polymorphonuclear cells in 5 patients in whom surgery was performed immediately after embolization. Technical problems such as rupture, inability to remove or premature occlusion of the microcatheter related to the embolic agent were not recorded. CONCLUSION: Squid is a safe and effective embolic agent for treatment of cerebral AVMs, AV fistulas, tumors and aneurysms with satisfactory obliteration rate.

Effect of port-care frequency on venous port catheter-related complications in cancer patients.

PURPOSE: Subcutaneous central venous port catheters (SCVPC) are of great importance in the treatment of patients with malignancies since they provide secure vascular access. Our aim was to assess the impact of long-term catheter care frequency on the frequency of port-related complications. PATIENTS AND METHODS: Two hundred and seven patients who had not been on active chemotherapy through their SCVPC for at least 3 months were enrolled into the study. Those who received catheter care every 3 months or more frequently were assigned to the frequent care group, and the others to the infrequent care group. The patients were examined for port-related complications and thrombosis including port occlusion. Routinely in our clinic, catheter care was done by using 300 IU of heparin. RESULTS: According to the frequency of SCVPC care, 49 (23.7 %) patients were in the frequent care group and 158 (76.3 %) were in the infrequent care group. Median follow-up of all patients was 671 days (range 133-1712). Median frequency of port care in the frequent care group was 90 days (range 30-90), but 441.5 days in the infrequent care group (range 91-1630). None of the patients experienced port-related severe complications during the follow-up time. None of them presented with port occlusion. When the groups were analysed for thrombus (symptomatic and asymptomatic), there was no statistically significant difference (6.4 vs 13.8 %, p = 0.17). Those patients who had received more than first-line chemotherapy were found to have more thrombi than the patients who were treated with only one type of chemotherapy protocol (28.6 vs 10.2 %, p = 0.01), and the patients who had metastatic disease at the last control were found out to have thrombi more frequently than the non-metastatic patients (24.3 vs 9.3 %) (p = 0.01). CONCLUSIONS: In the present study, there was no difference in port-related severe complications between frequent and infrequent care groups during follow-up. However, the rate of thrombosis was slightly higher in the infrequent port care group.

Comparison of Dexmedetomidine and Midazolam in Sedation for Percutaneous Drainage of Hepatic Hydatid Cysts.

OBJECTIVE: Hydatid cyst still continues to be a public health problem. The basic treatment for the disease is surgery, but ultrasound-guided percutaneous drainage has become an important treatment alternative. Agents preferred for sedation during drainage performed under local anaesthesia must also preserve respiration and hemodynamic stability while providing adequate sedation. We compared the sedative properties of midazolam, which has a short duration of action, and a selective α2 adrenergic receptor agonist, dexmedetomidine, and the intraoperative complications. METHODS: After approval by the clinical trials ethics committee, 40 patients with similar demographic data were randomized into two groups. All patients received 10 mg metoclopramide and 45.5 mg pheniramine before the procedure. Then, midazolam (0.07 mg kg(-1) IV bolus followed by 0.01 mg kg(-1) h(-1) infusion) was administered to Group 1, and dexmedetomidine (1 µg kg(-1) loading dose in 10 minutes, followed by 0.2 µg kg(-1) h(-1) continuous infusion) was administered to Group 2 for sedation. Just before the surgical procedure, all patients received IV propofol in a subhypnotic dose of 0.5 mg kg(-1); the dose was repeated if adequate sedation could not be achieved. Observer's assessment of alertness/sedation (OAA/S) scale and Bispectral index (BIS) were used to evaluate the sedation level during the procedure. Heart rate (HR), mean arterial pressure (MAP), respiratory rate (RR), peripheral oxygen saturation (SpO2) and end-tidal carbon dioxide pressure (ETCO2) were monitored before and after induction and every 5 minutes thereafter. Propofol requirement was noted for each group. RESULTS: Sedation in the dexmedetomidine group was as effective and adequate as that observed in the midazolam group. BIS values were significantly lower in the dexmedetomidine group, especially after 10 minutes and thereafter. RR, SpO2, and ETCO2 were similar in both groups, whereas clinically insignificant decreases in HR and MAP were observed in the dexmedetomidine group. Propofol requirements were similar in both groups. CONCLUSION: We conclude that dexmedetomidine, providing adequate sedation without respiratory depression, can be considered as an appropriate agent for sedation in surgical procedures performed under local anaesthesia.

Isolated pericardial hydatid cyst in an asymptomatic patient: a remark on its radiologic diagnosis.

Cardiac hydatid cyst disease is uncommon, representing approximately 0.2% to 2% of all cyst-related cases. Cardiac hydatid cysts are found mostly within the myocardium. Most cardiac hydatid cysts are located in the interventricular septum or in the left ventricular wall. Only few cases of pericardial location have been reported; isolated pericardial hydatid cysts are especially extremely rare. Patients with a cardiac hydatid cyst are usually asymptomatic. We present the case of an asymptomatic patient with isolated pericardial hydatid cyst disease and discuss the role of chest X-rays in the incidental diagnosis of this condition.