Juvenile angiofibroma: major and minor complications of preoperative embolization.

INTRODUCTION: Juvenile angiofibromas (JA) are highly vascular, benign tumours for which surgery is the treatment of choice. In most services, embolisation is performed prior to resection. Nevertheless, there are few data on the complications of preoperative embolisation for JA. AIM: To describe major and minor complications of preoperative embolisation in a 32-year experience of patients undergoing surgical resection of JA at a tertiary hospital. METHODS: Retrospective chart review study of 170 patients who underwent surgical resection of JA at a tertiary hospital between September 1976 and July 2008. RESULTS: All patients were male. Age ranged from 9 to 26 years. Ninety-one patients had no complications after embolisation. Overall, 105 complication events occurred of which four major and 101 minor. CONCLUSION: In our series, preoperative embolisation for JA produced no irreversible complications and no aesthetic or functional sequelae. The vast majority of complications were transient and amenable to clinical management.

Changes in perfusion-weighted magnetic resonance imaging after carotid angioplasty with stent.

Carotid artery stenosis due to arteriosclerosis increases the risk of cerebral ischemia via embolic phenomena or reduced blood flow. The changes in cerebral perfusion that may occur after treatment are not clearly understood. This study evaluated the changes in cerebral microcirculation following carotid angioplasty with stenting (CAS) under cerebral protection with filters using ultrafast gradient echo (GRE) perfusion weighted imaging (PWI) with magnetic resonance imaging (MRI). Prospectively, 21 cervical carotid stenosis patients, mean age 69.95 years, underwent MRI 12 h before and 72 h after CAS. PWI parameters were collected for statistical analysis: cerebral blood volume (CBV), mean transit time (MTT) and time to peak (TTP). Statistical analysis was applied to absolute parameters and to values normalized against those from the contralateral parenchyma. The main finding of this study was improved hemodynamics for the normalized data after CAS, shown by reduced MTT (p<0.001) and TTP (p=0.019) in the territory fed by the middle cerebral artery ipsilateral to the CAS. Absolute data showed increased blood volume in the cerebral hemispheres after CAS, which was more accentuated on the stent side (p=0.016) than the contralateral side (p=0.029). Early improvements in cerebral perfusion, mainly seen in the normalized data, were clearly demonstrated in the timing parameters - TTP & MTT - after CAS.

Stem cells in the treatment of chronic spinal cord injury: evaluation of somatosensitive evoked potentials in 39 patients.

STUDY DESIGN: A prospective, non-randomized clinical series trial. OBJECTIVE: To evaluate the effect of autogenous undifferentiated stem cell infusion for the treatment of patients with chronic spinal cord injury (SCI) on somatosensory evoked potentials (SSEPs). SETTING: A public tertiary hospital in São Paulo, Brazil. METHODS: Thirty-nine consecutive patients with diagnosed complete cervical and thoracic SCI for at least 2 years and with no cortical response in the SSEP study of the lower limbs were included in the trial. The trial patients underwent peripheral blood stem cell mobilization and collection. The stem cell concentrate was cryopreserved and reinfused through arteriography into the donor patient. The patients were followed up for 2.5 years and submitted to SSEP studies to evaluate the improvement in SSEPs after undifferentiated cell infusion. RESULTS: Twenty-six (66.7%) patients showed recovery of somatosensory evoked response to peripheral stimuli after 2.5 years of follow-up. CONCLUSION: The 2.5-year trial protocol proved to be safe and improved SSEPs in patients with complete SCI. SPONSORSHIP: None.

Extracranial vertebral artery involvement in neurofibromatosis type I. Report of four cases and literature review.

SUMMARY: Neurofibromatosis type 1 (NF-1) is one of the most common inherited diseases and as an autosomal dominant genetic disorder results from NF-1 gene mutation with 100% penetration and wide phenotypic variability. The disease can involve a wide variety of tissues derived from all three embryonic layers. NF-1 vasculopathy has been described primarily in peripheral arteries, but arteries supplying the CNS may also be involved. Of those, extracranial vertebral involvement is the commonest and most important. A series of four patients with NF-1 and vascular disease of the vertebral artery is described with a review of the pathophysiology, vascular phenotypes, their management and the pertinent literature.

[MRI sequences in the detection of cavernous angiomas]. / Séquences de résonance magnétique dans la détection de cavernomes.

We prospectively evaluated 30 patients with CNS cavernous angioma with a high field (1.5T) magnetic resonance imager. In all patients the MRI protocol included: gradient echo T1*-weighted imaging, spin echo T2*-weighted imaging and gradient echo T2*-weighted imaging. We evaluated each case for the number of lesions detected on each sequence. Gradient echo T2*-weighted imaging with a long TE (TE: 35ms) was the most sensitive sequence for the detection of cavernous angiomas allowing detection of small lesions that were not identified on the other sequences.

Ovarian follicular dynamics of five-eighths Girolando cows.

The objective of this study was to examine the follicular dynamics of five-eighths Girolando cows by observing the number of follicular development waves, days of emergence of those waves, diameters of the dominant and largest subordinate follicles and the processes of follicular selection and dominance. Ovarian follicle dynamics were monitored for 24 oestrous cycles in 12 cows, of 4 to 10 years of age, presenting regular oestrous cycles and with body scores between 3 and 4. Ovaries were observed daily for two consecutive oestrous cycles and follicles were measured with ultrasonographic equipment. The dominant follicle was considered to be that which presented a diameter > or = 10 mm for three consecutive days and on the day of wave emergence, when a group of follicles measuring 3-5 mm in diameter would appear. Of the 24 cycles monitored, 62.5% presented two waves of follicular development and 37.5% presented three waves. The cycles presenting two waves had an average duration of 20 days, with the emergence of the waves on days 1 and 9, whereas the cycles presenting three waves had an average duration of 22 days, with emergences on days 1, 10 and 16. For cycles with two waves, both the first and second dominant follicles reached an average size of 13.8 mm, with the first regressing on day 10 and the second ovulating around day 20. For cycles with three waves, the dominant follicles of the first and second waves reached maximum diameters of 11.8 and 12 mm, respectively, with the first regressing on day 11 and the second regressing on day 17. The third dominant follicle reached a maximum diameter of 12.4 mm on day 20, and ovulated on day 22. These results lead to the conclusion that the follicular dynamics of five-eighths Girolando cows are characterized by the presence of two to three waves of follicular growth.

Doppler mapping of direct carotid-cavernous fistulae (DCCF).

The aims of this study were to establish Doppler criteria for identifying direct carotid-cavernous fistulae (DCCF), as well as the level of agreement between results obtained by Doppler mapping vs. angiography. Doppler mapping and angiography were used to assess the direction of flow in the superior ophthalmic veins and the resistivity index in the internal carotid arteries of 30 patients with DCCF. Both methods independently demonstrated reverse flow in superior ophthalmic vein ipsilateral to the DCCF in 22 patients and normal flow in another four. The mean resistivity index for internal carotid arteries with ipsilateral DCCF was significantly reduced (p = 0.0001) compared with that for contralateral internal carotid arteries without DCCF. A resistivity index value of 0.495 offered a sensitivity and specificity of 86.6% in diagnosing ipsilateral DCCF. These findings suggest that a resistivity index < 0.495 in the ipsilateral internal carotid artery, with or without reverse flow in the superior ophthalmic vein, is associated with a reasonable probability of diagnosing DCCF.

Intracranial vertebral artery dissection presenting as subarachnoid hemorrhage: successful endovascular treatment.

INTRODUCTION: Intracranial vertebral artery dissection is a rare condition which may present as subarachnoid hemorrhage. In this situation, treatment is controversial. CASE REPORT: A case of intracranial right vertebral artery dissection in a 55-year-old woman presenting with subarachnoid hemorrhage is reported. The patient underwent therapeutic occlusion of the dissected artery through microcatheterization using pushing detachable platinum microcoils and had a good outcome. At this moment, the patient has a normal neurologic examination and a control digital subtraction angiography 1 year after the procedure showed an occluded right vertebral artery at V3; there was retrograde flow in the right intracranial vertebral artery up to the origin of a meningeal branch; the artery was thin and had mural irregularities, without any evidence of aneurismatic dilatation. DISCUSSION: We review the literature and discuss the role of endovascular therapy and other therapeutic options in the treatment of this condition.

Unruptured aneurysm: vasospasm after surgery and endovascular treatment. A case report.

SUMMARY: Arterial cerebral vasospasm in different pathological conditions other than subarachnoid haemorrhage (SAH) caused by ruptured aneurysm is uncommon. The haemodynamicsclinical consequences of such conditions makes a quick diagnosis, vital to choose the best therapeutic strategy. A 55-year-old woman presented chronic headache. Computed tomography scan revealed an image suggesting carotid aneurysm on the left which was confirmed by digital angiography in the ophthalmic segment. Programmed surgery of clipping aneurysm was carried out without complications. The patient remained without morbidity for the first 16 hours, then she developed progressive aphasia, right motor deficit and loss of consciousness. The angiography showed severe vasospasm in horizontal segments of anterior cerebral artery (A1) and middle cerebral artery (Ml). Vasodilatation with topic papaverine by selective microcatheterism in Al and M1 segments achieved clinical-radiological success in time. The patient was discharged on the seventh day, with Glasgow Coma Scale (GCS) 15/15 and slight right hemiparesis. Vasospasm pathogenesis in conditions other than SAH from ruptured aneurysm remains a scientific frontier for ongoing research. We know about the short half-life effect of papaverine and believe that the success in this particular case was accurate and definite due to the fact that the mechanism of the spasm presented no bleeding in the subarachnoid cisterns.

Anomalous vessel in the middle ear: the role of CT and MR angiography.

An 8-year-old child was examined because of conductive hearing loss with a retrotympanic mass on otoscopy. CT and MR angiography showed a large inferior tympanic artery traversing the hypotympanum and joining a thin, irregular internal carotid artery with a normal middle meningeal artery. These investigations, coupled with knowledge of the embryological development allowed a diagnosis of a complex vascular anomaly in the middle ear and avoided potential surgical complications.

[Magnetic resonance study of the pineal region. Normal pineal gland and simple cysts]. / Estudo por ressonância magnética da região da pineal. Pineal normal e cistos simples.

A magnetic resonance imaging (MRI) study of the normal pineal gland and pineal simple cysts was performed in 762 cases. A fine section technique (maximum 3 millimeters) enabled most of the times the identifying of a normal pineal in addition to demonstrating that a pineal without any cyst shows an isointense signal in T1 and T2 which, in turn, is enhanced following gadolinium. The measure of the normal pineal was of about 6.1 millimeters in its diameter length. Pineal simple cysts were observed in a 2.6% frequency in relation to the whole series (762 cases); however reaches 6.1% when only the visualized pineals were considered (329 cases). Also, it was found out that simple cysts were not correlated to age or gender. Simple cysts characteristics are: dimension less or equal to 20 millimeters; absence of expansive effect; similar signal to that of the cerebrospinal fluid; absence of cyst growth.

Endovascular treatment of intracavernous carotid aneurysm with hyperprolactinaemia.

SUMMARY: A 42-year-old woman presented with headache, galactorrhoea, marked hyperprolactinemia and normal neurologic examination. CT, MR and MR-angiography showed an intracavernous carotid artery aneurysm with minimal displacement of the pituitary stalk. Treatment by embolisation using GDC coils allowed exclusion of the aneurysm. Galactorrhoea resolved and serum prolactin levels fell to normal after eight months. Followup MR showed absence of the aneurysm, although the discrete mass effect persisted, suggesting that hyperprolactinaemia was due to pulsatility.

Ophthalmic artery aneurysms: an investigation by duplex scan.

With the objective of analyzing the postaneurysmal peak systolic velocity (PSV) in ophthalmic arteries, duplex scanning was analyzed in 28 carotid-ophthalmic artery segments after exclusion of ipsilateral carotid stenosis. For comparison, the angiographic study of the extracranial and intracranial carotid system was utilized as the "gold standard." A subgroup of 7 subjects with 8 ophthalmic arteries with aneurysms identified where the artery leaves the internal carotid artery presented with PSVs significantly reduced (mean PSVs 17.95 +/- 7.99 cm/s) compared to the mean PSVs in the healthy group (27.95 +/- 5.54 cm/s) (p = 0.006). A PSV of less than 19 cm/s offered a sensitivity of 80% and a specificity of 100% in diagnosing ophthalmic artery aneurysms. We conclude that duplex scan is diagnostically useful in the identification of patients with ophthalmic artery aneurysms when severe ipsilateral carotid stenosis is excluded.

[Acute embolic stroke treated with rt-PA during elective coronary angiography]. / Acidente vascular cerebral isquêmico agudo embólico tratado com rt-PA durante cinecoronariografia eletiva.

A 56-year-old female with unstable angina, presented an acute embolic ischaemic stroke of right medium cerebral artery during elective coronary angiography. Complete patency was achieved after an intraarterial infusion of rt-PA (60mg/60min) with important functional improvement.

[Simple intraparenchymal cysts of the cerebellum. Apropos of 2 cases]. / Kystes simples intra-parenchymateux du cervelet. A propos de 2 cas.

INTRODUCTION: Cysts of the posterior fossa are common in the literature, but the simple cyst is rarely considered in the differential diagnosis of these cysts. METHOD: The cases of two female patients with clinical symptoms of expansive cerebellar lesion are described. These patients were explored by MRI. They were operated upon and an anatomico-pathological diagnosis was made. RESULTS: Both patients had an intraparenchymal cystic lesion of the cerebellum. No mural nodule and no enhancement after gadolinium injection were noted. The anatomico-pathological examination confirmed that the lesion was an intra-parenchymal simple cyst the walls of which showed no tumoral features. CONCLUSION: Although this anatomico-pathological entity has not previously been described in the literature, such rare diagnosis should be borne in mind in patients presenting with a cystic tumour of the posterior fossa. MRI is of paramount importance in the evaluation of these lesions, but the anatomico-pathological diagnosis is indispensable to exclude a possible tumour.

[Orbital phlebography evaluation in 8 cases of Tolosa-Hunt syndrome]. / Avaliação da flebografia orbitária em oito casos de síndrome de Tolosa-Hunt.

Tolosa-Hunt syndrome (THS), or painful ophthalmoplegia is associated to a non-specific granulomatosis of unknown etiology, that involves the superior orbital fissure and its nervous and vascular structures. The clinical picture that responds to steroid therapy, is variable and is always associated with pain. Inflammatory conditions, tumors and aneurysms can produce similar symptoms. Computed tomography, cerebral angiography and orbital phlebography are the imaging methods of choice for making the diagnosis. We revised the results of these radiological examinations of eight patients seen at the Hospital São Paulo from 1989 to 1991, with the diagnosis of THS according to Hunt and Hannerz criteria. The analysis of orbital phlebographic changes based upon Hannerz et al. systematization showed non-specific features, but those were able to help the diagnosis.

Avaliaçäo da flebografia orbitária em oito casos de síndrome de Tolosa-Hunt / Orbital phlebography evaluation in 8 cases of Tolosa-Hunt syndrome

A Síndrome de Tolosa-Hunt (STH) ou oftalmoplegia dolorosa é associada a granulomatose inespecifica de etiologia desconhecida que acomete a fissura orbitária superior. Compromete estruturas nervosas e vasculares causando quadro clínico variável que sempre se associa a dor e apresenta resposta favorável à corticoterapia. Processos inflamatório, tumores e anmeurismas dessa regiäo podem causar sintomas semelhantes. A tomografia computadorizada, a angiografia cerebral e a flebografia orbitária säo métodos de imagem indicados para orientar o diagnóstico. Revisamos os resultados destes exames radiológicos de oito pacientes atendidos no Hospital Säo Paulo no período 1989 a 1991, com diagnóstico de STH segundo os critérios de Hunt e Hannerz. A análise das alteraçöes da flebografia orbitária, de acordo com a sistematizaçäo feita por Hannerz e col. Mostrou ser este exame inespecífico, porém capaz de orientar melhor mo diagnóstico

[Secondary malignant tumors of the vestibulocochlear and facial nerves]. / Tumeurs malignes secondaires des nerfs vestibulo-cochléaire et facial.

INTRODUCTION: Neuromas and meningiomas represent by far the most frequent tumors of the cerebellopontine cistern (respectively over 80% and over 10%). Secondary malignant tumors are exceptional. METHOD: Presentation of four cases of malignant tumors of the cerebellopontine cistern, either revealing or complicating a primary tumor: a bronchial cancer, a cancer of the kidney, a medulloblastoma and a lymphoma. Patients were studied in T2- and T1-weighted high-field MRI sequences before and after gadolinium injection. RESULTS: The four tumors were enhanced by gadolinium and shown to invade the internal auditory canal, including one bilateral involvement. In most cases, the tumors were slightly heterogeneous and had irregular margins. CONCLUSION: These observations suggest that other diagnoses than acoustic neuroma should be taken into account.