Safety and Clinical Effectiveness of Percutaneous Vertebroplasty in the Elderly (≥80 years).

PURPOSE: To evaluate the safety and clinical effectiveness of percutaneous vertebroplasty (PVP) in patients aged 80 and over. METHODS: One hundred and seventy-three patients (127 women, 46 men; mean age = 84.2y) underwent 201 PVP procedures (391 vertebrae) in our institution from June 2008 to March 2012. One hundred and twenty-six patients (73 %) had osteoporotic vertebral compression fractures (VCF), 36 (20.5 %) were treated for tumour lesions, and the remaining 11 (6.5 %) for lesions from another cause. Comorbidities and American Society of Anesthesiologists (ASA) scores were assessed before treatment. Periprocedural and delayed complications were systematically recorded. A qualitative scale was used to evaluate pain relief at 1-month follow-up, ranging from significant pain worsening to marked improvement or disappearance. New fracture occurrence was assessed on follow-up imaging. RESULTS: Forty-five percent of patients had pretreatment ASA class scores ≥3. No major complication occurred. Pain was unchanged in 16.9 % of cases, mildly improved in 31.5 %, and disappeared in 47.8 %. We identified 27 (11 %) symptomatic new VCFs in patients with osteoporosis on follow-up imaging. The mean delay in diagnosis of new fractures was 5 ± 8.7 months. CONCLUSIONS: Even in the elderly, PVP remains a safe and effective technique for pain relief, independently of the underlying disease. KEY POINTS: • Post-PVP pain improvement was observed in 79.3 % of elderly patients. • PVP remains a safe technique in elderly patients. • No decompensation of comorbidity was observed in our series.

Rescue N-butyl-2 cyanoacrylate embolectomy using a Solitaire FR device after venous glue migration during arteriovenous malformation embolization: technical note.

One of the procedural risks in arteriovenous malformation (AVM) embolization is possible migration of the embolic agent into the venous drainage with an incomplete nidus occlusion, which may lead to severe hemorrhagic complications. This report presents the case of a 29-year-old man who presented with a deep intraparenchymal hematoma on the left side secondary to the spontaneous rupture of a claustral AVM. Upon resorption of the hematoma, the patient underwent an initial therapeutic session of N-butyl-2 cyanoacrylate endovascular embolization, with the purpose of reducing the AVM volume and flow before performing Gamma Knife radiosurgery. After glue injection into one of the arterial feeders, the control angiography showed a partial migration of the glue cast into the straight sinus, with most of the nidus still visible. Because of the bleeding risk due to possible venous hypertension, it was decided to try to retrieve the glue from the vein by using a stent retriever via jugular access. This maneuver allowed a nearly complete removal of the glue cast, thereby restoring normal venous flow drainage. The patient showed no clinical worsening after the procedure. To the authors' knowledge, this is the first report of the use of the Solitaire FR device as a rescue glue retriever. This method should be considered by physicians in cases of unintended glue migration into the venous circulation during AVM embolization.

Has the percutaneous vertebroplasty a role to prevent progression or local recurrence in spinal metastases of breast cancer?

OBJECTIVE: To evaluate the effectiveness of percutaneous vertebroplasty (PV) on the prevention of progression or local recurrence in patients with spinal metastases from breast cancer. MATERIALS AND METHODS: Retrospective study on 55 patients between 27-78 years of age (mean age: 55 years) treated for metastatic breast cancer in the same institution (Curie institute, Paris, France), who underwent percutaneous vertebroplasty (PV) (number of vertebrae treated=137) for spinal metastases from January 2000 to December 2009 at the Pitié-Salpêtrière hospital. Statistical correlation between the local tumor progression/recurrence, and the presence of an epidural or a paravertebral metastatic extension at diagnosis, the rate of cement filling the lesion (<50%, ≥50% but incomplete, complete/almost complete) and radiotherapy was evaluated using Chi(2) and Fisher's exact test. RESULTS: The rate of local tumor progression/recurrence of the vertebrae treated by vertebroplasty was 14% (19/137). No statistically significant correlation between either the rate of cement filling of the lesion, or the presence of an epidural or paravertebral metastatic extension, and progression/local recurrence after vertebroplasty was found. No influence of radiotherapy in preventing local progression/recurrence was noted. Distant new bone metastases were observed in 47 out of 55 patients (86%). CONCLUSION: The low rate of local tumor progression/recurrence after a vertebroplasty may support the hypothesis of an antitumor effect of the cement.

Occlusion of M1 segment after superficial temporal artery-middle cerebral artery bypass in a giant M1 aneurysm with Onyx-34 injected via a double-lumen balloon under balloon inflation.

A 29-year-old patient attended our institution for recurrent strokes related to a giant partially thrombosed M1 aneurysm. Superficial temporal artery-middle cerebral artery (STA-MCA) bypass and subsequent occlusion of both the aneurysm and the dysplastic M1 segment were planned. However, owing to the shortness of the non-dysplastic segment of M1 and the risk of occlusion of the lenticulostriate arteries, the use of a double-lumen balloon was considered for coiling and subsequent injection of Onyx. STA-MCA bypass was performed using a regular technique. Endovascular occlusion of both the aneurysm and the parent artery was subsequently performed by means of coils and Onyx-34 that was injected via the Ascent balloon under balloon inflation. No complications were recorded and no stroke was observed on control MRI. The injection of Onyx-34 through a double-lumen balloon under balloon inflation is a quick and safe technique for precise occlusion of a parent artery.

Occlusion of M1 segment after superficial temporal artery-middle cerebral artery bypass in a giant M1 aneurysm with Onyx-34 injected via a double-lumen balloon under balloon inflation.

A 29-year-old patient attended our institution for recurrent strokes related to a giant partially thrombosed M1 aneurysm. Superficial temporal artery-middle cerebral artery (STA-MCA) bypass and subsequent occlusion of both the aneurysm and the dysplastic M1 segment were planned. However, owing to the shortness of the non-dysplastic segment of M1 and the risk of occlusion of the lenticulostriate arteries, the use of a double-lumen balloon was considered for coiling and subsequent injection of Onyx. STA-MCA bypass was performed using a regular technique. Endovascular occlusion of both the aneurysm and the parent artery was subsequently performed by means of coils and Onyx-34 that was injected via the Ascent balloon under balloon inflation. No complications were recorded and no stroke was observed on control MRI. The injection of Onyx-34 through a double-lumen balloon under balloon inflation is a quick and safe technique for precise occlusion of a parent artery.

Safety and effectiveness of percutaneous sacroplasty: a single-centre experience in 58 consecutive patients with tumours or osteoporotic insufficient fractures treated under fluoroscopic guidance.

OBJECTIVE: To report our experience in percutaneous sacroplasty (PSP) for tumours and insufficiency fractures of the sacrum. METHODS: Single-centre retrospective analysis of 58 consecutive patients who underwent 67 PSPs for intractable pain from sacral tumours (84.5 %) or from osteoporotic fractures (15.5 %). The following data were assessed: visual analogue scale (VAS) before and after the procedure for global pain; short-term (1-month) clinical follow-up using a four-grade patient satisfaction scale (worse, unchanged, mild improvement and significant improvement); modification in analgesics consumption; referred short-term walking mobility. Minor and major complications were systematically assessed. RESULTS: The mean VAS score was 5.3 ± 2.0 in pre-procedure and 1.7 ± 1.8 in post-procedure. At 1-month follow-up, 34/58 (58.5 %) patients experienced a mild improvement; 15/58 (26 %) presented a significant improvement while 4/58 (7 %) and 5/58 (8.5 %) patients had unchanged or worse pain, respectively. Decreased analgesic consumption was observed in 34 % (20/58) of the patients. Eighty percent of patients with walking limitation experienced improvement, 16 % remained unchanged and 4 % were worse. We noted minor complications in 2/58 patients (3.4 %) and major complications in 2/58 patients (3.4 %). CONCLUSION: Percutaneous sacroplasty for metastatic and osteoporotic fractures is a safe and effective technique in terms of pain relief and functional outcome. KEY POINTS: • Percutaneous sacroplasty provides pain relief and functional improvement for insufficiency sacral fractures. • Percutaneous sacroplasty provides pain relief and function improvement for sacral tumours. • The major complication rate is acceptable (3.4 %), and is higher in sacral tumours. • Posterior wall/cortical sacral bone disruption is not statistically associated with more complications. • However, osteolytic tumours seem to be associated with higher risk of complications.

Onyx injection by direct puncture for the treatment of hypervascular spinal metastases close to the anterior spinal artery: initial experience.

Presurgical devascularization of hypervascular spinal metastases has been shown to be effective in preventing major blood loss during open surgery. Most often, embolization can be performed using polyvinyl alcohol (PVA) microparticles. However, in some cases, the close relationship between the feeders of the metastases and the feeders of the anterior spinal artery (ASA) poses a risk of spinal cord ischemia when PVA microparticle embolization is performed. The authors present their early experience in the treatment of spinal metastases close to the ASA; in 2 cases they injected Onyx-18, by direct puncture, into hypervascular posterior arch spinal metastases situated close to the ASA. Two women, one 36 and the other 55 years of age, who presented with spinal lesions (at the posterior arch of C-4 and T-6, respectively) from thyroid and a kidney tumors, were sent to the authors' department to undergo presurgical embolization. After having performed a complete spinal digital subtraction angiography study, a regular angiography catheter was positioned at the ostium of the artery that mainly supplied the lesion. Then, with the patient in the left lateral decubitus position, direct puncture with 18-gauge needles of the lesion was performed using roadmap guidance. Onyx-18 was injected through the needles under biplanar fluoroscopy. Satisfactory devascularization of the lesions was obtained; the ASA remained patent in both cases. The metastases were surgically removed in both cases within the 48 hours after the embolization and major blood loss did not occur. Presurgical devascularization of hypervascular spinal metastases close the ASA by direct puncture with Onyx-18 seems to be an effective technique and appears to be safe in terms of the preserving the ASA's patency.

Combined Angio-Seal™ and stenting rescue treatment in a case of iatrogenic common carotid artery dissection during direct puncture for ruptured intracranial aneurysm embolization: a technical note.

BACKGROUND AND IMPORTANCE: Direct puncture may offer an alternative access for embolization of intracranial aneurysms in patients presenting with tortuous vessels. Nevertheless, major complications such as compressive hematoma and arterial dissection can occur with this technique. CLINICAL PRESENTATION: A tight common carotid artery (CCA) dissection was seen secondary to direct puncture in a 72-year-old patient who presented with a ruptured anterior communicating artery (ACom) aneurysm. After regular coiling of the aneurysm and using a femoral approach, an Angio-Seal™ device (St Jude Medical, Saint Paul, MN, USA) was placed and a carotid wallstent (Stryker Neurovascular, Fremont, CA, USA) successfully deployed at the dissected CCA, which was followed by good clinical and angiographic outcomes. CONCLUSION: A combined rescue technique combining Angio-Seal insertion and stent deployment was safe and effective for managing iatrogenic carotid artery dissection.

Spontaneous closure of intracranial dural arteriovenous fistulas: a report of 3 cases.

Spontaneous closures of dural arteriovenous fistulas (dAVFs) are rare. We present spontaneous occlusion of dAVFs in 3 cases (one type IIa dAVF, one type IIb and one type III). Patients were 3 males with a mean age of 55 years (range 45-61). For two patients, the dAVF was revealed by hemorrhage. No head trauma was recorded at the interrogatory. Mean delay for spontaneous closure was 4 months (3-5 months). Review of the literature about this rare occurrence is presented and the factors that may lead to spontaneous occlusion of dAVFs are discussed.

Transoral approach for percutaneous vertebroplasty in the treatment of osteolytic tumor lesions of the lateral mass of the atlas: feasibility and initial experience in 2 patients.

STUDY DESIGN: Case series. OBJECTIVE: To report our early experience of percutaneous vertebro-plasty via a transoral approach of the lesions of the lateral mass of C1. SUMMARY OF BACKGROUND DATA: Percutaneous vertebroplasty has gained acceptance for the treatment of osteolytic lesions of the spine. However, scant data are available on the percutaneous vertebroplasty of the C1 lesions. METHODS: Two patients (a 74-yr-old female and a 53-yr-old male) presenting respectively a metastasis of the left lateral mass of C1 from a pancreatic adenocarcinoma and a hemangioma of the left lateral mass of C1 underwent a percutaneous vertebroplasty via a transoral approach in a hybrid angio suite associating a monoplane flat panel and a computed tomography scan, using polymethylmetacrilate bone cement.For the second patient, a nondetachable balloon was used to protect the vertebral artery from cement leakage. RESULTS: Satisfactory filing of the lesions was obtained in both patients. No complication was recorded. Both patients experienced pain improvement. CONCLUSION: Transoral approach for the treatment of osteolytic tumor lesions of the lateral mass of the atlas is feasible and seems to be a safe and effective technique.

Atorvastatin decreases computed tomography and S100-assessed brain ischemia after subarachnoid aneurysmal hemorrhage: a comparative study.

OBJECTIVE: Statins, which improve the bioavailability of endogenous nitric oxide and upregulate endothelial nitric oxide synthase, have been used to prevent cerebral vasospasm after aneurysmal subarachnoid hemorrhage. The objective of this study was to determine whether statin therapy diminished vasospasm-induced ischemia as assessed using daily measurements of serum S100B, a biomarker for cerebral ischemia, and computed tomography measurement of ischemic lesion volume. DESIGN: Single-center study of cases and historical controls. SETTING: Neurointensive care unit in a university hospital. PATIENTS: Consecutive patients with aneurysmal subarachnoid hemorrhage treated with clipping or coiling within 96 hrs of symptom onset (n = 278) were included from April 2004 to October 2007. INTERVENTION: Oral atorvastatin, 40 mg/day for 21 days, was used routinely starting on December 1, 2005, in 142 patients, who were compared with the 136 patients managed earlier. MEASUREMENTS AND MAIN RESULTS: Ischemic lesion size was measured using computed tomography on the last available scan and serum S100B was assayed daily for 15 days after admission. Angiographic narrowing was semiquantitatively assessed in patients with vasospasm. In the overall population, cerebral vasospasm was significantly less common in the statin-treated group. Severity of vasospasm, as assessed on the most severe angiogram, was lowered with statin. Statins significantly reduced volume of ischemia in patients with vasospasm and an uncomplicated coiling procedure. S100B levels were significantly lower in statin-treated patients, and the decrease was greatest among high-grade patients (World Federation of Neurological Surgeons 3-5). No differences were found between statin-treated and untreated groups regarding rescue therapy intensity or 1-yr clinical outcomes. CONCLUSIONS: Atorvastatin reduces the incidence, the severity and the ischemic consequences of vasospasm as assessed on computed tomography. In high-grade World Federation of Neurological Surgeons patients, atorvastatin decreases serum levels of S100B, a biomarker of brain ischemia. Despite these positive effects on biomarkers, no improvement of outcome was seen in the overall population, although there was a tendency for a better clinical outcome in high-grade patients.