Living with a Brain AVM: A Quality of Life Assessment.

BACKGROUND AND PURPOSE: Brain arteriovenous malformations (AVM) are uncommon vascular lesions with the risk of hemorrhage, epileptic seizures, neurological deficits, and headache. Comparing the risks of the natural history and that of preventive treatment, a recent study has found observation more beneficial than treatment for unruptured AVMs. This study, however, did not consider the long-term impact of carrying a brain AVM on everyday activities. In this study we analyzed the Quality Of Life (QOL) of patients with untreated AVMs, a measure increasingly used in clinical trials to asses this kind of impact. METHODS: We enrolled 36 patients with unruptured, untreated brain AVM from our hospital database and measured their QOL retrospectively using the EQ-5D-5L questionnaire. As a control group we used the results of the Research Report, a nationwide study based on the quality of life of 5534 healthy Hungarians in 2002. Due to the low number of cases, statistical analysis could not be made. RESULTS: Headache proved to be the most common AVM-related sign in our cohort (40%, n = 17), with a female predominance; neurological deficit was detected in 33% (n = 14), while epileptic seizures occurred in 26% (n = 11), more commonly affecting male subjects. Anxiety and discomfort seemed to be the most prevalent influencing factors on QOL, especially in the youngest age group (18-34 years). Female subjects showed a greater dependence than men in all age groups, though males had a more significant impairment in their usual activities. Older patients were affected more significantly in their self-care and usual activities compared with the younger population. CONCLUSIONS: Untreated AVMs have a significant negative impact on patients carrying unruptured brain AVMs, as proved by QOL assessment. Beside neurological deficits, this impact should also be considered in the therapeutic decision.

[Interventional neuroradiology: current options]. / Az intervenciós neuroradiológia korszeru lehetoségei.

Modern interventional neuroradiology has a leading role in the treatment of ischemic and hemorrhagic stroke, and it provides more and more important treatment options for degenerative diseases of the vertebral column and the management of correlated pain. During the last decades interventional neuroradiology has played a primary role in the treatment of intracranial berry aneurysms due to the continuous technical improvements. Ongoing studies proved superiority of mechanical stent-thrombectomy in acute proximal occlusion of cerebral arteries. Less invasive neurointerventional methods, such as vertebroplasty, are widely used in osteoporotic and neoplastic pathologic fractures of the vertebral bodies. These treatments should be performed in a specialized center by well trained physicians.

CHRONIC CEREBROSPINAL VENOUS INSUFFICIENCY--DISEASE OR MISDIAGNOSIS?

BACKGROUND AND PURPOSE: Former studies reported internal jugular vein stenosis in patients with multiple sclerosis. We aimed to evaluate if these venous stenoses were real and cerebral venous outflow of patients with multiple sclerosis differed from that of normal controls. METHODS: 20 controls were prospectively investigated by angiography and duplex ultrasound. Seven patients with multiple sclerosis underwent angiography at other centers; we reviewed these registrations and performed venous ultrasound examinations. RESULTS: Angiography displayed > 50% stenosis of internal jugular vein in 19 controls (69 ± 17% on the right and 73 ± 13% on the left side) and < 50% stenosis in 1 control (43.5% and 44.6%). All 7 patients had at least one-sided stenosis. The mean degree of stenosis was 63 ± 16% on the right and 67 ± 13% on the left side. There was no significant difference in the degree of stenosis between patients and controls. However, these "stenoses" disappeared if the contrast agent was injected at a catheter position below the orifice of the subclavian vein during venography. The venous flow volume was also similar between groups: 479.7 ± 214.1 and 509.8 ± 212.0 ml/min (right and left side) in the patients and 461.3 ± 224.3 and 513.6 ± 352.2 ml/min in the control group; p = 0.85 and 0.98 (right and left). Color and power duplex imaging also revealed normal blood flow of the internal jugular vein in all patients and controls. CONCLUSION: The cerebral venous status of patients with multiple sclerosis and controls were similar. The angiographic "stenoses" were virtual, caused by the contrast dilution effect of the non-contrast blood stream of the subclavian vein.

Pipeline for uncoilable or failed aneurysms: results from a multicenter clinical trial.

PURPOSE: To evaluate the safety and effectiveness of the Pipeline Embolization Device (PED; ev3/Covidien, Irvine, Calif) in the treatment of complex intracranial aneurysms. MATERIALS AND METHODS: The Pipeline for Uncoilable or Failed Aneurysms is a multicenter, prospective, interventional, single-arm trial of PED for the treatment of uncoilable or failed aneurysms of the internal carotid artery. Institutional review board approval of the HIPAA-compliant study protocol was obtained from each center. After providing informed consent, 108 patients with recently unruptured large and giant wide-necked aneurysms were enrolled in the study. The primary effectiveness endpoint was angiographic evaluation that demonstrated complete aneurysm occlusion and absence of major stenosis at 180 days. The primary safety endpoint was occurrence of major ipsilateral stroke or neurologic death at 180 days. RESULTS: PED placement was technically successful in 107 of 108 patients (99.1%). Mean aneurysm size was 18.2 mm; 22 aneurysms (20.4%) were giant (>25 mm). Of the 106 aneurysms, 78 met the study's primary effectiveness endpoint (73.6%; 95% posterior probability interval: 64.4%-81.0%). Six of the 107 patients in the safety cohort experienced a major ipsilateral stroke or neurologic death (5.6%; 95% posterior probability interval: 2.6%-11.7%). CONCLUSION: PED offers a reasonably safe and effective treatment of large or giant intracranial internal carotid artery aneurysms, demonstrated by high rates of complete aneurysm occlusion and low rates of adverse neurologic events; even in aneurysms failing previous alternative treatments.

Rare angioproliferative tumors mimicking aggressive spinal hemangioma with epidural expansion.

BACKGROUND AND PURPOSE: We present two cases of angio-proliferative tumors that were misdiagnosed and treated as typical hemangiomas with epidural expansion. MATERIALS AND METHODS: Two middle-aged women presented with symptoms and radiological signs characteristic for aggressive hemangioma with epidural expansion. In the first case preoperative embolization and decompressive surgery with open transpedicular vertebroplasty was performed. Within less than a year, epidural recurrence of the tumor prompted for radical excision and corpectomy. The diagnosis after the histological studies and the further clinical evolution was metastasizing leiomyomatosis. No further recurrence occured during the next 6 years. In the second case percutaneous vertebroplasty was performed and complicated by epidural polymethyl-methacrylcate (PMMA) leakage, requiring urgent decompressive surgery. Histological study of the lesion raised the possibility of myopericytoma. This was confirmed 16 months later when complete vertebrectomy was performed due to severe epidural propagation of the recurring tumor. No further recurrence occurred in next the two years. CONCLUSIONS: Rare angio-proliferative tumors, like benign metastasizing leiomyoma and myopericytoma radiologically may resemble aggressive vertebral hemangiomas of the spine. Unlike hemangiomas, such tumors require radical removal due to their likely recurrence. As imaging studies may not be able to completely exclude such pathologies, bone biopsy and thorough histopathological studies are warranted prior to the therapeutic decision.

[Initial clinical experience with radiofrequency-guided percutaneous vertebral augmentation in the treatment of vertebral compression fractures]. / Rádiófrekvencia-támogatott percutan csigolyastabilizációval szerzett elso klinikai tapasztalataink kompressziós csigolyatörések kezelésében.

PURPOSE: Percutaenous Vertebroplasty (PVP) is effective in alleviating pain and facilitating early mobilization following vertebral compression fractures. The relatively high risk of extravertebral leakage due to uncontrolled delivery of low viscosity bone cement is an inherent limitation of the technique. The aim of this research is to investigate the ability of controlled cement delivery in decreasing the rate of such complications by applying radiofrequency heating to regulate cement viscosity. METHOD AND MATERIAL: Thirty two vetebrae were treated in 28 patients as part of an Ethics Committee approved multicenter clinical trial using RadioFreqency assisted Percutaenous Vertebral Augmentation (RF-PVA) technique. This technique is injecting low viscosity polymethylmethacrylate (PMMA) bone cement using a pressure controlled hydraulic pump and applying radiofrequency heating to increase cement viscosity prior to entering the vertebral body. All patients were screened for any cement leakage by X-ray and CT scan. The intensity of pain was recorded on a Visual Analog Scale (VAS) and the level of physical activity on the Oswestry Disability Index (ODI) prior to, one day, one month and three months following procedure. RESULTS: All procedures were technically successful. There were no clinical complication, intraspinal or intraforaminal cement leakage. In nine cases (29%) a small amount of PMMA entered the intervertebral space through the broken end plate. Intensity of pain by VAS was reduced from a mean of 7.0 to 2.5 and physical inactivity dropped on the ODI from 52% to 23% three months following treatment. CONCLUSION: In this small series controlled cement injection using RF-PVA was capable of preventing clinically hazardous extravertebral cement leakage while achieving outcomes similar to that of conventional vertebroplasty.

Continuous thrombolysis and repeated thrombectomy with the Penumbra System in a child with hemorrhagic sinus thrombosis: technical note.

UNLABELLED: Cerebral venous sinus thrombosis (CVST) is an uncommon but potentially lethal event. When showing a malignant clinical course despite anticoagulant therapy, new endovascular techniques and technology allow the possibility of more aggressive thrombolysis and thrombectomy. The authors present a case of recanalization of an extensive cerebral thrombosis using a new endovascular thromboaspiration device, the Penumbra System. BACKGROUND AND PURPOSE: CVST in children is a rare but potentially lethal disorder. When showing a malignant progression despite anticoagulant therapy, the use of local thrombolytics and thrombectomy procedures might provide therapeutic solution. METHODS: A 16-year-old girl presented with signs and symptoms of a hemorrhagic cerebral sinus thrombosis and showed progression despite full dose anticoagulant therapy. The evolution being attributed to increasing mass effect, decompressive surgery was performed without clinical improvement. Further brain imaging demonstrated progression of the sinus thrombosis. Repeated local thrombectomy with the Penumbra thrombectomy system and continuous, relatively low dose local thrombolysis was performed during a period of 60 h, resulting in recanalization and clinical improvement. The methodology of combined thromboaspiration and thrombolysis is described. CONCLUSIONS: We present a novel method for revascularization using the Penumbra System in combination with long-term, relatively low dose thrombolysis, in the setting of both clinically and morphologically progressive, hemorrhagic sinus thrombosis. The procedure proved to be both safe and effective and may be considered in the future for patients with progressive sinovenous thrombosis despite adequate medical therapy.

Coronary stent implantation for acute basilar artery occlusion with underlying stenosis.

AIMS: Our aim was to study the effectiveness of coronary stent implantation during the endovascular treatment (EVT) of acute basilar artery occlusion (BAO) with occlusion-underlying intracranial atherosclerotic stenosis (ICAS). METHODS AND RESULTS: We retrospectively analysed 91 consecutive BAO patients who underwent EVT between February 2014 and January 2019 in a single, high-volume neurointerventional centre. We studied the effect of immediate coronary stent implantation on the clinical outcome of BAO with occlusion-underlying stenosis. BAO patients with underlying ICAS (n=41) were characterised by longer symptom-onset-to-reperfusion times (231 min vs 173 min, p=0.0020), lower TICI 2b-3 reperfusion rates (65.85% vs 90.00%, p=0.0084), and higher overall mortality (HR 2.021, p=0.0417) compared to the BAO cases without ICAS (n=50). The patients undergoing stenting (n=18) had lower residual basilar artery (BA) stenosis (14.7% vs 81.0%, p<0.0001), higher chance for functional recovery (OR 7.6, p=0.0250) and higher chance of survival (HR 4.163, p=0.0026) compared to the BAO-ICAS cases treated without coronary stents (n=21). CONCLUSIONS: The immediate treatment of the occlusion-underlying stenosis with coronary stents and dual antiplatelet therapy (DAPT) in BAO was associated with improved overall survival and better functional outcomes.

Vertebral artery dissection as an extremely rare cause of spinal epidural hematoma: case report and review of the literature.

OBJECTIVE: To present a patient with a cervico-thoracic ventrally located epidural hematoma caused by dissection and subsequent bleeding of the cervical portion of the vertebral artery. SUMMARY AND BACKGROUND DATA: Non traumatic epidural hematoma is a rare entity. The etiology usually is not clarified: a venous origin is usually suspected although an arterial source is also possible. CLINICAL REPORT: A 32-year-old woman presented with a ventrally located cervico-thoracic epidural hematoma caused by non traumatic dissection and dissecting aneurysm rupture of the cervical portion of the vertebral artery. The dissection was demonstrated by magnetic resonance imaging and digital subtraction angiography. The patient had no neurological symptoms and was treated by conservative methods. Follow up imaging showed healing of the vertebral artery and resorption of the epidural hematoma. CONCLUSION: Dissection of the cervical portion of the vertebral artery with subsequent perivascular bleeding is not well recognized as a possible cause of a spinal epidural hematoma. Even though this entity and the underlying cause may be rare, we suggest a vigilant search for vertebral artery injury in cases of ventrally located cervical and upper thoracic epidural hematoma.

[Frequency of adjacent vertebral fractures following percutaneous vertebroplasty]. / Szomszédos csigolyatörések elofordulása percutan vertebroplastica után.

INTRODUCTION AND AIMS: Percutaneous vertebroplasty (PVP) proved to be very effective in the treatment of pain caused by osteoporotic vertebral compression fractures. A certain proportion of patients, however, suffer a new fracture after treatment. Our purpose was to analyze the frequency of new fractures, and to estimate the causative role of PVP in the treated population. METHODS: The retrospective study reviewed all consecutive patients treated with PVP for osteoporotic compression fractures during a 5.5 years period. The study group comprised those patients, who suffered a new fracture during the follow up. The primary endpoint was the frequency of new fractures. The secondary endpoint was the occurrence of new fractures in a timeframe of 90 days after treatment that were adjacent to the previously treated segments. The causative role of PVP was estimated to be the highest in this subgroup. RESULTS: Altogether 396 consecutive patients were treated with PVP for osteoporotic compression fractures. Mean age was 68+11 years, and 23% of the population was male. The study group comprised 73 patients (18.4%). In this subgroup the patients had an average of 3.8 vertebral fractures. After PVP, adjacent fractures were significantly more likely, than distal fractures. Altogether 44 patients (11% of the entire population) suffered an adjacent fracture in 90 days after PVP. In this group there were significantly less male patients as compared to the entire population. CONCLUSIONS: After PVP almost every fifth patient is at risk for developing a new fracture, however, it is likely to be related to the vertebral augmentation in every tenth subject only. Female patients with severe osteoporosis are probably facing the highest risk for developing new fractures.

Pipeline for uncoilable or failed aneurysms: 3-year follow-up results.

OBJECTIVE The long-term effectiveness of endovascular treatment of large and giant wide-neck aneurysms using traditional endovascular techniques has been disappointing, with high recanalization and re-treatment rates. Flow diversion with the Pipeline Embolization Device (PED) has been recently used as a stand-alone therapy for complex aneurysms, showing significant improvement in effectiveness while demonstrating a similar safety profile to stent-supported coil treatment. However, relatively little is known about its long-term safety and effectiveness. Here the authors report on the 3-year safety and effectiveness of flow diversion with the PED in a prospective cohort of patients with large and giant internal carotid artery aneurysms enrolled in the Pipeline for Uncoilable or Failed Aneurysms (PUFS) trial. METHODS The PUFS trial is a prospective study of 107 patients with 109 aneurysms treated with the PED. Primary effectiveness and safety end points were demonstrated based on independently monitored 180-day clinical and angiographic data. Patients were enrolled in a long-term follow-up protocol including 1-, 3-, and 5-year clinical and imaging follow-up. In this paper, the authors report the midstudy (3-year) effectiveness and safety data. RESULTS At 3 years posttreatment, 74 subjects with 76 aneurysms underwent catheter angiography as required per protocol. Overall, complete angiographic aneurysm occlusion was observed in 71 of these 76 aneurysms (93.4% cure rate). Five aneurysms were re-treated, using either coils or additional PEDs, for failure to occlude, and 3 of these 5 were cured by the 3-year follow-up. Angiographic cure with one or two treatments of Pipeline embolization alone was therefore achieved in 92.1%. No recanalization of a previously completely occluded aneurysm was noted on the 3-year angiograms. There were 3 (2.6%) delayed device- or aneurysm-related serious adverse events, none of which led to permanent neurological sequelae. No major or minor late-onset hemorrhagic or ischemic cerebrovascular events or neurological deaths were observed in the 6-month through 3-year posttreatment period. Among 103 surviving patients, 85 underwent functional outcome assessment in which modified Rankin Scale scores of 0-1 were demonstrated in 80 subjects. CONCLUSIONS Pipeline embolization is safe and effective in the treatment of complex large and giant aneurysms of the intracranial internal carotid artery. Unlike more traditional endovascular treatments, flow diversion results in progressive vascular remodeling that leads to complete aneurysm obliteration over longer-term follow-up without delayed aneurysm recanalization and/or growth. Clinical trial registration no.: NCT00777088 (clinicaltrials.gov).

Long-Term Clinical and Angiographic Outcomes Following Pipeline Embolization Device Treatment of Complex Internal Carotid Artery Aneurysms: Five-Year Results of the Pipeline for Uncoilable or Failed Aneurysms Trial.

BACKGROUND: Early and mid-term safety and efficacy of aneurysm treatment with the Pipeline Embolization Device (PED) has been well demonstrated in prior studies. OBJECTIVE: To present 5-yr follow-up for patients treated in the Pipeline for Uncoilable or Failed Aneurysms clinical trial. METHODS: In our prospective, multicenter trial, 109 complex internal carotid artery (ICA) aneurysms in 107 subjects were treated with the PED. Patients were followed per a standardized protocol at 180 d and 1, 3, and 5 yr. Aneurysm occlusion, in-stent stenosis, modified Rankin Scale scores, and complications were recorded. RESULTS: The primary endpoint of complete aneurysm occlusion at 180 d (73.6%) was previously reported. Aneurysm occlusion for those patients with angiographic follow-up progressively increased over time to 86.8% (79/91), 93.4% (71/76), and 95.2% (60/63) at 1, 3, and 5 yr, respectively. Six aneurysms (5.7%) were retreated. New serious device-related events at 1, 3, and 5 yr were noted in 1% (1/96), 3.5% (3/85), and 0% (0/81) of subjects. There were 4 (3.7%) reported deaths in our trial. Seventy-eight (96.3%) of 81 patients with 5-yr clinical follow-up had modified Rankin Scale scores ≤2. No delayed neurological deaths or hemorrhagic or ischemic cerebrovascular events were reported beyond 6 mo. No recanalization of a previously occluded aneurysm was observed. CONCLUSION: Our 5-yr findings demonstrate that PED is a safe and effective treatment for large and giant wide-necked aneurysms of the intracranial ICA, with high rates of complete occlusion and low rates of delayed adverse events.

Neuroophthalmological outcomes associated with use of the Pipeline Embolization Device: analysis of the PUFS trial results.

OBJECT: Neuroophthalmological morbidity is commonly associated with large and giant cavernous and supraclinoid internal carotid artery (ICA) aneurysms. The authors sought to evaluate the neuroophthalmological outcomes after treatment of these aneurysms with the Pipeline Embolization Device (PED). METHODS: The Pipeline for Uncoilable or Failed Aneurysms (PUFS) trial was an international, multicenter prospective trial evaluating the safety and efficacy of the PED. All patients underwent complete neuroophthalmological examinations both before the PED procedure and at a 6-month follow-up. All examinations were performed for the purpose of this study and according to study criteria. RESULTS: In total, 108 patients were treated in the PUFS trial, 98 of whom had complete neuroophthalmological follow-up. Of the patients with complete follow-up, 39 (40%) presented with a neuroophthalmological baseline deficit that was presumed to be attributable to the aneurysm, and patients with these baseline deficits had significantly larger aneurysms. In 25 of these patients (64%), the baseline deficit showed at least some improvement 6 months after PED treatment, whereas in 1 patient (2.6%), the deficits only worsened. In 5 patients (5%), new deficits had developed at the 6-month follow-up, while in another 6 patients (6%), deficits that were not originally assumed to be related to the aneurysm had improved by that time. A history of diabetes was associated with failure of the baseline deficits to improve after the treatment. The aneurysm maximum diameter was significantly larger in patients with a new deficit or a worse baseline deficit at 6 months postprocedure. CONCLUSIONS: Patients treated with the PED for large and giant ICA aneurysms had excellent neuroophthalmological outcomes 6 months after the procedure, with deficits improving in most of the patients, very few deficits worsening, and few new deficits developing.

Impact of aneurysmal geometry on intraaneurysmal flow: a computerized flow simulation study.

INTRODUCTION: This study was performed to assess the effect of aneurysm geometry on parameters that may have an impact on the natural history of intracranial aneurysms, such as intraaneurysmal flow pressure and shear stress. METHODS: Flow was simulated in 21 randomly selected aneurysms using finite volume modeling. Ten aneurysms were classified as side-wall aneurysms, with either single-sided or circumferential involvement of the parent artery wall, and 11 as bifurcation aneurysms (symmetric or asymmetric), with an axis either perpendicular or parallel to the parent artery. The flow patterns were classified as either jet or vortex types (with regular or irregular vortex flow). Pressures and shear stresses were characterized as evenly or unevenly distributed over the aneurysm wall and neck. RESULTS: All side-wall and four of the bifurcation aneurysms with a perpendicular axis had a vortex type flow pattern and seven bifurcation aneurysms with a parallel axis (four symmetric and two asymmetric) had a jet flow pattern. Jet type flow was associated with an uneven pressure distribution in seven out of seven aneurysms. Vortex type flow resulted in an even pressure distribution in five out of six aneurysms with an irregular flow pattern and six out of eight with a regular flow pattern. No firm relationship could be established between any geometrical type and shear stress distribution. Only 1 of 14 aneurysms with a perpendicular axis, but 4 of 7 aneurysms with a parallel axis, had ruptured. CONCLUSION: Aneurysm geometry does have an impact on flow conditions. Aneurysms with a main axis parallel to the parent artery have a tendency to have a jet flow pattern and uneven distribution of unsteady pressure. These aneurysms may have a higher rate of rupture as than those with a main axis perpendicular to the parent artery.

HydroCoil as an adjuvant to bare platinum coil treatment of 100 cerebral aneurysms.

INTRODUCTION: The overall safety of the HydroCoil, an expansile hybrid hydrogel-platinum coil, is unknown. We report a prospective observational study of our first 100 cerebral aneurysms treated with HydroCoils, focusing on safety and initial efficacy. METHODS: Indications, procedural complications, clinical and angiographic outcomes were recorded. Packing density, number of coils deployed and angiographic results were compared with those in a matched control group of 100 aneurysms treated solely with bare platinum coils. HydroCoil complication rates were compared to bare platinum coil rates at our institution and in published series. RESULTS: Adjuvant HydroCoil treatment led to increased mean percentage aneurysm filling compared to controls (50 +/- 21% versus 27 +/- 13%, P < 0.001). Immediate posttreatment angiographic results showed significantly (P < 0.001) more complete occlusions and fewer incomplete (<95%) occlusions compared to controls. Intermediate follow-up angiograms (median 7.5 months) in 63 aneurysms showed a trend towards fewer incomplete occlusions with HydroCoil treatment. There were significantly fewer major recurrences with HydroCoil treatment compared to the control treatment (9.5% versus 22.6%, P = 0.046). In the adjuvant HydroCoil group, major recurrent aneurysms had significantly less percentage volume packing with HydroCoils than non-recurrent aneurysms (50.3 +/- 5.0% versus 65.3 +/- 18.0%, P = 0.04). There was a 12% procedural complication rate, 6% procedural morbidity and 1% mortality rate, similar to institutional and reported bare platinum coil complication rates. CONCLUSION: HydroCoils can be safely deployed with a similar complication rate to bare platinum coils. They result in improved aneurysm filling. Intermediate follow-up angiography showed significantly fewer major recurrences. Long-term follow-up is required to confirm initial improved stability.