The role of the pipeline embolization device for the treatment of dissecting intracranial aneurysms.

Intracranial dissecting aneurysms constitute rare lesions with complex management and elevated morbidity and mortality. Results of 23 patients harboring such lesions treated with the PED are reported. Standard dual antiplatelet therapy was instituted. Neurologic and angiographic assessments were obtained at 3, 6, and 12 months. Clinical presentation included SAH (52%), symptoms of mass effect (22%), ischemia (4%), and incidental finding (22%). The posterior circulation was affected in 91% of cases. Total occlusion was demonstrated in 69.5% of patients, with an increment to 87.5% considering only patients with at least 3 months of follow-up. Small aneurysms demonstrated higher rates of total occlusion (6/7) compared with large (5/7) and giant (5/9) ones. Good clinical outcome was achieved in 74% of patients. Reconstructive endovascular treatment of intracranial dissecting aneurysms with the PED provided good clinical and angiographic results with acceptable risks, representing an attractive therapeutic option for this complex disease, especially when parent vessel preservation is mandatory.

Aneurysm rupture following treatment with flow-diverting stents: computational hemodynamics analysis of treatment.

BACKGROUND AND PURPOSE: Flow-diverting approaches to intracranial aneurysm treatment had many promising early results, but recent apparently successful treatments have been complicated by later aneurysm hemorrhage. We analyzed 7 cases of aneurysms treated with flow diversion to explore the possible rupture mechanisms. MATERIALS AND METHODS: CFD analysis of pre- and posttreatment conditions was performed on 3 giant aneurysms that ruptured after treatment and 4 successfully treated aneurysms. Pre- and posttreatment hemodynamics were compared including WSS, relative blood flows, vascular resistances, and pressures, to identify the effects of flow-diverter placements. RESULTS: Expected reductions in aneurysm velocity and WSS were obtained, indicating effective flow diversion from the sac into the parent artery, consistent with periprocedural observations. In each case with postaneurysm rupture, the result of flow diversion led to an increase in pressure within the aneurysm. This pressure increase is related to larger effective resistance in the parent artery from placement of the devices and, in 2 cases, the reduction of a preaneurysm stenosis. CONCLUSIONS: Flow-diversion devices can cause intra-aneurysmal pressure increases, which can potentially lead to rupture, especially for giant aneurysms. This relates both to changes in the parent artery configuration, such as reduction of a proximal stenosis, and to the flow diversion into higher resistance parent artery pathways combined with cerebral autoregulation, leading to higher pressure gradients. These may be important effects that should be considered when planning interventions. Potentially dangerous cases could be identified with angiography and/or patient-specific CFD models.

[Superficial haemosiderosis of the central nervous system, neuro otological manifestations and images from a magnetic resonance brain scan: a case report]. / Hemosiderosis superficial del sistema nervioso central, manifestaciones neurootológicas e imágenes de resonancia magnética cerebral: a propósito de un caso.

INTRODUCTION: Superficial haemosiderosis of the central nervous system (SHCNS) is an infrequent clinical entity; it is produced by the formation of clinically silent haemosiderin deposits in the leptomeninges, the subpial tissue, the cranial nerves and spinal cord, secondary to chronic bleeding in the subarachnoid space. Aetiology is idiopathic in half the cases or secondary to a vascular malformation or other structural abnormalities. At least 100 cases have been reported in the literature, most of which were diagnosed post mortem. In these descriptions there is a predominance of cerebellar ataxia, progressive hypoacusis, nystagmus, recurring headaches, pyramidal signs, an absence of caloric responses and xanthochromic cerebrospinal fluid. Magnetic resonance (MR) brain scanning in T2 revealed hypointensity in the brain stem, the cerebellum and the Sylvian fissure, with atrophy of the cerebellum and the brain stem. CASE REPORT: A 64 year old male with bilateral tinnitus and progressive neurosensory hipoacusis, who visited because of loss of balance, urinary incontinence and oscillopsia. The patient s personal history included an episode of unbearable headache at the age of 53. The neurological and neuro otological examination was pathological and the MR brain scan confirmed the diagnosis of SHCNS. CONCLUSIONS: We wish to highlight how extremely rare this entity is, and especially so when there is a predominance of progressive neuro otological manifestations; we also want to emphasize the importance of carrying out specific imaging studies to enable a diagnosis to be made while the patient is still alive.

Combined endovascular treatment of dissecting vertebral artery aneurysms by using stents and coils.

OBJECT: With the recent development and refinement of endovascular stents, the significant potential for these devices in the treatment of wide-necked dissecting and fusiform aneurysms has become apparent. In this article the authors report on the use of stents and coils to treat dissecting and fusiform vertebral artery (VA) aneurysms. METHODS: Eight consecutive patients harboring eight dissecting aneurysms and one fusiform aneurysm of the VA were succesfully treated using a procedure in which the authors inserted an intravascular stent and secondary endosaccular coils when needed. In all but one patient complete aneurysm occlusion was achieved, and in all cases there was no neurological complication. Follow-up angiography examinations were performed in all patients (mean duration of follow-up angiography review 13.1 months, range 3-42 months). The patients remained stable throughout the clinical follow-up period (mean 14.1 months, range 4-42 months). No rebleeding was recorded. CONCLUSIONS: At present this combined approach represents a reliable and safe alternative for the treatment of VA dissecting aneurysms, especially in patients who cannot tolerate occlusion tests.

[Endovascular treatment of partially clipped aneurysms]. / Tratamiento endovascular de remanentes aneurismáticos.

Partial clipping may occur in about 4% of surgical procedures. The risk of hemorrhage persists if the aneurysm is not completely excluded. Reoperations are often difficult, technically demanding and may carry an increased risk of complications. We report our experience with the use of Guglielmi detachable coils in the treatment of 9 aneurysm remnants. Five patients (55.6%) presented with a second subarachnoid hemorrhage. Eight of the aneurysms (88.9%) were located on the anterior circulation. Postoperative angiography showed complete occlusion in 8 cases (88.9%). Certain partial clipping types may assist and favor a stable coiling procedure allowing a more compact cast. On the other hand, the clip may interfere with the correct visualization of the neck. In this series, there was no neurological morbidity associated with the procedure. There were no hemorrhagic events during or after the embolization. Endovascular treatment of aneurysm remnants can be performed safely and may constitute a valuable option to microsurgery.

Estado actual de la radiología intervencionista para el tratamiento del dolor de la columna vertebral: cirugía minimamente invasiva / Present status of the interventional radiology from the treatment of spine pain: minimument invasiveness surgery

En los últimos años las técnicas percutáneas han evolucionado de forma tal, que a la fecha estos procedimiento se efectúan rutinaria y extensivamente en muchos centros, para el diagnóstico y el tratamiento del dolor originada en la columna vertebral por diferentes procesos. Estas técnicas permiten una reducción de los costos de hospitalización y una rápida reincorporación del paciente a sus tareas habituales. En este artículo analizamos las indicaciones, resultados y complicaciones de los procedimientos, así como tambien el desarrollo de nuevas técnicas que son y serán de utilidad en la práctica.

Treatment of a vertebral dissecting aneurysm with stents and coils: technical case report.

OBJECTIVE AND IMPORTANCE: A clinical case of a dissecting aneurysm of the intracranial vertebral artery successfully treated with a combination of stents and coils is presented. The importance of long-term follow-up and the development of suitable materials and devices are emphasized. CLINICAL PRESENTATION: This 48-year-old man with a history of progressive bilateral loss of vision caused by glaucoma developed sudden headache, nausea, and vomiting. At admission, he presented with psychomotor agitation and neck pain. A neurological examination showed bilateral IInd and VIth cranial nerve palsy and neck stiffness. Computed tomography demonstrated a diffuse subarachnoid hemorrhage. Digital subtraction angiography showed a fusiform dilation of Segment IV of the left vertebral artery, with a double lumen sign. TECHNIQUE: A bifemoral intra-arterial approach was used. A FasTracker 18 (Target Therapeutics, Fremont, CA) microcatheter was advanced through the true arterial lumen and was then replaced by a self-expandable metallic wall stent. Because of reduced radiopacity, a balloon-expandable metallic stent was then placed as well. Next, with a FasTracker 10 advanced through the stent mesh, the aneurysm was embolized using Guglielmi detachable coils. CONCLUSION: We applied a new technique to treat a dissecting aneurysm of the intracranial portion of the vertebral artery with a combination of stents and coils. Further work is required on the tracking, flexibility, and thrombogenic properties of diverse materials and devices. This evolving technology may play a role in the near future as the alternative of choice in some cases of aneurysm treatment via the endovascular route.

Prevalencia de Esclerosis múltiple en Junín (B), Argentina al 1/1/1991 / Multiple sclerosis prevalence in Junín (B) Argentina

Para determinar la prevalencia de esclerosis múltiple en el partido de Junín (B), Argentina, a 34º de latitud S, se utilizó como estrategia para el hallazgo de casos, aquella aplicable para enfermedades crónicas y raras. Estas estrategias fueron: uso de sistema de registro de prestadores de salud; examen en dos fases; red de muestreo; sistema bola de nieve; fuentes múltiples de información y sensibilización de la población. Nosotros utilizamos el criterio de diagnóstico delineado en el Workshop de la Universidad de Boston de 1982. Para la recolección de datos en pacientes con E.M. o probable enfermedad, usamos el modelo de historia clínica y ficha epidemiológica provista por la Asociación Civil Argentina Anti-Esclerosis Múltiple. Se tomó como día de prevalencia el 1 de enero de 1991 y la tasa de prevalencia de esclerosis múltiple fue 12 por 100.000 habitantes. Zona de riesgo medio. Edad media al diagnóstico era de 30 años para los hombres, 42 años para la mujer, y 36 para ambos sexos. La tasa de prevalencia ha sido significativamente más alta para mujeres que para hombres