Functional outcome 1 year after aneurysmal subarachnoid hemorrhage due to ruptured intracranial aneurysm in elderly patients.

BACKGROUND: Population aging raises questions about extending treatment indications in elderly patients with aneurysmal subarachnoid hemorrhage (aSAH). We therefore assessed functional status 1 year after treatment. METHODS: This study involved 310 patients, aged over 70 years, with ruptured brain aneurysm, enrolled between 2008 and 2014 in a prospective multicentre trial (FASHE study: NCT00692744) but considered unsuitable for randomisation and therefore analysed in the observational arms of the study: endovascular occlusion (EV), microsurgical exclusion (MS) and conservative treatment. The aims were to assess independence, cognition, autonomy and quality of life (QOL) at 1 year post-treatment, using questionnaires (MMSE, ADLI, IADL, EORTC-QLQ-C30) filled in by independent nurses after discharge. RESULTS: The 310 patients received the following treatments: 208 underwent EV (67.1%), 54 MS (17.4%) and 48 were conservatively managed (15.5%). At 1 year, independence rates for patients admitted with good clinical status (WFNS I-III) were, according to the aneurysm exclusion procedure (EV, MS or conservative), 58.9%, 50% and 12.1% respectively. MMSE score was pathological in 26 of the 112 EV patients (23.2%), 10 of the 25 MS patients (40%) and 4 of the 9 patients treated conservatively (44%), without any statistically significant difference [Pearson's Chi2 test, F ratio=4.29; P=0.11]. Regarding QoL, overall score was similar between the EV and MS cohorts, but significantly lower with conservative treatment. CONCLUSION: Elderly patients in good clinical condition with aSAH should be treated regardless of associated comorbidities. Curative treatment (EV or MS) reduced mortality without increasing dependence, in comparison with conservative treatment.

Long-term follow-up of 1036 cerebral aneurysms treated by bare coils: a multicentric cohort treated between 1998 and 2003.

BACKGROUND AND PURPOSE: The endovascular treatment (EVT) of cerebral aneurysms has experienced a revolution since 1991 with the introduction of platinum coil technology. During the past 10 years, there has been significant study of the feasibility of this technique, and clinical results of EVT have been published. The long-term durability of Guglielmi detachable coil (GDC) embolization of cerebral aneurysms still remains unknown. The purpose of this study was to evaluate the stability of anatomic occlusion of aneurysms and to assess the rate of recanalization and retreatment of these aneurysms. MATERIALS AND METHODS: Between January 1998 and December 2003, 1036 aneurysms (804 ruptured and 232 nonruptured) were treated consecutively with GDC coils in 5 neuroradiology centers. Procedural feasibility, acute angiographic occlusion results, morbidity, and mortality associated with this technique were assessed. All patients were regularly followed by digital subtraction angiography and MR imaging each year after treatment. RESULTS: Initial acute angiographic results in 1036 aneurysms demonstrated total occlusion in 731 patients (70.5%), subtotal occlusion in 252 (24.3%), incomplete occlusion in 20 (1.9%), and failures in 33% (3.3%) aneurysms. A remodeling technique was used in 10%. A second procedure was performed for 72 aneurysms (7%). The total aneurysm follow-up time was 49,923 months (4160.25 aneurysm-years). The retreatment period was either in the months following initial treatment in aneurysms incompletely occluded or in years due to recanalization or de novo aneurysms. Fewer than 5 patients rebled during 10 years of follow-up. Long-term follow-up angiograms were obtained in 899 aneurysms, with 646 total, 230 subtotal, and 23 incomplete results. CONCLUSIONS: Long-term follow-up of cerebral aneurysms is necessary to depict recanalization. Only 7% of the aneurysms were retreated. Use of bare coils gives a good long-term level of occlusion.

Endovascular treatment of brain arteriovenous malformations using onyx: results of a prospective, multicenter study.

BACKGROUND AND PURPOSE: To evaluate the safety and efficacy of onyx for embolization of brain arteriovenous malformations (BAVM). METHODS: A prospective, multicenter study was conducted in France to evaluate embolization of BAVM with onyx. From May 2003 to March 2005, 50 patients (26 females, 24 males; mean age: 34.8 years, range: 16-64years) were included. Clinical presentation was haemorrhage in 22 patients (44.0%), seizures in 16 patients (32.0%), headaches in six patients (12.0%) and progressive neurological deficit in two cases (4.0%). Four patients were asymptomatic (8.0%). RESULTS: One hundred and forty-ninesessions of embolization were performed: one to eight sessions/patient with a mean of 3.0sessions. One hundred and sixteen sessions (77.9%) were performed with onyx, 20 sessions (13.4%) with glue and 13 sessions (8.7%) with onyx and glue. Symptomatic acute postembolization haemorrhage (APEH) was observed in four cases (8.0% per patient). At 1 month, morbidity and mortality related to the treatment were of 8% and 2%, respectively. Complete BAVM occlusion was obtained in 8.3% of cases. In the remaining cases, occlusion rate was between 99 and 80% in 56.3% of patients, 79 and 60% in 16.7%, and less than 60 in 18.7%. In case of incomplete occlusion, complementary treatment was performed by radiosurgery. CONCLUSION: Onyx is suitable for BAVM embolization with acceptable morbidity and mortality.

Feasibility, procedural morbidity and mortality, and long-term follow-up of endovascular treatment of 321 unruptured aneurysms.

BACKGROUND AND PURPOSE: The purpose of our study was to evaluate the technical feasibility, morbidity and mortality, and durability of occlusion of unruptured aneurysms treated with Guglielmi detachable coils (GDCs) with a long-term follow-up. MATERIALS AND METHODS: Between January 1998 and January 2005, we treated 321 unruptured aneurysms with GDCs in 5 neuroradiologic institutions. During this period, 63% of unruptured aneurysms were treated by endovascular technique. Procedural feasibility, technical complications, morbidity and mortality, and acute and long-term angiographic occlusion were assessed. RESULTS: Overall technical feasibility of coiling treatment was 94%; 302 aneurysms were treated by endovascular technique. At the end of the initial procedure, acute occlusion was classified as complete in 207 cases (70%), subtotal in 84 cases (26.1%), and incomplete in 11 cases (3.9%). Ischemic complications were observed in 28 patients (9%); 8 patients (2.6%) had perforation of their aneurysms. Treatment-related morbidity was 14.4%, and morbidity with clinical complications was evaluated at 7.7% (n = 23 patients). Five patients (1.7%) died as a result of aneurysm perforation. Final follow-up angiograms, after 9 secondary treatments, demonstrated complete occlusion in 193 patients (69.5%), subtotal in 80 aneurysms (28.5%), and incomplete occlusion in 5 (1.8%). Nineteen patients were lost to follow-up (6.3%). CONCLUSION: Endovascular coiling with detachable coils is an attractive option for treatment of unruptured aneurysms. This method of treatment is safe with a low rate of complications. Prospective studies with longer follow-up periods are needed to assess the long-term durability of occlusion in unruptured aneurysms.

[GDC 18 treatment of ruptured and non-ruptured aneurysms: angiographic results and early and midterm follow-up of 115 aneurysms]. / Traitement par GDC 18 d'anévrismes rompus et non rompus: résultats angiographiques et suivi à court et moyen termes de l'occlusion anévrismale de 115 anévrismes.

OBJECTIVES: To demonstrate the technical feasibility, safety and results of intracranial aneurysm treatment by coils of 0.018-inch diameter wire (GDC 18) for ruptured and non-ruptured intracranial aneurysms. MATERIALS AND METHODS: From a commune database from five neuroradiological centers, we analysed endovascular technique with Gugliemi Detachable Coils (GDC) 18, complications of technique, acute angiographic occlusion results and long-term angiographic follow-up. Sixty-six percent of aneurysms were ruptured. The mean size of treated aneurysms was 13.7 mm. RESULTS: Overall feasibility of coil 18 treatments was 95%. Acute angiographic results in 110 aneurysms demonstrated total occlusion in 63 aneurysms (57.2%), subtotal occlusion in 37 cases (33.6%), and incomplete occlusion in 10 cases (9%). A second treatment was performed in 15 cases; follow-up demonstrated 60 (61%) total occlusions, 32 (33%) subtotal occlusion and 5 (5%) incomplete. Five patients were lost to follow-up, and 8 patients had died. Stability of occlusion with these coils was 61%. CONCLUSION: Coiling of intracranial aneurysms, ruptured or non-ruptured, using coils with a wire diameter of 0.018-inch is safe, with no more complications than standard coils. Remodelling technique is possible. This type of coils must be considered for treatment of large aneurysms.

[Emergency surgery of a large ruptured arteriovenous malformation previously treated by several embolization procedures]. / Intervention en urgence après rupture d'une malformation arterio-veineuse intracérébrale complexe embolisée à plusieurs reprises.

A 56-year-old patient with a giant parieto-occipital left-sided arteriovenous malformation (AVM) revealed by seizure was treated by four embolization procedures. Stereotactic radiosurgery was scheduled for the residual nidus but significant intracranial hemorrhage occurred and surgical excision had to be performed. The immediate post-operative status was precarious, but the final outcome was successful. Therapeutic indications are discussed. A multidisciplinary approach for judicious patient selection is surely the key to safe overall management of AVMs.

Endovascular treatment of brain arteriovenous malformations using onyx: preliminary results of a prospective multicenter study.

SUMMARY: The main final goal of the treatment of brain AVMs is to prevent bleeding and to obtain a complete occlusion of the nidus. The strategy of treatment of brain arteriovenous malformations (AVM) has to be defined by a multidisciplinary team and will usually combine several modalities (surgery, radiosurgery, embolization). Embolization is generally the first step of treatment. Occasionally embolization is able to completely occlude a small AVM. Otherwise embolization is the first step before surgery or radiosurgery. Several embolic agents have been proposed for embolization of brain AVMs like particles or cyanoacrylates. The main disadvantage of particles is the high frequency of recanalization. The cyanoacrylates are probably more appropriate, providing a permanent occlusion. However, due to the polymerizing characteristics of the glue, the time of injection is relatively short (few seconds or minutes) and a complete or substantial occlusion of the nidus is difficult to obtain, especially in the case of medium or largesized AVMs. Onyx is a nonadhesive liquid polymer made of a mixture of ethylene-vinyl-alcohol copolymer and dimethylsulfoxide. The theoretical advantage of a nonadhesive liquid is to eliminate the risk of gluing the microcatheter and subsequently to perform a more durable injection with a larger amounts of agent delivered in a single injection. Several French centers have undertaken a prospective, multicentric study to evaluate the clinical value of Onyx in embolization of brain AVMs. As required, 50 patients were included. Preliminary results are presented regarding the first 48 patients, the last 2 patients being included after writing of this paper. The treatment is now completed in 15 patients. As expected, it was possible with Onyx to perform long duration injections (5 to 70 minutes with a mean of 34 minutes). Volumes injected per session were also important (0.25 to 6 ml with a mean of 1.6 ml). According to the clinical experience of the centers, duration and volume injected were most important with Onyx than with cyanoacrylates. Out of the 15 patients for whom embolization is now completed, 14 had a percentage of occlusion of the nidus greater than 60% (with 2 complete occlusion). With regard to procedural complications, four acute postembolization hemorrhages (APEH) were observed (8% per patient, 4% per procedure). This rate of APEH is in the same range as with cyanoacrylates.

[Epistaxis and hospitalization: a retrospective observational study over 4 years of 260 patients]. / Epistaxis et hospitalisation: étude rétrospective observationnelle sur 4 ans à propos de 260 patients.

OBJECTIVE: Epistaxis is a frequent emergency for which guidelines and treatment are well known. Nevertheless few studies have evaluated the factors that may influence the decision for hospitalisation. Through a retrospective study we have searched to define potential factors which lead to taking such a decision. METHODS: Retrospective analysis of charts of 260 patients hospitalized for epistaxis. For each patient we have reviewed several data including, age, associated pathologies, current treatment, duration of the stay, complications, recurrences etc... RESULTS: If the severity of the bleeding is one of the major factor, socio-economic factors are also taken into account and may influence the decision to hospitalize. Age, associated pathologies (hypertension, hemopathy) and their treatment (anti-coagulant) also play a role in this decision. Furthermore an obvious strategy in the choice of the different treatment may help to reduce the length of stay and the morbidity of each treatment. CONCLUSION: We propose some modifications to our strategy to improve the management of epistaxis. This includes the use of endoscopic techniques for diagnosis and treatment.

[Endovascular treatment of sinus dural fistulas using vein catheterism]. / Traitement endovasculaire par voie veineuse des fistules durales du sinus caverneux.

PURPOSE: We report two techniques for treatment of dural arteriovenous fistulas using femoral vein catheterism and direct surgery via the superior ophthalmic vein. We will attempt to show the advantages of these new techniques instead of using the arterial pathway, which is currently the reference procedure. SUBJECTS AND METHOD: Mrs G, 75 years old was sent by her ophthalmologist because of a suspected orbital tumor. Visual acuity: right eye: 3/10, exophthalmia, chemosis, with no thrill or murmur. The fundus examination was normal. The ultrasound exam with color Doppler imaging showed an arterialization of the superior ophthalmic vein compatible with an arteriovenous sinus dural fistula. Angio-MRI revealed a large left cavernous sinus, confirming the diagnosis. Considering the type of the fistula and the weak physical condition of the patient, we decided to attempt an endovascular embolization with coil placement, using femoral vein catheterism. Exophthalmia regressed within days. The fistula remains sealed 1 year after the procedure. Mr D, 40 years old, showed a similar clinical aspect of sinus dural fistula. We attempted an embolization with the femoral vein, which failed. We decided to embolize the cavernous sinus via the direct surgical pathway of the superior ophthalmic vein. Coils were placed and the fistula was sealed. CONCLUSION: These clinical cases show two less invasive alternatives giving better results than arterial embolization, the reference method (Brooks 1930; Spearmann 1964; Parkinson 1965), endovascular trapping, or surgery.

Utility of balloon-assisted Guglielmi detachable coiling in the treatment of 49 cerebral aneurysms: a retrospective, multicenter study.

BACKGROUND AND PURPOSE: The management of wide-necked aneurysms or aneurysms with a neck-to-body ratio close to 1 is a difficult challenge for the interventional radiologist because of the risk of coil migration or coil protrusion into the parent vessel. Our objective was to evaluate the efficacy and safety of balloon-assisted coiling as well as the follow-up results of occlusion for those difficult aneurysms in which conventional treatment with Guglielmi detachable coils (GDCs) had failed. METHODS: A nondetachable balloon was used in 49 procedures performed in 44 patients (35 women and nine men) who underwent GDC coiling of aneurysms. Every aneurysm had either a wide neck or a sac diameter/neck size ratio (SNR) of 1.5 or less. RESULTS: In four (8%) of the procedures, balloon placement failed, leaving a total of 45 aneurysms treated with balloon-assisted coiling. Final results consisted of total occlusion in 30 cases (67%), subtotal occlusion in 11 cases (24%), and incomplete occlusion in four cases (9%). We found a correlation between the diameter of the sac and the occlusion rate, but not between the size of the neck or the SNR and the occlusion rate. Two thromboembolic complications occurred, but neither had clinical consequences. No aneurysmal rupture was observed during treatment. Final angiographic follow-up time ranged from 3 months to 5 years (mean, 16 months). CONCLUSION: Balloon-assisted coiling is an important adjunct in the treatment of aneurysms with a wide neck or low SNR. In our experience, this technique allowed safe and efficient treatment of aneurysms when conventional GDC treatment had failed.

[Pathological laughter after the brainstem infarction]. / Fou rire prodromique d'une occlusion du tronc basilaire.

We report a case of 'fou rire prodromique' heralding a brainstem infarct with favorable prognosis after thrombolysis. Different clinical forms of pathological laughter, the pathophysiological mechanisms and clinico-anatomical correlations of this rare phenomenon are discussed.

[Mammary bypass dysfunction caused by proximal stenosis of the homolateral subclavian artery: treatment by percutaneous angioplasty. Apropos of a case]. / Dysfonction de pontage mammaire secondaire à une sténose proximale de l'artère sous-clavière homolatérale: traitement par angioplastie percutanée. A propos d'un cas.

Proper function of a coronary bypass using the internal mammary artery obviously depends upon the quality of the mammary artery used and of the distal coronary system, but also the absence of any significant stenosis of the first centimetres of the homolateral subclavian artery. The authors report the case of a patient in whom angina was destabilized by dysfunction of a bypass between the left internal mammary artery and the left anterior descending coronary artery. This mammary bypass dysfunction was related not to stenosis of the bypass but to stenosis of the proximal part of the left subclavian artery. Angioplasty of this stenosis led to disappearance of anterior myocardial circulatory impairment and of angina attacks.

[MRI in infectious and spontaneous tumoral epidural hemorrhagic pathology]. / IRM et pathologie épidurale tumorale infectieuse et hémorragique spontanée.

Several studies have served to underline the interest of MRI in the diagnosis and assessment of epidural abscess and malignant extradural spinal tumors. In our work, one of the quantitatively greatest published to this day, 64 patients presenting epidural pathology were evaluated by means of MRI. All the explorations were brought about through weighted multiplaned sequences T1, T2 and gadolinium injection. The pathological spectrum encountered is comprised of: metastatic extradural spinal tumors (58%), primary extradural spinal tumors (7%), epidural localizations of hematological diseases (9%), epidural abscess (25%), and one case of epidural hematoma. Assessment was brought to bear upon behavior in relation to type of sequence, spread of disease, medullary effects, type of enhancement following gadolinium injection. Degree of correlation with clinical data and surgical findings was also appraised. As concerns tumourous epidural pathology, positive diagnosis due to a lesion hinges upon the T1 and T2 sequences. Gadolinium's contribution is restricted to analysis of perivertebral and vertebral spreading; it also facilitates recognition of the spinal cord in circumferential epiduritis. So much said, gadolinium appears to be essential in frequently less compressive forms of infectious epiduritis; it plays a pronounced role in both follow-up of their evolution and recognition of acute epidural hematoma.

[Congenital arteriovenous malformation of the internal iliac artery discovered during pregnancy]. / Malformation artérioveineuse congénitale de l'artère iliaque interne découverte au cours de la grossesse.

We report a case found at the start of labour because of the presence of a "tumour praevia". Ultrasound, Doppler and tomodensitometric examination carried out after caesarean section confirmed the vascular origin of this lesion. Arteriography made it possible to decide the pattern of this arteriovenous malformation which was occurring in several branches of the left internal iliac artery. It was not possible to obliterate it completely by selective arterial embolisation, so it was removed surgically a few months later. Little is known about the complications that occur because of these arteriovenous malformations in pregnancy and during delivery. There is the theoretical risk that spontaneous rupture will occur in pregnancy but this does not justify terminating the pregnancy. It is better to carry out caesarean section because the tumour can obstruct delivery and may rupture as well as causing delay in labour. The treatment for these lesions is sometimes difficult and complex and one has to decide whether to preserve the uterus or not. Selective embolisation and pre-operative embolisation followed by surgical removal of dysplasic tissue are the therapies of choice.

[Adamantinoma of the tibia. X-ray computed tomographic and MRI study. Apropos of a case]. / Adamantinome du tibia. Etude tomodensitométrique et par IRM. A propos d'un cas.

Adamantinoma of the long bones in a very rare tumor that mainly affects the tibia. Its diagnosis is difficult both radiologically, as the lesion appears as a poorly specific metaphyseal lacuna with or without periosteal reaction, and histologically. Its prognosis used to be guarded because of recurrence and of possible metastatic diffusion, but it has been considerably improved by wide resection with reconstruction. On the occasion of a new case, the authors describe the appearance observed with MRI and the merits of this examination for the preoperative assessment.

Optimal central trapping (OPCETRA) vena caval filter: results of experimental studies.

The authors present the in vitro and in vivo results of use of a new vena caval filter, the optimal central trapping (OPCETRA) filter. The in vitro study was designed to compare the clot-trapping effectiveness of three filters: the OPCETRA, the stainless steel Greenfield, and the original Vena Tech-LGM. Standardized 3-mm, 5-mm, and 7-mm clots were captured in 66%, 100%, and 100% of cases, respectively, with the OPCETRA filter; in 34%, 82%, and 100% of cases with the Greenfield filter; and in 50%, 100%, and 100% of cases with the LGM filter. When filters were tilted 15 degrees, 100% of the 5-mm clots were trapped with the OPCETRA filter versus 50% with the Greenfield (P < 1.04 x 10(-9)) and 70% with the LGM (P < 1.78 x 10(-5)) filters. The in vivo animal study was designed to confirm ease of placement, tolerance, and effectiveness of the OPCETRA filter in sheep. Animals were separated into two groups: Group 1 underwent embolization through the femoral vein 40 days after filter implantation and were killed immediately; group 2 underwent embolization at 90 days and were killed 8 days later. In all cases pathologic analysis on the vena cava wall was performed after resection. The in vivo study demonstrated no tilting or migration with the OPCETRA filter. These encouraging results can be explained by the filter's hourglass shape, the number of arms, and the slow release of the filter at insertion.(ABSTRACT TRUNCATED AT 250 WORDS)