Endovascular treatment of intracranial aneurysms with Guglielmi detachable coils: analysis of midterm angiographic and clinical outcomes.

BACKGROUND AND PURPOSE: The previous decade has witnessed increasing application of Guglielmi detachable coils (GDCs) for the treatment of intracranial aneurysms. However, the midterm angiographic and clinical outcomes are not well documented. We report here the angiographic and clinical outcomes of patients treated with GDCs over an 8-year period. METHODS: Between 1992 and 1998, 144 patients with 160 intracranial aneurysms were treated with GDCs. Clinical follow-up data were obtained from medical records, questionnaires, and telephone interviews. Angiographic studies were reviewed by 2 neuroradiologists to obtain consensus regarding the degree of aneurysm occlusion. RESULTS: Eighty-one patients had ruptured aneurysms; 63 had unruptured aneurysms. Technical success was achieved in 91% of patients, with complete aneurysm occlusion in 46%, neck remnants in 16%, and residual body filling in 38%. Angiographic follow-up revealed that residual body filling in some aneurysms was resolved, small neck remnants were stable, and the recanalization rate decreased with time. All 63 patients with unruptured aneurysms were discharged from hospital with independent clinical status (Glasgow Outcome Score, 1 or 2). For patients with ruptured aneurysms, discharge clinical status correlated with the Hunt & Hess clinical grade at the time of treatment. Clinical follow-up for a minimum of 2 years was available in 98.5% of patients. Ninety-four percent of patients treated for unruptured aneurysms were independent at 2 years, and 82% of Hunt & Hess grade I to II patients were independent. CONCLUSIONS: Coil embolization is a safe and effective treatment for both ruptured and unruptured aneurysms. Increasing angiographic stability is demonstrated in treated aneurysms up to 3 years from coil embolization. Therefore, follow-up angiography until this time is advisable.

Hepatic kinetics and magnetic resonance imaging of gadolinium-EOB-DTPA in dogs.

RATIONALE AND OBJECTIVES: To measure the hepatic uptake and biliary elimination kinetics of gadolinium (Gd)-EOB-DTPA in dogs. METHOD: Two groups of four beagles each were anesthetized and given an intravenous bolus of 25 mumol/kg or 250 mumol/kg of Gd-EOB-DTPA. Blood, hepatic bile, and urine were collected over 140 minutes, and liver samples were obtained immediately after the dogs were killed. Conventional T1-weighted spin echo sequences of the liver were performed on a 1.5-Tesla (T) magnetic resonance imager during sampling. A ninth beagle received a bolus of 25 mumol/kg followed 140 minutes later with a bolus of 250 mumol/kg of Gd-EOB-DTPA. Wedge liver biopsies were obtained for Gd estimation at various times after dosing, and Gd concentration was measured by inductively coupled plasma atomic emission spectroscopy. RESULTS: The plasma concentration of Gd-EOB-DTPA decreased in a biexponential manner with half-lives of approximately 4 minutes and 60 minutes for the distribution and elimination phase independent of the dose given. Gadolinium bile concentration reached peak values between 80 and 140 minutes: 6.3 +/- 1.6 mmol/L for the low dose (LD) and 11.6 +/- mmol/L for the high dose (HD). Bile Gd output was 62.0 +/- 8.8 (LD) and 78.3 +/- 30.2 (HD) nmol/minute-kg 50 to 80 minutes after injection. Gadolinium-EOB-DTPA was excreted by the biliary route to 24.8 +/- 2.6 (LD) and 3.6 +/- 1.2 (HD) percent of the dose within 140 minutes. Liver Gd concentration was 0.43 +/- 0.14 (LD) and 4.3 +/- 0.5 (HD) mmol/kg liver tissue at the conclusion of the studies. Calculated concentrations in the hepatocyte were 60 (LD) and 15 (HD) times higher than in plasma at 25 minutes after dosing. Whereas the low dose exhibited excellent contrast enhancement for the whole period, the high dose displayed a biphasic signal enhancement with a decreasing signal caused by the too-high hepatic gadolinium accumulation. CONCLUSIONS: Transport of the Gd-EOB-DTPA into the hepatocyte exceeded elimination from hepatocyte to bile. The high dose defined a biliary transport maximum for Gd-EOB-DTPA of 78.3 +/- 30.2 nmol/minute-kg. The liver accumulation results from fast transport into the hepatocyte and rate-limited slower transport from hepatocyte to bile. The accumulation occurs against a strong concentration gradient, suggesting energy-dependent active transport into the hepatocyte.

Gastrointestinal bleeding and mycotic superior mesenteric aneurysm.

This is a case report of management of a delayed mycotic superior mesenteric artery aneurysm occurring in a patient 2 years after aortic valve replacement for endocarditis. A chronic ulcer history, anticoagulation therapy, episodic gastrointestinal bleeding associated with negative gastrointestinal series, and gastritis seen at endoscopy delayed the ultimate diagnosis. An episode of massive hemorrhage precipitated angiography with subsequent surgical confirmation of the diagnosis. Management included debridement and extirpation of the major part of the aneurysm, Doppler assessment of the inadequacy of collateral mesenteric arterial blood flow, and restoration of flow with a bypassing saphenous vein graft segment. Although this technique of reconstruction has been suggested, we can find no other report of such a similar case among the few reported surgical successes with superior mesenteric artery mycotic aneurysm.

High resolution CT air cisternography in the diagnosis of small acoustic neuromas.

High resolution CT air cisternography was used to examine 38 patients with clinical findings and audiovestibular function studies consistent with a retrocochlear lesion. Four strictly intracanalicular lesions and 10 acoustic neuromas extending medially into the cerebellopontine angle (CPA) cistern by no more than 1 cm were detected and verified at surgery. There was one false-positive diagnosis produced by a tortuous inferior cerebellar artery branch. The contrast-enhanced axial scan was positive in only two patients. Both had extension of the tumor into the CPA by 1 cm. In these two cases the axial intravenous (IV) contrast-enhanced scan provided more information than the air CT. A patient with suspected acoustic neuroma is best examined initially with an IV contrast-enhanced axial scan followed by CT air cisternography where the contrast study is negative.

Resolution of third nerve paresis after endovascular management of aneurysms of the posterior communicating artery.

The effect of endovascular treatment on the recovery of neural function in patients with third nerve palsy caused by an aneurysm of the posterior communicating artery is poorly documented. We report three cases in which third nerve paresis resolved completely within 2 to 3 weeks of endovascular occlusion of a posterior communicating artery aneurysm.

Use of glycoprotein IIb-IIIa inhibitor for a thromboembolic complication during Guglielmi detachable coil treatment of an acutely ruptured aneurysm.

Thrombotic occlusion of the anterior communicating and right anterior cerebral arteries occurred during embolization of an acutely ruptured aneurysm of the anterior communicating artery. Traditional management, including superselective infusion of a fibrinolytic agent, was unsuccessful in reestablishing normal vessel patency. Therefore, an intravenous dose of abciximab was administered. Serial angiography showed that normal vessel patency was reestablished within 10 min. There were no adverse events related to abciximab administration, and the patient recovered from the procedure without neurologic deficit.

Vertebral synovial osteochondromatosis with compressive myelopathy.

STUDY DESIGN: A case report of vertebral synovial osteochondromatosis with compressive myelopathy. OBJECTIVES: To describe the clinical, radiologic, and histopathologic features of vertebral facet synovial osteochondromatosis with compressive myelopathy. SUMMARY OF BACKGROUND DATA: There has been only one previously reported case of synovial osteochondromatosis affecting the vertebral facet joint and no previous report of associated compressive myelopathy. METHODS: The case history, radiology, surgical findings, and histopathology are reviewed. RESULTS: Vertebral facet synovial osteochondromatosis is a potential and readily manageable cause of spinal cord compression. CONCLUSIONS: Synovial osteochondromatosis of the vertebral facet joint should be considered as a cause of compressive myelopathy.

Spinal abnormalities in young fast bowlers.

The action of fast bowling in the game of cricket is known to cause injuries to the lumbar spine. We studied a group of 16- to 18-year-old fast bowlers, selected for special training in Western Australia. All 24 had MR scans of the spine, 22 had radiographs and CT scans; in 20 the bowling technique was analysed biomechanically. There was a high incidence of back pain and this was always associated with a radiological abnormality. Pars interarticularis defects were diagnosed in 54% and intervertebral disc degeneration in 63%. Bowling actions which involved counter-rotation were associated with a higher incidence of both injuries.

Arteriovenous malformations of the mandible.

Arteriovenous malformations of the mandible may present with pulsatile tinnitus, pain, a bruit, loosening of teeth, or intraoral or facial deformation or discoloration. In the absence of these classic symptoms and signs, the unwary surgeon might attempt a limited excision, leading to massive intraoperative hemorrhage. Management includes external carotid as well as selective branch arteriography and preoperative arterial embolization with polyvinyl alcohol sponges and absorbable gelatin. Vessel ligation, mandibular resection, lesion excision, mandibular autografting, and intermaxillary fixation complete surgical treatment.

Some pitfalls in the diagnosis of pituitary tumours: the importance of carotid angiography.

Headache and the radiological finding of an abnormal pituitary fossa are a frequent mode of presentation in patients with pituitary tumours. The case histories and radiological findings of 4 patients who presented with the above features, and in whom the major abnormalities of the pituitary fossa were due mainly to variations in the cavernous portions of the carotid artery, are described. The role of carotid angiography in the investigation of a patient with an abnormal pituitary fossa is stressed.

Transarterial platinum coil occlusion of ruptured intracranial aneurysms: results in 51 patients.

Fifty-one patients with subarachnoid haemorrhage (SAH) due to ruptured intracranial aneurysm have been treated by the Guglielmi detachable platinum coil (GDC) treatment method; 36 patients within 28 days of the ictus. There was total body occlusion in 64.8%, subtotal body occlusion in 24.1% and failed coil placement in 11.1%. Technical success rates were highest in aneurysms with neck sizes up to 4 mm (75% total occlusion) and aneurysms smaller than 10 mm largest diameter (72.5% total occlusion). At discharge from primary care, there were 62.7% without deficit rising to 74.5% at follow-up assessment. Four patients are dead and one disabled (9.8%). Patient clinical outcomes relate most closely to Hunt and Hess grade at time of definitive treatment. Higher initial grades and poorer clinical outcomes are concentrated in patients treated in the first 14 days. The incidence of procedure related thrombo-embolic events has fallen from 20% in the first 30 patients to 4.8% in the next 21. Rebleeding during GDC procedures occurred in 20.6% of patients treated 1-14 days post SAH.

Disc degeneration and the young fast bowler in cricket.

Twenty-four male fast bowlers of mean age 13.7 years, who bowled competitively at a school and club level were selected from five Western Australian schools. At the time of the testing all bowlers, who were bowling completely freely, underwent magnetic resonance imaging to detect the presence of intervertebral disc abnormalities. While these radiological data were being analysed, the players were filmed both laterally (200 Hz) and from directly above (100 Hz) as their front foot impacted a force platform during the delivery stride of the fast bowling action. In addition these bowlers performed selected physical capacity tests. The occurrence of abnormal radiological data were then used to group the bowlers (group 1, no abnormal features; group 2, disc degeneration and/or bulging on scan). A Mann-Whitney U rank test was then used to identify any significant differences (P < 0.1) between the groups for all dependent variables. Five of the subjects recorded abnormal magnetic resonance imaging scans of the lumbar spine, while nineteen recorded normal intervertebral discs, normal alignment of the lumbar spine, and no sign of spondylolisthesis. Bowlers who rotated the trunk to realign the shoulders to a more side-on position between back foot impact and front foot impact in the delivery stride were more likely to record abnormal intervertebral disc features.

The Guglielmi coil for transarterial occlusion of intracranial aneurysm: preliminary Western Australian experience.

18 patients aged 3-75 years with cranial arterial aneuryms have been treated by transarterial insertion of Guglielmi Detachable Coils (GDC). 11 patients had previously bled and 9 pts had previous craniotomy for the same aneurysm. 22 technically successful procedures were performed in 17 aneurysms (16 patients). Subsequent repacking was performed 8 times (5 patients). There were 4 unsuccessful procedures in 2 patients. Including repackings, 9 aneurysms (8 patients) show complete occlusion and 7 aneurysms are considered stable with either a neck remnant or persistent partial filling of the aneurysm. 1 aneurysm showed repeated recanalisation necessitating multiple repackings. 1 patient developed recanalisation, aneurysm enlargement and died of recurrent subarachnoid haemorrhage (SAH) at 7 months. 8 patients suffered procedural complications or deficits. 3 patients showed occlusion of a parent artery. On 6-18 month follow up 13 survivors are well and symptom free and 1 has recovered mild hemiparesis. Three recent patients are progressing well but await follow up. Our results are compared with a larger series reported from the North American GDC trial.

Cost versus efficacy of magnetic resonance imaging.

Magnetic resonance imaging offers new and improved diagnostic capabilities in all body parts and organ systems. Examinations can be quicker, safer and less expensive than traditional radiological procedures. The cost/efficiency of magnetic resonance imaging is under active evaluation.

MR Imaging in Multiple Sclerosis: The Accuracy of 3D Double Inversion Recovery at 3 Tesla and the Potential for Single Sequence Imaging.

To compare the accuracy of a three dimensional, T2-weighted double inversion recovery (DIR) sequence with two dimensional fluid attenuated inversion recovery (FLAIR) and dual echo T2 (DE T2) sequences at 3 Tesla in the detection of intracranial demyelinating lesions in patients with known or suspected multiple sclerosis (MS), and to consider the appropriateness of a stand-alone DIR sequence in MS imaging. The studies of 98 patients who underwent imaging with DE T2, FLAIR and DIR sequences for known or suspected multiple sclerosis were retrospectively reviewed. In 42 cases, a diagnosis of MS had been clinically suspected. In the remaining 56 cases, a diagnosis of MS had been previously established. All patients were imaged on a 3T MRI unit. Coronal and sagittal FLAIR, axial DE T2, and three dimensional T2-weighted DIR sequences were utilised. Of the 42 patients with suspected multiple sclerosis, 11 demonstrated lesions characteristic of the disease. Demyelinating plaques were seen in all of the 56 patients with known MS. In all cases, all lesions seen on DE T2-or FLAIR sequences were visible and more conspicuous on the DIR sequence. In 22 of the 67 patients (33%) with demyelinating lesions, the DIR sequence showed additional lesions not visible on any of the other sequences. Additional detected lesions predominantly involved grey matter. At 3 Tesla, a T2 weighted, three dimensional DIR sequence is as accurate at detecting the presence of intracranial demyelinating lesions as two dimensional FLAIR and DE T2 sequences combined. A greater number of lesions were detected with the DIR sequence, and all lesions were more conspicuous. A single, stand alone DIR sequence may be considered appropriate for monitoring MS.