Retrospective Analysis of Delayed Intraparenchymal Hemorrhage after Flow-Diverter Treatment: Presentation of a Retrospective Multicenter Trial.

BACKGROUND AND PURPOSE: Intracranial aneurysm treatment with flow diverters has shown satisfying results in terms of aneurysm occlusion, and while some cases of delayed intraparenchymal hemorrhage have been described, no systematic analysis of the risk factors affecting its occurrence has been conducted in a large series of patients. This retrospective analysis of delayed intraparenchymal hemorrhage after flow-diverter treatment is a multicenter, retrospective study using a large series of treated patients to analyze factors affecting the occurrence of delayed intraparenchymal hemorrhage. MATERIALS AND METHODS: Patients treated with flow diverters and presenting with delayed intraparenchymal hemorrhage were included from December 2007 to December 2014 in 7 participating centers in France. Patient and aneurysm characteristics were recorded as were characteristics of bleeding (size, lateralization, and time to bleed), treatment, and clinical outcome after 1, 3, and 6 months. RESULTS: Delayed intraparenchymal hemorrhage occurred in 11 patients between 1 and 21 days after the procedure. In 10 of these patients, hemorrhages were ipsilateral to the treated aneurysms. Five of the 11 underwent surgery, and 9 of the 11 had good clinical outcomes at 6 months (mRS ≤2). CONCLUSIONS: The pathogenesis of delayed intraparenchymal hemorrhage occurring after flow-diverter treatment remains unclear. The multidisciplinary management of delayed intraparenchymal hemorrhage yields a relatively low morbidity-mortality rate compared with the initial clinical presentation.

Value of 4D MR angiography at 3T compared with DSA for the follow-up of treated brain arteriovenous malformation.

BACKGROUND AND PURPOSE: Four-dimensional, contrast-enhanced MRA is a useful technique for the diagnosis and classification of brain AVM. The purpose of this study was to evaluate its usefulness in the follow-up of treated brain AVM. MATERIALS AND METHODS: Patients with treated brain AVM (embolization, radiosurgery, and/or surgery) were investigated with both DSA (the "gold standard") and 4D MRA. Four-dimensional MRA was performed at 3T using a 4D sequence, combining contrast-enhanced timing-robust angiography, keyhole, and sensitivity encoding techniques. Examinations were evaluated by 2 independent readers and disagreements were resolved by a third reader. Interobserver and intermodality agreement with respect to residual nidus, residual venous drainage, and brain AVM patency were determined. RESULTS: Between May 2008 and February 2013, 37 patients with a median age of 45 years (interquartile range = 26-55) were prospectively included. Examinations were acquired 36 months (IQR = 10-45.5) after the last treatment. Interobserver agreement for brain AVM patency was very good for both 4D MRA (κ 0.82, 95% CI .67-.98) and DSA (κ 0.84, 95% CI .69-.98). After consensus reading, intermodality agreement for the evaluation of brain AVM patency was good (κ 0.73, 95% CI .55-.90). Diagnostic accuracy of 4D MRA for residual brain AVM compared with DSA, reached a sensitivity of 73.7%, specificity 100%, positive predictive value 100%, and negative predictive value 78.3%. Agreements by technique of treatment are also detailed. CONCLUSIONS: Four-dimensional MRA is a useful radiation-free technique for the follow-up of patients with treated brain AVM, especially patients treated by radiosurgery. However, given its actual limitations it is not sufficient to assert the cure; DSA remains mandatory for this purpose.

Combined treatment of brain AVMs with use of Onyx embolization followed by radiosurgery.

BACKGROUND AND PURPOSE: The treatment of cerebral AVMs is complex, reliant on interventions such as embolization, surgery, and radiosurgery, or a combination of these modalities. To date, treatment with the embolic agent Onyx, followed by radiosurgery, has not been evaluated. The goal of this study was to evaluate the safety and efficacy of this combination in a homogeneous, monocentric series. MATERIALS AND METHODS: From April 2003 to June 2008, a total of 20 patients (11 women and 9 men; age range, 10-55 years) were treated for AVMs with Onyx embolization followed by radiosurgery. AVM sizes were <3 cm in 7 patients and ≥3 cm in 13 patients. Modalities and complications of the procedure were analyzed as well as the long-term clinical and anatomic outcomes (2-5 years after treatment). RESULTS: Of 17 patients evaluated by DSA after radiosurgery, 10 (58.8%) were observed to have complete occlusion of the AVM nidus. Complete occlusion was observed in 5 (71.4%) of 7 Spetzler-Martin grade I-II AVMs and in 5 (50.0%) of 10 Spetzler-Martin grade III-IV AVMs. Complete occlusion was observed in 4 (80.0%) of 5 AVMs of <3 cm and 6 (50.0%) of 12 AVMs of >3 cm. One of 20 patients had significant worsening of clinical status (mRS ≥2) at long-term follow-up. CONCLUSIONS: In this preliminary series, the safety and efficacy of combined treatment by Onyx embolization followed by radiosurgery are quite satisfactory, with a low rate of clinical complications (5.0%) and a 58.8% rate of complete obliteration of the AVM.

Similar safety in centers with low and high volumes of endovascular treatments for unruptured intracranial aneurysms: evaluation of the analysis of treatment by endovascular approach of nonruptured aneurysms study.

BACKGROUND AND PURPOSE: The outcome of treatment for unruptured intracranial aneurysm by surgery or endovascular therapy appeared to be related to the volume of patients treated by the hospital. We performed an analysis in the ATENA series to determine whether the outcome of endovascular treatment was different in hospitals with low and high volumes of cases. MATERIALS AND METHODS: The ATENA series included 649 patients with 739 unruptured intracranial aneurysms. Patients were classified into 2 groups. Group A had 171 patients with 197 aneurysms in 13 centers that treated < or =20 patients; group B, 478 patients with 542 aneurysms in 14 centers that treated > or =21 patients. RESULTS: Groups A and B had similar patient populations and aneurysm characteristics. Stent placement was used in group B more frequently than in group A (9.6% versus 2.5%, P = .0016). The global rate of adverse events was not significantly different in groups A and B (16.0% and 14.4%, respectively). Thromboembolic events and intraoperative rupture were not significantly more frequent in group A than in group B. One-month mortality and morbidity rates were not significantly different in groups A (2.3% and 1.8%, respectively) and B (1.0% and 1.7%, respectively). Anatomic outcomes for groups A and B were not significantly different. CONCLUSIONS: Clinical and anatomic outcomes of endovascular treatments for unruptured intracranial aneurysms were similar in hospitals with low and high volumes of cases.

[Endovascular treatment of non-ruptured intracranial aneurysms: critical analysis of the literature]. / Traitement endovasculaire des anévrismes intracrâniens non rompus: analyse critique de la littérature.

BACKGROUND: The goal was to evaluate, from the published data, the results of the endovascular treatment of unruptured aneurysms. METHODS: We have searched Medline for studies publishing results for endovascular coiling of unrupured aneurysms. Studies were classified as single-center, multicenter, or meta-analysis. RESULTS: Single-center studies always underestimate morbidity and mortality rates. However, it is possible to estimate mortality rate around 1.5% and morbidity rate between 3 and 6%. Some published series have directly compared results of endovascular treatment with surgical treatment. The results are always in favour of endovascular treatment, demonstrating a lower rate of complications and lower total hospital charges. CONCLUSION: All published series of unruptured aneurysms favour the endovascular treatment instead of surgery. However, there is a lack of multicenter prospective series evaluating the results of the endovascular treatment of unruptured aneurysms. Likewise, there is no scientific arguments demonstrating that preventive treatment of unruptured aneurysms decreases the mortality and allows to decrease the risk of neurologic sequellae.

Preoperative embolization of a cervicodorsal paraganglioma by direct percutaneous injection of onyx and endovascular delivery of particles.

We report the feasibility and efficacy of percutaneous injection of Onyx (Micro Therapeutics, Irvine, Calif.), a nonadhesive liquid embolic agent, into an unusually located paraganglioma, followed by endovascular embolization with particles before surgery.

Endovascular treatment of intracranial aneurysms with matrix detachable coils: immediate posttreatment results from a prospective multicenter registry.

BACKGROUND AND PURPOSE: Endovascular treatment of intracranial aneurysms by using detachable coils has become an accepted alternative to surgery. To reduce the rate of aneurysm recanalization after treatment, biologically active polyglycolic/polylactic acid-covered platinum coils have been proposed. A prospective and multicenter registry was conducted in France to evaluate the safety and short-term and long-term efficacy of Matrix detachable coils. This first analysis is focused on the safety and short-term efficacy. METHODS: Two hundred sixty-one patients having ruptured or unruptured aneurysms treated via endovascular approach were included in this registry. Patients with giant aneurysms or in poor clinical condition (Glasgow Coma Scale < 10) were excluded. Because of various protocol violations, clinical analysis was conducted in 236 patients having 244 aneurysms. Technical and clinical complications were systematically recorded. Angiographic analysis was performed by a core laboratory by using the Raymond Grading Scale on 224 patients having 232 aneurysms. RESULTS: Complete occlusion was achieved in 102 aneurysms (44.0%); neck remnant, in 58 aneurysms (25.0%); and aneurysm remnant, in 72 aneurysms (31.0%). Technical and clinical complications related to the procedure were encountered in 43 patients (18.2%). Postoperative modification of the clinical status was observed in 12 patients (5.1%). Two patients died (0.8%), 6 had a permanent deficit (2.5%), and 4 had a transient deficit (1.7%). Treatment-related mortality was 0.8% and permanent morbidity was 2.5%. CONCLUSION: Endovascular treatment of intracranial aneurysms by using Matrix detachable coils is feasible and demonstrated initial angiographic results and overall morbidity and mortality rates that are within the ranges found in the literature in the use of bare platinum coils.

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.

[Imaging of skull base tumors in adults]. / Imagerie des tumeurs de la base du crâne de l'adulte.

The skull base is divided into three parts: anterior, central and posterior. Numerous foramina are located in the skull base and transmit important neurovascular structures. Numerous types of tumor can be observed at the skull base. They are classified as anterior, central and posterior skull base tumors. They are also divided into three groups according to their origin: tumors arising from the skull base itself, intracranial tumors and extracranial tumors invading the skull base. Imaging is very important for diagnosis, treatment and follow-up of patients with skull base tumors. Magnetic resonance imaging is the most useful modality as it visualizes the lesion on different planes and permits the planning of therapy. Computed tomography depicts the osseous lesions more precisely and may be necessary before surgery. Catheter angiography is now in most cases replaced by magnetic resonance angiography. Interventional neuroradiology is necessary if the lesion is highly vascularized or if a vessel is encased in the tumor.

Selective endovascular treatment of intracranial aneurysms using micrus microcoils: preliminary results in a series of 78 patients.

PURPOSE: To determine the safety and reliability of a new platinum microcoil (Micrus), in the treatment of intracranial aneurysms. PATIENTS AND METHODS: Seventy-eight patients (28 male and 50 female patients; age range, 28-83 years; mean age, 44 years) with 80 intracranial aneurysms were treated in 10 centers in Belgium and France. All aneurysms were smaller than 15 mm. Nine aneurysms (11%) were located in the posterior circulation and 71 (89%) in the anterior. Fifty aneurysms (63%) were ruptured and 30 (37%) unruptured. Micrus microcoil is a new platinum coil. It is electrically detached with a time of detachment close to 5 seconds. RESULTS: The degree of occlusion of the aneurysm was classified as total in 49 aneurysms (61%), subtotal in 28 cases (35%) and incomplete in 3 cases (4%). Technical complications were encountered in 10 patients (13%) including parent artery occlusion and thromboembolism (4 cases), coil migration (2 cases) and non-detachment of the coil (2 cases). The immediate morbidity rate was 1.3% and mortality rate 1.3%. CONCLUSION: Micrus microcoils are effective and safe in the selective treatment of ruptured and unruptured intracranial aneurysms. Spherical microcoils are helpful to create a good basket in the aneurysmal sac at the beginning of treatment.

Intracranial aneurysm associated with relapsing polychondritis.

We describe a 50-year-old man with relapsing polychondritis (RP) involving auricular cartilage, uveitis and hearing loss, who had an aneurysm of the anterior cerebral artery. Intracranial aneurysm is a rare manifestation of RP.

Functional MRI in double cortex: functionality of heterotopia.

A 12-year-old boy with epilepsy and subcortical laminar heterotopia (band heterotopia) underwent a functional MRI protocol to study voluntary motor activity in the hand. Finger tapping produced an activation of a contralateral limited and focused frontal cortical area both in the subcortical band heterotopia and the overlying cortex. Despite its epileptogenic activity, subcortical laminar heterotopia seems to be responsible for part of the functional activity of the brain. This has to be pointed out for epilepsy surgery resecting cortical dysplasia.

Giant-cell tumour involving the cranial vault: imaging and treatment.

A giant-cell tumour involving the cranial vault was diagnosed in a 37-year-old man who presented with a large swelling at the vertex. The role of imaging in the diagnosis and treatment of this tumour is described. On CT and MRI the appearances were nonspecific and the diagnosis was established by histological examination after removal of the tumour. A preoperative angiogram showed a tumour blush and before surgery, embolisation was performed via the percutaneous and transarterial routes.

Postoperative aneurysm remnants: endovascular treatment as an alternative to further surgery.

Because further surgery on postoperative aneurysm remnants can be difficult and lead to significant morbidity and mortality, endovascular treatment, using controlled detachable coils, was performed in three patients with such remnants. The endovascular approach was technically more difficult in these cases than in previously untreated patients. In one case, the "remodelling" technique was necessary. Given the successful outcome in these patients, endovascular treatment can be proposed as an alternative to another operation, when further surgery appears too risky or is refused by the patient.

Percutaneous biopsy of the thoracic and lumbar spine: transpedicular approach under fluoroscopic guidance.

Eighteen patients with vertebral lesions located in the thoracic or lumbar spine underwent percutaneous biopsy performed via a transpedicular approach under fluoroscopic guidance. This technique led to an accurate diagnosis in 16 cases (89%). No complications were encountered. For percutaneous lumbar and thoracic vertebral biopsy, the transpedicular approach is a safe and accurate alternative to the posterolateral approach.

The endovascular approach in the management of patients with multiple intracranial aneurysms.

To investigate the role of endovascular treatment we performed a retrospective study of our patients with multiple intracranial aneurysms seen in our institution between October 1992 and March 1995. This period was chosen to study a homogeneous group of patients since the appearance of controlled detachable coils, and to obtain the largest number of patients with angiographic follow-up of the aneurysms treated. We studied 53 patients with a total of 128 aneurysms, in 46 of whom we treated 67 aneurysms by the endovascular approach. Of these, 5 aneurysms in 3 patients were treated by occlusion of the parent vessel and 62 aneurysms in 43 patients with coils, 52 with Guglielmi detachable coils and 10 with mechanically detachable spirals. Complete occlusion was obtained in 58 aneurysms, and partial occlusion in 9. The therapy caused permanent neurological deficit in 3 cases (6.5%), and there was 1 case of rebleeding (incomplete occlusion of the aneurysm). No deaths occurred. All aneurysms were treated in 29 of the 53 patients. Endovascular procedures were used for 16 patients (30%), surgery was performed in 1 patient (2%) and the two were combined in 12 (23%). In 23 of 53 cases (43%), unruptured aneurysms were left untreated, usually because of their small size. In 1 patient with unruptured aneurysms, the endovascular approach failed and the patient refused surgery.

The role of CT in evaluation of the effectiveness of embolisation of spinal dural arteriovenous fistulae with N-butyl cyanoacrylate.

A failed embolisation of a spinal dural arteriovenous fistula (AVF), because a pedicular injection has not reached the initial venous compartment, must be identified immediately, to allow prompt surgery and thus avoid clinical deterioration. The purpose of our study was to determine the role of CT in confirming a complete cure just after embolisation with N-butyl cyanoacrylate (NBCA). Seven patients embolised for spinal dural AVFs with perimedullary venous drainage had an immediate postembolisation CT scan. In six patients a complete cure was achieved, with a normal postembolisation angiogram in five cases. Just after injection of NBCA, we were unable to determine on plain films whether or not the glue had reached the draining vein in six of seven cases. The postembolisation CT showed various patterns: in two cured patients, the glue was visible in the inner surface of the dura mater and therefore on the venous side. In five cases, the glue was approaching the dura mater around the cord or seemed to reach its surface: in the four patients cured, the glue column was 7-18 mm high, whereas it was less than 2 mm high in the patient with angiographic proof of recurrent fistula. The follow-up angiogram remains the only way to confirm a durable cure. We suggest that immediate postembolisation CT may help in assessing endovascular treatment of spinal dural AVFs.

Cerebral dural arteriovenous fistulas: clinical and angiographic correlation with a revised classification of venous drainage.

PURPOSE: To review the symptoms and progression of dural arteriovenous fistulas (AVFs) and correlate the findings with various angiographic patterns. MATERIALS AND METHODS: Patterns of venous drainage allowed classification of dural AVFs into five types: type I, located in the main sinus, with antegrade flow; type II, in the main sinus, with reflux into the sinus (IIa), cortical veins (IIb), or both (IIa + b); type III, with direct cortical venous drainage without venous ectasia; type IV, with direct cortical venous drainage with venous ectasia; and type V, with spinal venous drainage. RESULTS: Type I dural AVFs had a benign course. In type II, reflux into the sinus induced intracranial hypertension in 20% of cases, and reflux into cortical veins induced hemorrhage in 10%. Hemorrhage was present in 40% of cases of type III dural AVFs and 65% of type IV. Type V produced progressive myelopathy in 50% of cases. CONCLUSION: This classification provides useful data for determination of the risk with each dural AVF and enables decision-making about the appropriate therapy.