Cerebral vasospasm patterns following aneurysmal subarachnoid hemorrhage: an angiographic study comparing coils with clips.

BACKGROUND AND PURPOSE: Cerebral vasospasm following aneurysmal subarachnoid hemorrhage (aSAH) results in significant morbidity due to ischemia. Subarachnoid hematoma evacuation during aneurysm clipping reduces the incidence of vasospasm. However, studies comparing endovascular coiling with open clipping have reported similar rates of spasm. We addressed the question of how coiling produces similar (if not less) vasospasm without the benefit of clot evacuation by evaluating vasospasm patterns among patients with aSAH. We hypothesize that cerebrospinal fluid (CSF) circulation plays a major role in clearing blood breakdown products, and that coiling may preserve CSF flow in the subarachnoid space. METHODS: A retrospective chart review identified 36 (18 coiled/18 clipped) patients with aSAH who developed angiographic vasospasm. The degree of spasm was quantified using an ordinal scale from 0 (none) to 5 (severe) for 26 anatomic vessel segments evaluated on 164 successive angiograms. Statistical analysis was performed using the Fisher exact test for proportions and the Wilcoxon and Student t tests on ordinal/continuous measures. Quadratic regression was also used as a model for spasm activity versus post-bleed days. RESULTS: In both the coiling and clipping groups the most severely spastic vessels were located adjacent to aneurysm rupture. Perianeurysmal spasm affected all subjects. However, whereas spasm remained largely confined in patients treated by clipping, those who underwent coiling developed stepwise progression distally over time. The distal vasospasm severity scores were higher among subjects treated by coiling, particularly in the most dependent regions of the subarachnoid space. CONCLUSIONS: Patients with aSAH treated by endovascular coiling and surgical clipping demonstrate distinct vasospasm patterns. While both initially exhibit perianeurysmal spasm, patients treated by coiling go on to develop stepwise progression distally over time. This finding may reflect dispersion of blood breakdown products along preserved CSF egress pathways in patients treated by endovascular coiling.

Prevención de la recurrencia peritoneal en el tratamiento quirúrgico del cáncer gástrico / Prevention of peritoneal recurrence of gastric cancer

The peritoneal cavity is the main site of gastric cancer recurrence after curative surgery. When this recurrence occurs, patients may experience bowel obstruction, dehydration and multiple hospital admissions. The therapeutic options that may decrease the rate of peritoneal recurrence and increase five years survival are intraoperative hyperthermic chemotherapy, extensive intraoperative peritoneal lavage and routine bursectomy. We herein review the oncological results of curative surgery for gastric cancer, its failure patterns and the risk factors for peritoneal recurrence. We also review the studies aiming to prevent peritoneal carcinomatosis.

La recurrencia peritoneal en el cáncer gástrico avanzado, luego de una cirugía con intención curativa es un problema que debe ser considerado una prioridad en nuestro país, debido a la alta proporción de pacientes con compromiso de la serosa gástrica al momento del diagnóstico, siendo el peritoneo el principal sitio de recurrencia luego de una cirugía con intención curativa en este grupo. Luego de la recurrencia peritoneal, los pacientes presentan un deterioro importante de la calidad de vida, principalmente por episodios de obstrucción intestinal, deshidratación y rehospitalizaciones. Se han realizado múltiples estudios en el extranjero de potenciales medidas que se pueden realizar durante la cirugía inicial con intención curativa que previenen la recurrencia. Algunas de estas medidas han disminuido la recurrencia peritoneal y aumentado la sobrevida a 5 años, como son la quimioterapia hipertérmica intraoperatoria, el lavado peritoneal extensivo y la bursectomía rutinaria, en pacientes seleccionados. El objetivo de la presente revisión es mostrar los resultados oncológicos de la cirugía curativa, los patrones de falla luego de una cirugía curativa, los factores de riesgo para una recurrencia peritoneal y los estudios que se han realizado en relación a la prevención de la carcinomatosis peritoneal.

Partial recanalization of concomitant internal carotid-middle cerebral arterial occlusions promotes distal recanalization of residual thrombus within 24 h.

OBJECTIVES: Acute, simultaneous, concomitant internal carotid artery (ICA) and middle cerebral arteries (MCA) occlusions almost invariably lead to significant neurological disability if left untreated. Endovascular therapy is frequently the method of treatment in such situations but there remains a chance of incomplete recanalization. Successful recanalization of the proximal aspect of the occlusion may allow for endogenous thrombolysis and facilitate further endogenous recanalization of any residual MCA occlusion. METHODS: Consecutive patients with acute ischemic stroke undergoing endovascular therapy for tandem extracranial ICA-MCA or contiguous intracranial ICA-MCA occlusions were retrospectively analyzed. Rates of facilitated endogenous recanalization at 24 h (FER(24)) were compared by imaging within the immediate post-intervention 5-24 h period in those with proximal recanalization and in those without. RESULTS: 17 patients were included in the analysis. 12 patients had good initial proximal recanalization but a residual partial or total occlusion of the MCA while five patients failed any recanalization. Seven patients (58.3%) in the first group and none in the second had FER(24) on interval imaging after intervention (p=0.04). The probability of death and disability at discharge was less in patients with FER(24) than those without (p=0.05). CONCLUSIONS: More than half of all patients who present with both ICA and MCA occlusions who are only partially recanalized will undergo facilitated endogenous recanalization within the subsequent 24 h following intervention.

Recanalization rates decrease with increasing thrombectomy attempts.

BACKGROUND AND PURPOSE: Use of the Merci retriever is increasing as a means to reopen large intracranial arterial occlusions. We sought to determine whether there is an optimum number of retrieval attempts that yields the highest recanalization rates and after which the probability of success decreases. MATERIALS AND METHODS: All consecutive patients undergoing Merci retrieval for large cerebral artery occlusions were prospectively tracked at a comprehensive stroke center. We analyzed ICA, M1 segment of the MCA, and vertebrobasilar occlusions. We compared the revascularization of the primary AOL with the number of documented retrieval attempts used to achieve that AOL score. For tandem lesions, each target lesion was compared separately on the basis of where the device was deployed. RESULTS: We identified a total of 97 patients with 115 arterial occlusions. The median number of attempts per target vessel was 3, while the median final AOL score was 2. Up to 3 retrieval attempts correlated with good revascularization (AOL 2 or 3). When >or=4 attempts were performed, the end result was more often failed revascularization (AOL 0 or 1) and procedural complications (P = .006). CONCLUSIONS: In our experience, 3 may be the optimum number of Merci retrieval attempts per target vessel occlusion. Four or more attempts may not improve the chances of recanalization, while increasing the risk of complications.

Resultados perioperatorios y sobrevida alejada de la pancreatoduodenectomía con resección vascular / Pancreaticoduodenectomy with vascular resection: perioperative results and long-term survival

Background: Pancreaticoduodenectomy (PDD) with vascular resection (VR) of the portal and superior mesenteric vein for locally advanced periampullary tumors is controversial. Aim: To evaluate the perioperative results and long-term survival of PDD with VR. Patients and Methods: Retrospective study. We included patients with periampullary tumors who underwent a PDD with VR between 1990 and 2008. We compared perioperative results and long-term survival with PDD without VR during the same period. We compared survival with non resected patients. Results: One hundred and eighty eight patients underwent a PDD, a VR was performed in 8 (4 percent) patients (Age: 58 +/- 14 years, Male: 4). Morbidity for PDD with and without VR was 75 percent and 59 percent (p = ns). Surgical mortality for PDD with and without VR was 0 percent and 8 percent (p = ns). In 6 of 8 patients the diagnosis was pancreatic cancer and histopathologic confirmation of vascular invasion was present in 4 patients. Long-term survival for patients with PDD with and without VR was similar (median 25 and 16 months; p = ns). Survival for patients with PDD with VR was superior to non resected patients (median 25 and 3 months; p = 0.0001). Conclusions: PDD with VR has similar perioperative results and long-term survival to PDD without VR. The survival reached with this type of surgery is far superior to non resected patients.

Introducción: La pancreatoduodenectomía (PDD) con resección vascular (RV) cuando existe invasión de la vena porta o mesentérica superior (VP-VMS) es controversial. Objetivo: Evaluar los resultados del perioperatorio y la sobrevida alejada de los pacientes sometidos a esta técnica. Material y Método: Estudio retrospectivo que incluyó a los pacientes con un tumor periampular en quienes se realizó una PDD con RV entre 1990 y 2008. Se compararon los resultados del perioperatorio y de sobrevida alejada con el grupo sometido a una PDD sin RV durante el mismo período. Se comparó también la sobrevida con los pacientes no resecados. Resultados: Se realizaron 188 PDD, en 8 (4 por ciento) de estos pacientes se realizó PDD con RV (Edad: 58 +/- 14 años, Hombres: 4). La morbilidad postoperatoria para la PDD con y sin RV fue de 75 por ciento y 59 por ciento (p = ns). La mortalidad postoperatoria para los grupos con y sin RV fue de 0 por ciento y 8 por ciento (p = ns). En 6 de los 8 pacientes el diagnóstico fue cáncer de páncreas y en 4 se confirmó histopatológicamente la invasión de VP-VMS. La sobrevida del grupo con y sin RV no tuvo diferencia significativa (medianas 25 y 16 meses; p = ns). La sobrevida de los pacientes sometidos a una PDD con RV fue superior a los pacientes no resecados (medianas 25 y 3 meses; p = 0,0001). Conclusiones: La PDD con RV obtiene resultados perioperatorios y de sobrevida alejada comparables a una PDD sin RV. La sobrevida alcanzada con esta técnica es ampliamente superior a la de los pacientes no resecados.

Gastrectomía laparoscópica en cancer gástrico / Laparoscopic gastrectomy for gastric cancer

Introducción: La cirugía laparoscópica ha sido incorporada como una alternativa de tratamiento curativo en cancer gástrico. El objetivo de este estudio es evaluar los resultados quirúrgicos inmediatos de pacientes sometidos a gastrectomía laparoscópica por cancer gástrico incipiente e intermedio en el Hospital Clínico de la Pontificia Universidad Católica de Chile y en el Hospital Dr. Sótero del Río. Material y método: Se incluyen todos los pacientes sometidos a gastrectomía laparoscópica por cancer gástrico incipiente e intermedio (T1 - T2) en ambas instituciones. Resultados: Desde Mayo de 2005 a Diciembre del 2006, 13 pacientes fueron sometidos a gastrectomía laparoscópica, 9 hombres (70%). Edad promedio 62+ 12 años. El tiempo operatorio promedio fue 293 + 51 minutos, la estadía hospitalaria 7,3 + 2,8 días. No hubo complicaciones quirúrgicas. El promedio de ganglios resecados fue de 27 + 18. De acuerdo a la clasificación TNM-AJCC, 9 pacientes se encontraban en etapa IA y 4 en etapa IB. Discusión: La gastrectomía laparoscópica es una alternativa segura en el tratamiento quirúrgico del cancer gástrico incipiente e intermedio.

Introduction: Laparoscopic surgery has been incorporated as an alternative of treatment for gastric cancer. The aim of this study was to evalúate the postoperative surgical results of laparoscopic gastrectomy in patients with early and intermedíate gastric cancer in the University Hospital of the Pontificia Universidad Católica de Chile and Hospital Dr. Sótero del Río. Material and methods: All patients who underwent laparoscopic gastrectomy for early and intermedíate gastric cancer (T1-T2) were included in this study. Results: From May2005to December2006, laparoscopic gastrectomy was performed in 13 patients. Mean age was 62+12 years and 9 of them were men (70%). Mean operative time and hospital stay was 293 +/- 51 minutes and 7.3 +/- 2.8 days, respectively. There were no postoperative complications. The mean number of lymph node dissected was 27 + 18. According to the TNM-AJCC classification system 9 patients were in stage IA and 4 a safe alternative in the surgical treatment of early in stage IB. Discussion: Laparoscopic gastrectomy is and intermedíate gastric cancer.

Cholesterol level and symptomatic hemorrhagic transformation after ischemic stroke thrombolysis.

BACKGROUND: Prestroke statin use may improve ischemic stroke outcomes, yet there is also evidence that statins and extremely low cholesterol levels may increase the risk of intracranial hemorrhage. We evaluated the independent effect of statin use and admission cholesterol level on risk of symptomatic hemorrhagic transformation (sHT) after recanalization therapy for acute ischemic stroke. METHODS: We analyzed ischemic stroke patients recorded in a prospectively maintained registry that received recanalization therapies (IV or intra-arterial fibrinolysis or endovascular embolectomy) at a university medical center from September 2002 to May 2006. The independent effect of premorbid statin use on sHT post intervention was evaluated by logistic regression, adjusting for prognostic and treatment variables known to predict increased HT risk after ischemic stroke. RESULTS: Among 104 patients, mean age was 70 years, and 49% were men. Male sex, hypertension, statin use, low total cholesterol and low-density lipoprotein (LDL) cholesterol, current smoking, elevated glucose levels, and higher admission NIH Stroke Scale (NIHSS) score were all associated with a greater risk of sHT in univariate analysis. After adjusting for covariates, low LDL cholesterol (odds ratio [OR], 0.968 per 1-mg/dL increase; 95% CI, 0.941 to 0.995), current smoking (OR, 14.568; 95% CI, 1.590 to 133.493), and higher NIHSS score (OR, 1.265 per 1-point increase; 95% CI, 1.047 to 1.529) were independently associated with sHT risk. CONCLUSIONS: Lower admission low-density lipoprotein cholesterol level with or without statin use, current smoking, and greater stroke severity are associated with greater risk for symptomatic hemorrhagic transformation after recanalization therapy for ischemic stroke.

Swine model of carotid artery atherosclerosis: experimental induction by surgical partial ligation and dietary hypercholesterolemia.

INTRODUCTION: Limited availability of a large animal model of carotid atherosclerosis has limited preclinical evaluation of endovascular therapeutic devices. The present study is aimed at developing such animal models with a novel approach, emphasizing the role of hemodynamics. METHODS: Using 18 carotid arteries from 9 miniswine, surgical partial ligation (approximately 80% stenosis) was carried out in untreated (group I; n = 6) and balloon-injured arteries (group II; n = 9). Three arteries were subjected to sham-operation for control (group III; n = 3). All animals were fed with a high-fat diet until sacrifice. Angiograms and histologic sections of the vessels were analyzed to evaluate both models. RESULTS: Atherosclerotic changes were confirmed in 6 of 6 in group I and 6 of 9 arteries in group II, whereas all in group III remained intact. Three arteries in group II resulted in thrombotic occlusion. Advanced plaques with intraplaque hemorrhage and/or calcification were seen in 4 of 6 arteries in group I but none in group II. The cross-sectional area stenosis and atherosclerotic stage for plaques in group I were both significantly higher than that in groups II and III. CONCLUSION: In this series, surgical partial ligation with concomitant dietary hyperlipidemia is an appropriate experimental technique to develop advanced atherosclerotic plaques with minimal technical complications. This model showed no evidence of such benefits when applied in balloon-injured arteries.

Apendicectomía en la embarazada: Experiencia en un hospital público chileno / Appendectomies for suspected acute appendicitis during pregnancy: Experience at a Chilean public hospital

Background: Acute appendicitis is the most common non obstetric surgical emergency during pregnancy. Aim: To asses our experience in the diagnosis and management of acute appendicitis occurring during pregnancy. Patients and methods: Data from all pregnant patients who were subjected to an appendectomy for a suspected acute appendicitis from January 1998 to December 2002, were retrospectively analyzed. All pathological, surgical, clinical records and the delivery outcome registry of each patient were reviewed. Results: Among 47,322 deliveries, 46 pregnant women aged 29±9 years and with a gestational age of 21±7 weeks, were operated because of a presumptive acute appendicitis. Forty (87%) had a histopathologically proven appendicitis; ten (25%) cases had a perforated appendix and 30 (75%) had a non-perforated appendicitis. Five (10.9%) patients had a negative laparotomy and one had a necrotic ovarian tumor. Patients with perforated and non perforated appendices had a similar lapse from the onset of symptoms to operation (69±45 and 50±34 hours respectively, NS) and a similar white cell count (15,667±3,707 and 13,006±5,206 cells/mm3, respectively, NS). Wound infection was the most common surgical complication in 15%. Seven (15%) patients had a premature delivery and there was one fetal death (2.2%). There were no pregnancy complications on negative appendectomy cases. Conclusions: Acute appendicitis continues to be a challenge in diagnosis and treatment during pregnancy. Maternal and fetal outcome was better than previously reported.

Hidatidosis alveolar hepática / Liver alveolar echinococcosis

La hidatidosis alveolar es infrecuente en nuestro país. La mayoría de las veces se confunde con una neoplasia hepática por su caracter infiltrante. El diagnóstico generalmente se realiza en el postoperatorio. El tratamiento muchas veces necesita de una resección hepática mayor, debido a la extensión e infiltración de la enfermedad. El presente artículo describe las características de un paciente de sexo masculino, de 57 años, que presentó un quiste hidatídico hepático fistulizado al tórax y que fue intervenido quirúrgicamente. Se le realizó una resección parcial y una marzupialización de su quiste. El estudio anatomopatológico mostró un quiste hidatídico multilocular. Actualmente se encuentra en tratamiento nutricional para completar el tratamiento quirúrgico. Además, se discuten aspectos de esta interesante e infrecuente patología.

Colecistectomía laparoscópica ambulatoria: una experiencia factible en un hospital público chileno / Outpatient laparoscopic cholecystectomy: experience in 357 patients

Background: Laparoscopic cholecystectomy (LC) is a widely used technique in the treatment of gallstone disease. Outpatient laparoscopic cholecystectomy (OLC) is a cost/effective and safe procedure in selected patients. Aim: A pilot program of OLC was conducted in a Chilean Public Hospital to evaluate the feasibility and results, including and patients' satisfaction using OLC. Patients and Methods: Patients were eligible for OLC if they were less than 60 years old, had low anesthestetic risk (ASA I-II), normal liver function tests and an abdominal ultrasound showing gallstones or gallbladder polyps with a normal common bile duct. Results: We performed OLC in 357 patients aged 36±10 years, 90% female. Intraoperative complications were observed in 4 (1.1%) patients (uncontrolled bleeding in two and minor biliary tree injuries in two, both requiring conversion to the open technique). Four other patients required conversion due to anatomic reasons (overall conversion rate: 2.2%). Ninety two percent of patients were discharged within 6 hours of the operation. Eight (2.2%) were readmitted because of a mild acute pancreatitis (n=1), biliary leakage (n=1), persistent pain (n=2), vomiting (n=2), and retained stones (n=2). Two (0.6%) patients were re-operated. There was no mortality. Ninety-four percent of 277 patients (77.6%), who answered a Satisfaction Survey, evaluated OLC procedure with a high degree of satisfaction. Conclusion: OLC is a safe and feasible procedure in selected gallstone patients. The procedure has good outcomes and a high degree of patient satisfaction. A wide use of OLC should reduce both direct and indirect costs of surgical treatment of gallstone disease.

Head and neck hypervascular lesions: embolization with ethylene vinyl alcohol copolymer--laboratory evaluation in Swine and clinical evaluation in humans.

PURPOSE: (a) To assess in swine long-term (12-month) histopathologic changes, particularly, those related to recanalization and angiotoxicity after endovascular delivery of ethylene vinyl alcohol copolymer (EVAC), and (b) to evaluate initial clinical experience in 18 patients with head and neck tumors and arteriovenous malformations. MATERIALS AND METHODS: Embolization with EVAC was performed in one rete each in five swine. After 12 months, an angiogram was obtained, and the contralateral rete was also embolized (acute). Swine were sacrificed and the retia harvested for pathologic examination. In the clinical study, 18 patients with tumors (n = 14), facial arteriovenous malformations (n = 3), and vertebral arteriovenous fistula (n = 1) underwent therapeutic embolization. The technical aspects of EVAC embolization, percentage of occlusion, and clinical complications were evaluated. RESULTS: Angiographic 12-month follow-up in swine revealed persistent occlusion of the embolized rete or retia. Histologic examination of the same rete showed vascular occlusion and moderate intraluminal foreign body giant cell reaction; the acutely embolized rete showed no endothelial denudation or angionecrosis. Clinical evaluation in patients revealed satisfactory penetration of lesion vasculature with EVAC when the microcatheter was advanced within 2 cm of a lesion or when percutaneous puncture was performed. There were two transient complications: one increase in a preexisting fifth nerve palsy and one increase in preexisting hemiparesis. CONCLUSION: EVAC is a promising liquid embolic material providing long-term occlusion of blood vessels.

Enfermedad diverticular del colon: resultados del tratamiento quirúrgico electivo / Diverticular disease of the colon: results of elective surgical treatment

Los resultados después del tratamiento quirúrgico electivo de la enfermedad diverticular del colon (ED) son variables y dependen en gran parte de los criterios de selección de los pacientes. El objetivo de esta comunicación es evaluar los resultados del tratamiento quirúrgico electivo de la ED en un grupo de pacientes cuya indicación operatoria cumplió estrictos criterios establecidos previamente. Entre 1978 y 1997 se operaron en forma electiva 91 pacientes por ED. El antecedente de diverticulitis aguda recurrente fue la indicación en 46 pacientes (51 por ciento); la deformación anatómica, caracterizada por la presencia de estenosis y/o fístula, en 29 (32 por ciento); la sospecha de neoplasia en 10 (11 por ciento); la hemorragia digestiva baja recurrente en tres (3 por ciento) y el antecedente de diverticulitis aguda en un paciente menor de 40 años en tres (3 por ciento). Se efectuaron 41 sigmoidectomías, 48 hemicolectomías izquierdas y dos colectomías subtotales. Una paciente falleció en el período postoperatorio debido a un tromboembolismo pulmonar (mortalidad 1 por ciento). Nueve pacientes presentaron una o más complicaciones (morbilidad 10 por ciento), incluyendo dos filtraciones de anastomosis. El promedio de seguimiento fue de 61 meses (i: 19-180). Un paciente (1 por ciento), sometido a una sigmoidectomía, presentó una nueva diverticulitis aguda 8 años después de su operación que fue tratada médicamente . Una paciente presentó una estenosis de la anastomosis. Durante este período ningún paciente fue reintervenido. Estos resultados parecen confirmar que con una adecuada selección de pacientes, el tratamiento quirúrgico de la ED logra resultados satisfactorios en el corto y largo plazo, con baja morbilidad y mortalidad

Embolization of arteriovenous malformations with Onyx: clinicopathological experience in 23 patients.

OBJECTIVE: To report our experience in treatment of arteriovenous malformations (AVMs) using a new liquid embolic agent, Onyx (Micro Therapeutics, Inc., Irvine, CA). METHODS: Between January 1998 and May 1999, 23 patients (8 men and 15 women) were treated. The patients' average age was 40 years, with seizure being the most common presenting symptom (39%). The average Spetzler-Martin grade on presentation was 3. The average AVM volume before embolization was 14.5 cm3. RESULTS: We observed an average 63% reduction in AVM volume after 129 arterial feeders were embolized. There were four adverse events. Two patients experienced ischemia because of inadvertent occlusion of an arterial feeder. One of these patients made a full recovery, but the other patient had a permanent deficit. Two other patients experienced transient neurological deficits that resolved within 1 week of embolization. Permanent morbidity was thus 4% (1 of 23 patients). There were no deaths. Twelve patients underwent subsequent radiosurgery, and 11 patients had surgery that resulted in complete resection of their AVMs. Histopathological examinations showed mild acute inflammation in specimens resected 1 day after embolization. Chronic inflammatory changes were observed in specimens resected more than 4 days after embolization. In two patients, angionecrosis of the embolized vessels was noted. No evidence of parenchymal hemorrhage was observed in these patients, and vessel wall integrity was maintained as well. CONCLUSION: Onyx is a new nonadhesive liquid embolic agent that has been used to treat 23 patients at our institution with good results. Its nonadhesive nature and ease of use make it a promising agent in the future treatment of AVMs.

Surgical and endovascular treatment of spinal dural arteriovenous fistulas: long-term disability assessment and prognostic factors.

OBJECT: The authors assessed clinical outcomes of patients with treated spinal dural arteriovenous fistulas (DAVFs) and investigated prognostic factors. METHODS: Thirty consecutive patients with spinal DAVFs were treated at the authors' institution during the past 15 years: seven underwent surgery; seven underwent surgery after failed embolization: and 16 underwent embolization alone. The outcomes of gait and micturition disability, were analyzed. Follow up averaged 3.4 years (range 1 month-11.8 years). Age, duration of symptoms, pre- and postintervention magnetic resonance (MR) imaging findings, and preintervention disability were correlated with outcome. Seventeen patients (57%) experienced improved gait, 12 (40%) were unchanged, and one (3%) was worse. In 11 patients (37%) micturition function was improved, in 15 (50%) it was unchanged, and in four (13%) it was worse. Gait disability, as measured by the Aminoff-Logue Scale, was significantly improved after treatment, from 3.4+/-1.4 (average +/- standard deviation) to 2.7+/-1.5 (p = 0.007). Mean micturition disability scores decreased, but not significantly, from 1.9+/-1 to 1.6+/-1.1 (p = 0.20). Preintervention gait disability was not associated with improvement except for patients with Aminoff-Logue Scale Grade 4 disability (eight of nine improved; p = 0.024). For patients treated within 13 months of symptom onset, mean micturition disability decreased (p = 0.035). No association was found between clinical improvement and age, a symptom duration less than 30 months, or pre- and postintervention MR imaging-documented spinal cord edema. CONCLUSIONS: Spinal DAVF treatment significantly improved patients' mean gait disability score by almost one grade at last follow up. The mean micturition disability score was not significantly improved, unless treatment was performed within 13 months of symptom onset. Longer and more uniform follow-up study is needed to determine if improved and stabilized clinical outcomes are sustained.

Intraarterial chemotherapy for brain tumors by using a spatial dose fractionation algorithm and pulsatile delivery.

PURPOSE: To evaluate the cause of complications in intraarterial chemotherapy for brain tumors and validate a dosage algorithm based on arterial territory. MATERIALS AND METHODS: Four hundred sixty-two procedures were performed in 113 patients. Technique included pulsatile infusion of a chemotherapeutic agent. Dosage was calculated per hemisphere and divided per arterial territory according to a spatial dose fractionation algorithm based on the vascular territories of major cerebral arteries: middle cerebral artery, 60%; anterior cerebral artery, 20%; posterior cerebral artery, 15%; and perforator arteries, 5%. Hospital charts of all patients were retrospectively reviewed for complications, with specific attention given to the angiograms to determine a cause. Then, subgroup analysis of the chemotherapy protocol with the largest patient population was performed to evaluate predictors of complications. RESULTS: Six (1.3%) complications were asymptomatic; 12 (2.6%), transient neurologic; three (0.6%), permanent minor neurologic; three (0.6%), permanent major neurologic; and 32 (7.0%), seizures. In the subgroup analysis, the hemispheric dose administered according to the algorithm was strongly predictive of seizure and neurologic deficit. CONCLUSION: Neurotoxicity of intraarterial cerebral chemotherapy can be minimized by using pulsatile injection and the described spatial dose fractionation algorithm.

Laboratory evaluation of a microangioscope for potential percutaneous cerebrovascular applications.

A laboratory-based study of the physical and performance characteristics of a new 0.25-mm-thin microangioscope was performed. The microangioscope tested was compatible with currently available microcatheters, but its tip was considerably stiff and of limited radiopacity. Poor image quality and difficult image interpretation were further drawbacks. Intensive efforts are directed at addressing current limitations and testing further innovations that could pave the way for future performance in neurovascular endoscopy.

N-butyl 2-cyanoacrylate embolization of spinal dural arteriovenous fistulae.

BACKGROUND AND PURPOSE: Because they are not well established, we investigated the technical success and recurrence rates of n-butyl 2-cyanoacrylate (NBCA) embolization of spinal dural arteriovenous fistulae (SDAVF), and assessed clinical outcomes. METHODS: We retrospectively studied all patients with SDAVF treated by NBCA embolization at our institution over an 8-year period. Gait and micturition disabilities were analyzed. Follow-up periods averaged 3.1 years (range, 1 month to 8.9 years). RESULTS: NBCA embolization was feasible in 74% (20/27) of patients. Of 20 patients who underwent embolization, initial embolization failure occurred in two (10%) and fistula occurrence in three (15%). All five patients in whom NBCA embolization failed underwent surgery. All patients who underwent embolization had either improved (55%) or unchanged (45%) gait disability at last follow-up. Seventeen (85%) patients had improved (40%) or unchanged (45%) micturition disability, but three (15%) had worsened. Mean Aminoff gait disability grade significantly decreased at last follow-up (2.4 [1.4] average [SD] vs 3.2 [1.4] [P = .0008]). Mean micturition disability grade decreased, but not significantly (1.4 [1.0] vs 1.7 [1.1] [P = .28]). CONCLUSION: NBCA embolization of SDAVF was technically feasible in 75% of patients. Initial apparent successful embolization was achieved in 90%; the fistula recurrence rate (failure to occlude the draining vein) for NBCA was 15%. Comparing favorably to surgical series, NBCA embolization of SDAVF appears efficacious, significantly improving mean gait disability by almost one grade at last follow-up. Close clinical and angiographic surveillance is mandatory. Longer and more uniform follow-up is needed to determine if clinical improvement and stabilization after NBCA embolization are sustained.

Prognostic factors in recurrent glioblastoma multiforme and anaplastic astrocytoma treated with selective intra-arterial chemotherapy.

BACKGROUND AND PURPOSE: Factors predictive of primary brain tumor outcome have been studied extensively, although the prognostic value of radiologic data, such as MR imaging and angiographic characteristics, has not been studied in depth. The purpose of this study was to determine whether radiologic data were prognostic factors among patients with recurrent glioblastoma multiforme and anaplastic astrocytoma treated with selective intra-arterial chemotherapy. METHODS: Forty-six patients were enrolled in a Phase II study of intra-arterial chemotherapy with carboplatin and Cereport (Alkermes Inc.; Cambridge, MA), a bradykinin analog that selectively increases permeability of the blood-tumor barrier. MR imaging volumes of enhancing tumor, resection cavity, and T2 signal abnormality were measured with T1-weighted and T2-weighted sequences. Volumes were analyzed individually and in various combinations. Tumor vascularity was graded on angiograms. Outcome was measured by time to tumor progression and survival. RESULTS: Of 46 patients included in this study, 41 underwent evaluation. Thirty were male and 11 were female; mean age was 48.5 years. Karnofsky scores ranged from 70 to 100. Thirty-two patients had glioblastoma multiforme, whereas nine had anaplastic astrocytoma. Twenty-eight patients had tumor progression and 13 had stable disease. Twenty-three patients died after an average of 205 days; 18 were surviving at an average of 324 days from the start of intra-arterial chemotherapy. In multivariate analysis, time from diagnosis to intra-arterial chemotherapy was predictive both of time to tumor progression and survival. Net tumor volume and vascularity also were significant for survival. Age, Karnofsky performance status, histologic findings, gender, MR imaging area, resection cavity volume, T2 signal abnormality volume, and various combined volumes were not significant. CONCLUSION: If confirmed by further studies, radiologic factors such as tumor volume and angiographic vascularity should be considered in design and stratification of future chemotherapy trials.

Embolization of incidental cerebral aneurysms by using the Guglielmi detachable coil system.

OBJECT: Guglielmi detachable coil (GDC) technology is a valuable therapeutic alternative to the surgical treatment of ruptured or incidental intracranial aneurysms. The authors describe their technical and clinical experience in the use of the GDC technique in patients who underwent endovascular occlusion for the treatment of incidentally found intracranial aneurysms. METHODS: One hundred fifteen patients with 120 incidentally found intracranial aneurysms underwent embolization by means of the GDC endovascular technique. Ninety-one patients were females and 24 were males. Patient age ranged from 13 to 80 years. In 64 patients the incidental aneurysms were discovered when unrelated nonneurological conditions signaled the need for angiography or magnetic resonance angiography (Group 1). Twenty patients who presented with incidental aneurysms that were discovered during treatment for an acutely ruptured aneurysm underwent treatment of both types of aneurysm during the acute phase of subarachnoid hemorrhage (SAH) (Group 2). Sixteen patients with incidental aneurysms were treated during the chronic phase of SAH (Group 3). Group 4 included 15 patients who had incidental aneurysms associated with brain tumors or arteriovenous malformations. Angiographic results revealed complete or near-complete occlusion in 109 aneurysms (91%) and incomplete occlusion in five aneurysms (4%). Guglielmi detachable coil embolization was attempted unsuccessfully in six aneurysms (5%). One hundred nine patients (94.8%) remained neurologically intact or unchanged from their initial clinical status. Five patients (4.3%) deteriorated as a result of immediate procedural complications. All these complications occurred in the first 50 patients treated in the series. No clinical complications were observed in the last 65 patients. In one patient, a partially embolized aneurysm ruptured 3 years postprocedure. In Groups 1 and 3, the average length of hospitalization was 3.3 days. CONCLUSIONS: The evolution of GDC technology has proved to provide safe treatment of incidental aneurysms (a morbidity rate of 0% was achieved in the last 65 patients). The topography of the aneurysm and the clinical condition of the patient did not influence final anatomical or clinical outcomes. The GDC technology also confers a positive economic impact by decreasing hospital length of stay and by eliminating the need for postembolization intensive care.