A randomized trial of intraarterial treatment for acute ischemic stroke.

BACKGROUND: In patients with acute ischemic stroke caused by a proximal intracranial arterial occlusion, intraarterial treatment is highly effective for emergency revascularization. However, proof of a beneficial effect on functional outcome is lacking. METHODS: We randomly assigned eligible patients to either intraarterial treatment plus usual care or usual care alone. Eligible patients had a proximal arterial occlusion in the anterior cerebral circulation that was confirmed on vessel imaging and that could be treated intraarterially within 6 hours after symptom onset. The primary outcome was the modified Rankin scale score at 90 days; this categorical scale measures functional outcome, with scores ranging from 0 (no symptoms) to 6 (death). The treatment effect was estimated with ordinal logistic regression as a common odds ratio, adjusted for prespecified prognostic factors. The adjusted common odds ratio measured the likelihood that intraarterial treatment would lead to lower modified Rankin scores, as compared with usual care alone (shift analysis). RESULTS: We enrolled 500 patients at 16 medical centers in The Netherlands (233 assigned to intraarterial treatment and 267 to usual care alone). The mean age was 65 years (range, 23 to 96), and 445 patients (89.0%) were treated with intravenous alteplase before randomization. Retrievable stents were used in 190 of the 233 patients (81.5%) assigned to intraarterial treatment. The adjusted common odds ratio was 1.67 (95% confidence interval [CI], 1.21 to 2.30). There was an absolute difference of 13.5 percentage points (95% CI, 5.9 to 21.2) in the rate of functional independence (modified Rankin score, 0 to 2) in favor of the intervention (32.6% vs. 19.1%). There were no significant differences in mortality or the occurrence of symptomatic intracerebral hemorrhage. CONCLUSIONS: In patients with acute ischemic stroke caused by a proximal intracranial occlusion of the anterior circulation, intraarterial treatment administered within 6 hours after stroke onset was effective and safe. (Funded by the Dutch Heart Foundation and others; MR CLEAN Netherlands Trial Registry number, NTR1804, and Current Controlled Trials number, ISRCTN10888758.).

CT angiography and CT perfusion improve prediction of infarct volume in patients with anterior circulation stroke.

INTRODUCTION: We investigated whether baseline CT angiography (CTA) and CT perfusion (CTP) in acute ischemic stroke could improve prediction of infarct presence and infarct volume on follow-up imaging. METHODS: We analyzed 906 patients with suspected anterior circulation stroke from the prospective multicenter Dutch acute stroke study (DUST). All patients underwent baseline non-contrast CT, CTA, and CTP and follow-up non-contrast CT/MRI after 3 days. Multivariable regression models were developed including patient characteristics and non-contrast CT, and subsequently, CTA and CTP measures were added. The increase in area under the curve (AUC) and R (2) was assessed to determine the additional value of CTA and CTP. RESULTS: At follow-up, 612 patients (67.5%) had a detectable infarct on CT/MRI; median infarct volume was 14.8 mL (interquartile range (IQR) 2.8-69.6). Regarding infarct presence, the AUC of 0.82 (95% confidence interval (CI) 0.79-0.85) for patient characteristics and non-contrast CT was improved with addition of CTA measures (AUC 0.85 (95% CI 0.82-0.87); p < 0.001) and was even higher after addition of CTP measures (AUC 0.89 (95% CI 0.87-0.91); p < 0.001) and combined CTA/CTP measures (AUC 0.89 (95% CI 0.87-0.91); p < 0.001). For infarct volume, adding combined CTA/CTP measures (R (2) = 0.58) was superior to patient characteristics and non-contrast CT alone (R (2) = 0.44) and to addition of CTA alone (R (2) = 0.55) or CTP alone (R (2) = 0.54; all p < 0.001). CONCLUSION: In the acute stage, CTA and CTP have additional value over patient characteristics and non-contrast CT for predicting infarct presence and infarct volume on follow-up imaging. These findings could be applied for patient selection in future trials on ischemic stroke treatment.

The Prognostic Value of CT Angiography and CT Perfusion in Acute Ischemic Stroke.

BACKGROUND: CT angiography (CTA) and CT perfusion (CTP) are important diagnostic tools in acute ischemic stroke. We investigated the prognostic value of CTA and CTP for clinical outcome and determined whether they have additional prognostic value over patient characteristics and non-contrast CT (NCCT). METHODS: We included 1,374 patients with suspected acute ischemic stroke in the prospective multicenter Dutch acute stroke study. Sixty percent of the cohort was used for deriving the predictors and the remaining 40% for validating them. We calculated the predictive values of CTA and CTP predictors for poor clinical outcome (modified Rankin Scale score 3-6). Associations between CTA and CTP predictors and poor clinical outcome were assessed with odds ratios (OR). Multivariable logistic regression models were developed based on patient characteristics and NCCT predictors, and subsequently CTA and CTP predictors were added. The increase in area under the curve (AUC) value was determined to assess the additional prognostic value of CTA and CTP. Model validation was performed by assessing discrimination and calibration. RESULTS: Poor outcome occurred in 501 patients (36.5%). Each of the evaluated CTA measures strongly predicted outcome in univariable analyses: the positive predictive value (PPV) was 59% for Alberta Stroke Program Early CT Score (ASPECTS) ≤7 on CTA source images (OR 3.3; 95% CI 2.3-4.8), 63% for presence of a proximal intracranial occlusion (OR 5.1; 95% CI 3.7-7.1), 66% for poor leptomeningeal collaterals (OR 4.3; 95% CI 2.8-6.6), and 58% for a >70% carotid or vertebrobasilar stenosis/occlusion (OR 3.2; 95% CI 2.2-4.6). The same applied to the CTP measures, as the PPVs were 65% for ASPECTS ≤7 on cerebral blood volume maps (OR 5.1; 95% CI 3.7-7.2) and 53% for ASPECTS ≤7 on mean transit time maps (OR 3.9; 95% CI 2.9-5.3). The prognostic model based on patient characteristics and NCCT measures was highly predictive for poor clinical outcome (AUC 0.84; 95% CI 0.81-0.86). Adding CTA and CTP predictors to this model did not improve the predictive value (AUC 0.85; 95% CI 0.83-0.88). In the validation cohort, the AUC values were 0.78 (95% CI 0.73-0.82) and 0.79 (95% CI 0.75-0.83), respectively. Calibration of the models was satisfactory. CONCLUSIONS: In patients with suspected acute ischemic stroke, admission CTA and CTP parameters are strong predictors of poor outcome and can be used to predict long-term clinical outcome. In multivariable prediction models, however, their additional prognostic value over patient characteristics and NCCT is limited in an unselected stroke population.

Coil-treated aneurysms: decision making regarding additional treatment based on findings of MR angiography and intraarterial DSA.

PURPOSE: To assess whether magnetic resonance (MR) angiography can be used as a noninvasive alternative to intraarterial digital subtraction angiography (DSA) to indicate additional treatment in the follow-up of patients with coil-treated intracranial aneurysms. MATERIALS AND METHODS: This was an ethics committee-approved multicenter study. Consecutive patients who were scheduled for follow-up intraarterial DSA after coil placement were invited for additional MR angiography after providing written informed consent. Interventional neuroradiologists gave treatment advice (additional treatment, extended follow-up imaging, or discharge from follow-up) for each imaging modality. Agreement between treatment advices based on intraarterial DSA and MR angiographic findings and interobserver agreement were assessed with weighted κ statistics. RESULTS: Agreement between intraarterial DSA- and MR angiography-based treatment recommendations was substantial (κ = 0.73; 95% confidence interval [CI]: 0.66, 0.80). In 34 of the 310 patients (11%), the advice was additional treatment based on findings of both modalities. In six patients (2%), the advice based on intraarterial DSA findings was additional treatment, while that based on MR angiographic findings was extended follow-up imaging; therefore, none of these patients were discharged from follow-up on the basis of MR angiographic findings. In six other patients (2%), the advice based on MR angiographic findings was additional treatment, while that based on intraarterial DSA findings was extended follow-up imaging (four patients), discharge from follow-up (one patient), and noninterpretable DSA (one patient). Extended follow-up imaging was suggested for 37 patients (12%) after intraarterial DSA and for 49 patients (16%) after MR angiography (difference: 4%; 95% CI: -0.6%, 8.4%). Interobserver agreement was substantial for intraarterial DSA (κ = 0.73; 95% CI: 0.64, 0.82) and moderate for MR angiography (κ = 0.53; 95% CI: 0.36, 0.70). CONCLUSION: The overall proportion of patients advised to undergo additional treatment is similar based on intraarterial DSA and MR angiographic findings, with only few individual discrepancies. MR angiography can therefore be used for therapeutic decision making in the follow-up of patients with coil-treated aneurysms. SUPPLEMENTAL MATERIAL: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.12112608/-/DC1.

Late reopening of adequately coiled intracranial aneurysms: frequency and risk factors in 400 patients with 440 aneurysms.

BACKGROUND AND PURPOSE: In aneurysms that are adequately occluded 6 months after coiling, the risk of late reopening is largely unknown. We assessed the occurrence of late aneurysm reopening and possible risk factors. METHODS: From January 1995 to June 2005, 1808 intracranial aneurysms were coiled in 1675 patients at 7 medical centers. At 6 months, 1066 aneurysms in 971 patients were adequately occluded. At mean 6.0 years after coiling, of the 971 patients, 400 patients with 440 aneurysms underwent 3 Tesla magnetic resonance angiography to assess occlusion status of the aneurysms. Proportions and corresponding 95% CI of aneurysm reopening and retreatment were calculated. Risk factors for late reopening were assessed by univariate and multivariate logistic regression analysis, and included patient sex, rupture status of aneurysms, aneurysm size≥10 mm, and aneurysm location. RESULTS: In 11 of 400 patients (2.8%; 95% CI, 1.4-4.9%) with 440 aneurysms (2.5%; 95% CI, 1.0-4.0%), late reopening had occurred; 3 reopened aneurysms were retreated (0.7%; 95% CI, 0.2-1.5%). Independent predictors for late reopening were aneurysm size≥10 mm (OR 4.7; 95% CI, 1.3-16.3) and location on basilar tip (OR 3.9; 95% CI, 1.1-14.6). There were no late reopenings in the 143 anterior cerebral artery aneurysms. CONCLUSIONS: For the vast majority of adequately occluded intracranial aneurysms 6 months after coiling (those<10 mm and not located on basilar tip), prolonged imaging follow-up within the first 5 to 10 years after coiling does not seem beneficial in terms of detecting reopened aneurysms that need retreatment. Whether patients might benefit from screening beyond the 5- to 10-year interval is not yet clear.

De novo aneurysm formation and growth of untreated aneurysms: a 5-year MRA follow-up in a large cohort of patients with coiled aneurysms and review of the literature.

BACKGROUND AND PURPOSE: Rates of development of de novo intracranial aneurysms and of growth of untreated additional aneurysms are largely unknown. We performed MRA in a large patient cohort with coiled aneurysms at 5-year follow-up. METHODS: In 276 patients with coiled intracranial aneurysms and 5±0.5 years of follow-up MRA (totaling 1332 follow-up patient-years), additional aneurysms were classified as unchanged, grown, de novo, or incomparable with previous imaging. We calculated 5-year cumulative incidence of de novo aneurysm formation and growth of untreated aneurysms. We searched PubMed and EMBASE databases for studies assessing aneurysm development, and growth. RESULTS: In 50 of 276 patients (18%), 75 additional aneurysms were present at follow-up MRA. Of these 75, 2 were de novo (both 3 mm), 58 were unchanged, 5 had grown from 1 to 3 mm (7.9% of 63 known additional aneurysms; 95% CI, 1.3%-14.6%), and 10 were incomparable. Five-year cumulative incidence for a de novo aneurysm developing was 0.75%. Four additional aneurysms in 3 patients were treated. Ten previous studies reported annual incidences of growth of additional aneurysms ranging from 1.51% to 22.7%, and 5 studies reported annual incidences of de novo aneurysm formation ranging from 0.3 to 1.8%. CONCLUSIONS: MRA screening of patients with coiled aneurysms within the first 5 years after treatment has a low rate of de novo aneurysm development and growth of additional aneurysms, and an even lower treatment rate.

Vertebroplasty versus conservative treatment in acute osteoporotic vertebral compression fractures (Vertos II): an open-label randomised trial.

BACKGROUND: Percutaneous vertebroplasty is increasingly used for treatment of pain in patients with osteoporotic vertebral compression fractures, but the efficacy, cost-effectiveness, and safety of the procedure remain uncertain. We aimed to clarify whether vertebroplasty has additional value compared with optimum pain treatment in patients with acute vertebral fractures. METHODS: Patients were recruited to this open-label prospective randomised trial from the radiology departments of six hospitals in the Netherlands and Belgium. Patients were aged 50 years or older, had vertebral compression fractures on spine radiograph (minimum 15% height loss; level of fracture at Th5 or lower; bone oedema on MRI), with back pain for 6 weeks or less, and a visual analogue scale (VAS) score of 5 or more. Patients were randomly allocated to percutaneous vertebroplasty or conservative treatment by computer-generated randomisation codes with a block size of six. Masking was not possible for participants, physicians, and outcome assessors. The primary outcome was pain relief at 1 month and 1 year as measured by VAS score. Analysis was by intention to treat. This study is registered at ClinicalTrials.gov, number NCT00232466. FINDINGS: Between Oct 1, 2005, and June 30, 2008, we identified 431 patients who were eligible for randomisation. 229 (53%) patients had spontaneous pain relief during assessment, and 202 patients with persistent pain were randomly allocated to treatment (101 vertebroplasty, 101 conservative treatment). Vertebroplasty resulted in greater pain relief than did conservative treatment; difference in mean VAS score between baseline and 1 month was -5·2 (95% CI -5·88 to -4·72) after vertebroplasty and -2·7 (-3·22 to -1·98) after conservative treatment, and between baseline and 1 year was -5·7 (-6·22 to -4·98) after vertebroplasty and -3·7 (-4·35 to -3·05) after conservative treatment. The difference between groups in reduction of mean VAS score from baseline was 2·6 (95% CI 1·74-3·37, p<0·0001) at 1 month and 2·0 (1·13-2·80, p<0·0001) at 1 year. No serious complications or adverse events were reported. INTERPRETATION: In a subgroup of patients with acute osteoporotic vertebral compression fractures and persistent pain, percutaneous vertebroplasty is effective and safe. Pain relief after vertebroplasty is immediate, is sustained for at least a year, and is significantly greater than that achieved with conservative treatment, at an acceptable cost. FUNDING: ZonMw; COOK Medical.

Long-term MRA follow-up after coiling of intracranial aneurysms: impact on mood and anxiety.

INTRODUCTION: Magnetic resonance angiography (MRA) screening for recurrence of a coiled intracranial aneurysm and formation of new aneurysms long-term after coiling may induce anxiety and depression. In coiled patients, we evaluated effects on mood and level of anxiety from long-term follow-up MRA in comparison to general population norms. METHODS: Of 162 patients participating in a long-term (>4.5 years) MRA follow-up after coiling, 120 completed the EQ-5D questionnaire, a visual analog health scale and a self-developed screening related questionnaire at the time of MRA. Three months later, the same questionnaires were completed by 100 of these 120 patients. Results were compared to general population norms adjusted for gender and age. RESULTS: Any problem with anxiety or depression was reported in 56 of 120 patients (47%; 95%CI38↔56%) at baseline and 42 of 100 patients (42%; 95%CI32↔52%) at 3 months, equally for screen-positives and -negatives. Compared to the reference population, participants scored 38% (95%CI9↔67%) and 27% (95%CI4↔50%) more often any problem with anxiety or depression. Three months after screening, 21% (20 of 92) of screen-negatives and 13% (one of eight) of screen-positives reported to be less afraid of subarachnoid hemorrhage (SAH) compared to before screening. One of eight screen-positives reported increased fear of SAH. CONCLUSIONS: Patients with coiled intracranial aneurysms participating in long-term MRA screening reported significantly more often to be anxious or depressed than a reference group. Screening did not significantly increase anxiety or depression temporarily. However, subjectively, patients did report an increase in anxiety caused by screening, which decreased after 3 months.

Postprocedural CT for perivertebral cement leakage in percutaneous vertebroplasty is not necessary--results from VERTOS II.

INTRODUCTION: During percutaneous vertebroplasty (PV), perivertebral cement leakage frequently occurs. There is some concern that cement deposits may migrate towards the lungs via the veins during follow-up. We used baseline and follow-up computed tomography (CT) to assess the incidence and extend of late cement migration in a large consecutive patient cohort. METHODS: VERTOS II is a prospective multicenter randomized controlled trial comparing PV with conservative therapy for osteoporotic vertebral compression fractures (OVCFs). Patients assigned to PV had baseline postprocedural CT scans of the treated vertebral bodies. After a mean follow-up of 22 months, 54 of 78 patients (69%) had follow-up CT. CT scans were analyzed and compared for perivertebral venous, discal, and soft tissue leakage. RESULTS: Perivertebral cement leakage occurred in 64 of 80 treated vertebrae (80%; 95% CI, 70% to 87%). All patients remained asymptomatic. Perivertebral venous leakage was present in 56 vertebrae (88%), mostly in the anterior external venous plexus (46 of 56, 82%). Discal leakage occurred in 22 of 64 vertebrae (34%) and soft tissue leakage in two of 64 (4%). Mean injected cement volume in vertebrae with leakage was higher (4.5 versus 3.7 cm(3), p = 0.04). Follow-up CT scan showed unchanged perivertebral cement leakages without late cement migration. CONCLUSION: Perivertebral cement leaks during PV for OVCFs occurred frequently in the VERTOS II trial. Cement leakage occurred more frequently with higher injected volumes. However, all patients remained asymptomatic, and late cement migration during follow-up did not occur. Standard postprocedural CT of the treated vertebral body in PV is not necessary.

Is an intrauterine device a contraindication for uterine artery embolization? A study of 20 patients.

The presence of an intrauterine device (IUD) has been traditionally considered a risk factor for postprocedural infection in patients undergoing uterine artery embolization (UAE). The authors retrospectively evaluated the occurrence of infectious complications following embolization in 20 women with IUDs. After a mean follow-up of 20.5 months, none of the patients developed an infectious complication. One patient required hysterectomy following embolization for persistent pain. Pathologic evaluation of the hysterectomy specimen demonstrated ischemia without evidence of inflammation. This experience suggests that the presence of an IUD might not be considered a contraindication for UAE.

Embolization of uterine leiomyomas with polyzene F-coated hydrogel microspheres: initial experience.

PURPOSE: To evaluate effectiveness and safety of Polyzene F-coated hydrogel microspheres for uterine artery embolization (UAE) in women with symptomatic uterine leiomyomas. MATERIALS AND METHODS: Between August 2006 and August 2008, 86 nonconsecutive premenopausal women (mean age, 43.9 years; median, 44 y; range, 28-54 y) were treated with UAE. Calibrated microspheres of 500, 700, and 900 µm, alone or in combination, were used as embolic agents. Change in uterine and tumor volume and tumor infarction rate during follow-up were assessed with magnetic resonance imaging. Clinical follow-up was evaluated by the Uterine Fibroid Severity and Quality Of Life (UFS-QOL) questionnaire at baseline, 3 months, and last follow-up in November 2008. RESULTS: At 3 months, mean volume reductions of the dominant leiomyoma and uterus were 45% and 42%, respectively, and complete infarction of the dominant leiomyoma was achieved in 69 patients (80%). Complete infarction of the overall tumor burden was achieved in 52 patients (60%). Infarction rates of the dominant tumor and overall tumor burden were more than 90% in 81 patients (94%) and 79 patients (91%), respectively. During follow-up, permanent amenorrhea developed in seven women (8.1%). Four women (4.7%) had additional therapy after UAE; three had a hysterectomy and one had a second embolization. The UFS-QOL showed significant improvement in symptom severity and quality of life after 3 months that continued to improve at last follow-up (mean, 12.8 months). CONCLUSIONS: In this preliminary study, Polyzene F-coated hydrogel microspheres for UAE resulted in good dominant and overall tumor infarction in most patients, with corresponding improvement of symptoms. Determining optimal sizing of the material and comparing outcomes versus those of other embolic agents requires additional study.

Coiling of intracranial aneurysms: a systematic review on initial occlusion and reopening and retreatment rates.

BACKGROUND AND PURPOSE: The proportion of incompletely occluded aneurysms after coiling varies widely between studies. To assess overall outcome of coiling, we systematically reviewed the literature to determine initial occlusion, reopening, and retreatment rates of coiled aneurysms according to predefined criteria and subgroups. METHODS: We searched PubMed and EMBASE (January 1999 to September 2008) for studies of >50 coiled aneurysms. Two reviewers independently extracted data. We grouped studies reporting on only ruptured aneurysms, posterior circulation aneurysms, and studies with large proportions of aneurysms >10 mm to assess possible determinants for incomplete occlusion, reopening, and retreatment. RESULTS: Forty-six studies totalling 8161 coiled aneurysms met inclusion criteria. Immediately after coiling, 91.2% (95% CI, 90.6% to 91.9%) of the aneurysms were adequately occluded. Aneurysm reopening occurred in 20.8% (95% CI, 19.8% to 21.9%) and retreatment was performed in 10.3% (95% CI, 9.5% to 11.0%). Reopening rate was lower in studies reporting on ruptured aneurysms only compared with all studies (11.4% versus 20.8%; relative risk, 0.55; 95% CI, 0.47 to 0.64) and higher in studies focusing on posterior circulation aneurysms compared with studies with >85% anterior circulation aneurysms (22.5% versus 15.5%; relative risk, 1.5; 95% CI,1.2 to 1.7). Regression analysis showed higher retreatment rates with increasing proportion of aneurysms >10 mm (beta=0.252; 95% CI, 0.073 to 0.432). We could not find a relation between reopening and type of coils used. CONCLUSIONS: At follow-up, one fifth of all coiled intracranial aneurysms shows reopening of which half is retreated. Possible risk factors for aneurysm reopening are location in the posterior circulation and size >10 mm. To confirm our findings, a meta-analysis on individual well-reported patient data is desirable.

Long-term recurrent subarachnoid hemorrhage after adequate coiling versus clipping of ruptured intracranial aneurysms.

BACKGROUND AND PURPOSE: Coiling is increasingly used as treatment for intracranial aneurysms. Despite its favorable short-term outcome, concerns exist about long-term reopening and inherent risk of recurrent subarachnoid hemorrhage (SAH). We hypothesized a higher risk for recurrent SAH after adequate coiling compared with clipping. METHODS: Patients with ruptured intracranial aneurysms coiled between 1994 and 2002 with adequate (>90%) aneurysm occlusion at 6-month follow-up angiograms were included. We interviewed these patients about new episodes of SAH. By survival analysis, we assessed the cumulative incidence of recurrent SAH after coiling and compared it with the incidence of recurrent SAH in a cohort of 748 patients with clipped aneurysms by calculating age and sex-adjusted hazard ratios. RESULTS: Of 283 coiled patients with a total follow-up of 1778 patient-years (mean, 6.3 years), one patient had a recurrent SAH (0.4%) and 2 patients had a possible recurrent SAH. For recurrent SAH within the first 8 years after treatment, the cumulative incidence was 0.4% (95% CI, -0.4 to 1.2) after coiling versus 2.6% (95% CI, 1.2 to 4.0) after clipping (hazard ratio, 0.2; 95% CI, 0.03 to 1.6). For possible and confirmed recurrent SAH combined, the cumulative incidence was 0.7% (95% CI, 0.3 to 1.7) after coiling versus 3.0% (95% CI, 1.3 to 4.6) after clipping (hazard ratio, 0.7; 95% CI, 0.2 to 2.3). CONCLUSIONS: Patients with adequately occluded aneurysms by coiling at short-term follow-up are at low risk for recurrent SAH in the long term. Within the first 8 years after treatment, the risk of recurrent SAH is not higher after adequate coiling than after clipping.

Safety and effectiveness of uterine artery embolization in patients with pedunculated fibroids.

PURPOSE: To assess complications and outcomes of uterine artery embolization (UAE) in women with pedunculated fibroids in a large single-center patient cohort. MATERIALS AND METHODS: From a database with prospectively collected data from 716 women treated with UAE between 1996 and 2008, 29 women were identified with 31 pedunculated fibroids. Magnetic resonance images obtained before and 3 months after UAE were used to calculate stalk diameter change and volume reduction of both the pedunculated fibroid and uterus. Two observers assessed the overall percentage infarction and infarction of pedunculated fibroid. Complications were recorded and long-term clinical follow-up (mean, 33 months; range, 10-78 months) assessed with use of a questionnaire. RESULTS: The mean reduction in uterine and pedunculated fibroid volume was 37% and 33%, respectively. The mean reduction in stalk diameter was 0.3 cm (95% confidence interval [CI]: 0.18, 0.52 cm) or 13% from initial mean diameter. Stalk enhancement was not affected by UAE. The mean pedunculated fibroid infarction and mean overall infarction rates were 87% and 92%, respectively, for observer 1 and 88% and 92% for observer 2, with good interobserver variability. All women returned the questionnaire and no early or late complications of UAE were reported (0%; 95% CI: 0.0%-13.9%). CONCLUSIONS: In this small series of pedunculated subserosal fibroids treated with UAE, no complications occurred. The findings suggest that the use of UAE to treat pedunculated subserosal fibroids may be safe and effective.

Iatrogenic lumbar pseudoaneurysm causing dural sac compression after spine surgery.

A 69-year-old man presented 3 months after lumbar spine surgery with progressive paraparesis and bladder and sphincter dysfunction caused by a lumbar artery pseudoaneurysm compressing the dural sac. After embolization with glue, the thrombosed pseudoaneurysm substantially decreased in size and the patient's neurological symptoms improved.

Endovascular treatment of dural arteriovenous fistulas with sinus drainage: Do we really need to protect the sinus?

BACKGROUND AND PURPOSE: Dural arteriovenous fistulas (DAVFs) with direct antegrade sinus drainage have a benign natural history but bruit can be disabling. Disconnection of the draining sinus is considered curative. We present the treatment results of 14 patients with a dural arteriovenous fistula with antegrade sinus return with emphasis on functionality of the involved sinus and the need for sinus patency. MATERIALS AND METHODS: Between January 2009 and January 2018, 14 patients with a DAVF with direct antegrade sinus drainage were treated in our institution. There were two men and 12 women (1: 6) with a mean age of 61 years (median 61, range 43-78). Clinical presentation was unbearable pulsatile bruit in all cases. Thirteen were draining in the sigmoid or transverse sinus and one drained into the inferior petrosal sinus. RESULTS: Twelve of 14 (86%) patients had a draining sinus non-functional for the brain. In ten of these 12 patients the sinus was occluded with liquid embolic or coils. In the two patients with a functional sinus, the fistula was successfully occluded without occluding the sinus. One patient with inferior petrosal sinus drainage required transvenous embolization. There were no permanent adverse events of treatment. CONCLUSIONS: Patients with DAVFs with direct antegrade sinus drainage were cured using a strategy of endovascular transarterial and transvenous embolization. Most patients had a non-functional sinus that could be occluded for cure.

Internal carotid bifurcation aneurysms: frequency, angiographic anatomy and results of coiling in 50 aneurysms.

INTRODUCTION: Internal carotid artery (ICA) bifurcation aneurysms are uncommon. Little is known about incidence, anatomical characteristics and results of endovascular treatment. We report our experience with endovascular treatment of 50 ICA bifurcation aneurysms in 46 patients. METHODS: There were 13 men (28%) and 33 women (72%) with a mean age of 49.3 years (range 23-76 years). Of 50 aneurysms, 26 (52%) were ruptured and 24 (48%) were unruptured. Of the 46 patients, 23 (50%) had one to five additional aneurysms. RESULTS: The frequency of ICA bifurcation aneurysms was 2.4% (53 of 2,249, 95% CI 1.8-3.1%). Their mean size was 9.6 mm (median 6 mm, range 2-55 mm). Aneurysm neck was symmetrically on A1 and M1 in 30 aneurysms (60%), dominant on A1 in 14 (28%), on M1 in 2 (4%) and on the ICA in 4 (8%). Aneurysm fundus projection was superior in 28 aneurysms (56%), posterior in 9 (18%), anterior in 10 (20%) and lateral in 3 (6%). Four aneurysms were coiled with balloon assistance. Procedural morbidity and mortality of coiling was 2% each. During follow-up, 7 of 50 aneurysms (all 10 mm or larger) were additionally treated (retreatment rate 14%). CONCLUSION: ICA bifurcation aneurysms are rare with a frequency of 2.4% of treated aneurysms in our institution. They are often associated with additional aneurysms. Most aneurysm necks are located symmetrically on A1 and M1 and fundus projection is mostly superior. Coiling is safe and effective for the management of these aneurysms. The aneurysms that needed retreatment were >/=10 mm.

How long does it take to coil an intracranial aneurysm?

INTRODUCTION: The change in the treatment of choice for intracranial aneurysms from clipping to coiling has been associated with an important change in logistics. The time needed for coiling is variable and depends on many factors. In this study, we assessed the procedural time for the coiling of 642 aneurysms and tried to identify predictors of a long procedural time. METHODS: The procedural time for coiling was defined as the number of minutes between the first diagnostic angiographic run and the last angiographic run after embolization. Thus, induction of general anesthesia and catheterization of the first vessel were not included in the procedural time. A long procedural time was defined as the upper quartile of procedural times (70-158 min). Logistic regression analysis was performed for several variables. RESULTS: The mean procedural time was 57.3 min (median 52 min, range 15-158 min). More than half of the coiling procedures lasted between 30 and 60 min. Multiple logistic regression analysis identified the use of a supportive device (OR 5.4), procedural morbidity (OR 4.5) and large aneurysm size (OR 3.0) as independent predictors of a long procedural time. A poor clinical condition of the patient, the rupture status of the aneurysm, gender, the occurrence of procedural rupture, and aneurysm location were not related to a long procedural time. The mean time for the first 321 coiling procedures was not statistically significantly different from mean time for the last 321 procedures. CONCLUSION: With optimal logistics, coiling of most intracranial aneurysms can be performed in one to two hours, including patient handling before and after the actual coiling procedure.

The Woven EndoBridge (WEB) as primary treatment for unruptured intracranial aneurysms.

Purpose The intrasaccular flow disruptor Woven EndoBridge (WEB) device is developed for the treatment of wide-necked aneurysms without supportive devices. We used the WEB as primary treatment for unruptured aneurysms suitable for the device, regardless of neck size. Methods Between February 2015 and June 2017, 59 aneurysms in 51 patients were selectively treated with the WEB. There were 15 men and 36 women with a mean age of 59 years. Mean aneurysm size was 7.0 mm (range 3-22 mm). Of 59 aneurysms, 45 (76%) had a wide neck defined as ≥4 mm or dome-neck ratio ≤1.5. No stents or supporting balloons were used. Results Initial WEB position was judged good in all 59 unruptured aneurysms. One patient with a basilar tip aneurysm had a late thrombotic posterior cerebral artery occlusion by protrusion of the WEB over the artery. There were no procedural ruptures. Overall complication rate was 2.0% (1 of 51, 95% CI 0.01-11.3%). Imaging follow-up was available in 55 of 59 aneurysms (93%). At 3 months, 41 of 57 aneurysms (72%) were completely occluded, 12 (21%) had a neck remnant and 4 (7%) were incompletely occluded. Conclusion WEB treatment is safe and effective in selected unruptured aneurysms suitable for the device, regardless of neck size or location. There was no need for supportive devices. Three-quarters of all unruptured small aneurysms could be treated with the WEB. In our opinion, the WEB is a valuable alternative to coils, especially in wide-necked aneurysms.