Internal carotid bifurcation aneurysms: anatomical features and outcome of endovascular treatment.

This study reports the anatomical presentation of internal carotid bifurcation aneurysms and the angiographic results of their endovascular treatment. We treated 17 patients with internal carotid bifurcation aneurysms by endovascular treatment using detachable coils. Follow-ups were conducted for three to 30 months. The pre- and postprocedural anatomical features of the aneurysms, procedural complications, and postprocedural angiographic outcomes were evaluated. The aneurysmal necks were located just above the internal carotid artery bifurcation or at the origins of anterior cerebral artery or the middle cerebral artery. Immediate angiography demonstrated complete occlusion, neck remnant, or residual aneurysms. Post-treatment, two aneurysms that were initially residual spontaneously progressed to complete occlusion, and two large aneurysms that initially demonstrated complete occlusion or neck remnants showed coil compaction and recanalization. Procedural complications occurred in two cases. Endovascular treatment is effective for ruptured and unruptured carotid terminal aneurysms with various anatomical features.

Angiographic and clinical results after endovascular treatment for middle cerebral artery berry aneurysms.

Sixty-five middle cerebral artery (MCA) aneurysms in 59 patients treated by endovascular treatment (EVT) without the remodelling technique were analyzed. For ruptured aneurysms, the patients in bad condition are predominant and those with Fisher group four is 47.8% and with Hunt and Hess grade (HHG) IV or V are 43.5%. The clinical result is that 58.7% is in mRS 0-3, 21.7% in 4-5 and 19.6% in death. Contrary, 92.3% of the patients in HHG I-III resulted in mRS 0-3. Re-rupture was observed in two cases (4.4%). For all the aneurysms, thromboembolic complications were observed in 12.3% and those were predominant in the aneurysms greater than 10mm in diameter (p<0.05). Hemorrhagic ones occurred in 6.2% which were predominant in the aneurysms less than 10mm in diameter. No mortality was observed by the accidents. In follow-up angiography, Raymond classification was employed and Complete Obliteration or Dog Ear was observed in 24 of 43 cases (55.8%). Recanalization occurred in 10.5% of the cases with complete or almost complete obliterated aneurysms. These results suggested that EVT for the ruptured MCA aneurysms with good grade or the unruptured ones is feasible. Strict follow-up is important like the other aneurysms.

Endovascular management for intracranial ruptured aneurysms in elderly patients: outcome and technical aspects.

The definition of an elderly person is debateable; however, age is a recognised negative prognostic factor for outcome after subarachnoid haemmorrhage, and the age cut-off of 60 years is accepted to define a high risk population. The goal of this article is to access the outcome in this precise population of patients that underwent endovascular treatment (EVT) after aneurysm rupture. Forty-two patients (mean age = 70.24) had 40 aneurysms located at the anterior circulation and nine at the posterior circulation. Thirty-seven (87.9%) patients had Fisher III or IV. Forty-six (93.8%) aneurysms were smaller than 15 mm. Twenty-eight (66.7%) patients were in good neurological state on admission (Hunt and Hess I-III) and 14 (33.3%) in poor state. Satisfactory occlusion rate (total occlusion or neck flow) was achieved in 75% of patients. Follow-up was available in 19 (43.18%) out of the 44 aneurysms treated. Aneurysm recanalization was disclosed in three cases. Satisfactory outcome was achieved on: 60.7% of good grades, 21.4% of poor grades, 43.7% of patients with and 57.6% of patents without comorbidites. Fisher grade (P = 0.0346), comorbidities (P = 0.525) and risk factors (P = 0.515) were not associated with clinical outcome. No age cut-off (65,70 and 75) for favourable outcome could be established, P-values were 0.723, 0.741 and 0.738, respectively. Advancing of age was not associated with an increase number of unfavourable outcome (P = 0.125). Poor neurological status on admission was the only variable associated with unfavourable outcome (P = 0.02). Mortality and morbidity rate related to the procedure were 4.8% and 9.5% respectively. Age should not be taken alone for precluding treatment in ruptured aneurysms, EVT can be considered as a first therapeutic option for elderly persons, since an overall favourable outcome could be achieved in most cases, mainly in non-comatose patients.

Giant spinal perimedullary fistula in hereditary haemorrhagic telangiectasia: diagnosis, endovascular treatment and review of the literature.

Hereditary hemorrhagic telangiectasia (HHT, Rendu-Osler-Weber disease) is a vascular disorder with dominant autosomal transmission characterised usually by multiple mucocutaneous and visceral abnormalities. Neurological manifestations due to the primary involvement of spinal cord by vascular malformations are rare. We present a young man with HHT associated with a central nervous system arteriovenous malformation and a giant perimedullary fistula, that was manifested as progressive myelopathy. The diagnosis was made coupling magnetic resonance imaging to selective spinal arteriography. The therapeutic option was endovascular treatment by mechanically detachable coils which resulted in full exclusion of the fistula with full improvement of symptoms. During follow-up a stable clinical and morphological outcome was achieved. Clinical manifestations in HHT, with emphasis on neurological symptoms, are reviewed as well as the therapeutic options to deal with giant perimedullary fistula.

Posterior cervical haemangiopericytoma with intracranial and skull base extension. Diagnostic and therapeutic challenge of a rare hypervascular neoplasm.

Haemangiopericytomas are rare hypervascular tumors arising from pericytes. They may occur anywhere in the body, but posterior cervical location is rather uncommon. A case of posterior cervical haemangiopericytoma with posterior fossa and temporal bone extension is reported. Although the patient had undergone preoperative endovascular embolization and surgical resection on three separate occasions, control of the skull base extension was not successful. Following endovascular embolization combined with radiotherapy, the patient has been asymptomatic for 48 months. Angiographic features may help in differentiating haemangiopericytomas from other hypervascular lesions. Preoperative endovascular embolization is recommended due to the pronounced tendency for haemorrhage throughout biopsy and surgical procedures.

Multiple intracranial aneurysms. Angiographic study and endovascular treatment.

SUMMARY: We evaluate endovascular treatment (EVT) as an option to deal with multiple intracranial aneurysms(MA). From 1994 to 2001, 24 patients underwent EVT for 59 MA. Patients were followed- up clinically and angiographically in a period ranging from 6 to 93 months (mean time of 22.2) and from 4 to 69 months (mean time of 19.3), respectively. Ten patients (41.6%) were treated either by EVT (n=7, 29,16%) or by mixed treatment (EVT and surgery; n=3, 12.5%). Reasons for treating just ruptured aneurysms: six (25%) had aneurysms smaller than 5 mm; three (12.5%) deaths; two (8.33%) were in the subacute period; two (8.33%) lost to follow-up; one (4.17%) authorised no procedure. No rebleeding was detected at the clinical follow-up, but there were five deaths.At immediate arteriographic control: 28 (85%) aneurysms were fully occluded, four (12%) with neck flow and one (03%) with sac flow. For 20 aneurysms followed-up: stability of occlusion was reached in seven cases (35%) and repermeabilization in 13 (65%). Management of recanalization was close arteriography in seven (54%), re-embolization in five (38%) and surgery in one (08%). When treating MA, EVT is advisable either alone or in mixed therapy. As a high degree of repermeabilization was disclosed, strict arteriographic control is required. The mechanisms underlying aneurysmal formation may be also involved in the recanalization phenomenon , a possible new manifestation of the fragility of the arterial wall.

Atypical MELAS syndrome associated with a new mitochondrial tRNA glutamine point mutation.

The authors studied a 47-year-old patient who presented with an association of deafness, acute cerebral stroke-like episode, leukoencephalopathy, and extensive basal ganglia calcifications. Late onset and neuroradiologic findings were atypical for MELAS syndrome (Mitochondrial Myopathy, Encephalopathy, Lactic Acidosis, and Strokelike episodes). A heteroplasmic G to A transition at nucleotide 4332 in the tRNA glutamine gene was identified in the patient's muscle mitochondrial DNA. The pathogenicity of the mutation was shown in single muscle fibers by the correlation between high mutation load and cytochrome c oxidase defect.

Endovascular Treatment of Berry Intracranial Aneurysms Using a New Detachable Coil System. (DCS ((R)) - Detachable Coil System Cook).

SUMMARY: We aimed to assess and to demonstrate the efficiency of a new mechanical system in the endovascular treatment of berry intracranial aneurysms. From September 1999 to October 2000, 38 patients with 40 aneurysms experienced selective embolization using Detach Coils (DCS((R)) - Cook). They were 12 men and 26 women, aged 26 to 77 years, mean age 53.4. The clinical status of patients was graded by Hunt and Hess scale: Stage 0: 8 - stage I: 3 - Stage II: 11 - Stage III: 11 - Stage IV: 2 - Stage V: 3. The localization of aneurysms was as follows: internal carotid artery: 11; sylvian artery: 10; anterior communicating artery: 5; anterior cerebral artery A1-A2: 5; intra-cavernous carotid artery: 1; basilar trunk: 5; PICA: 2; posterior cerebral artery: 1. The size of the aneurysms ranged from 2 to 40 mm. For embolization of aneurysms, we utilized 242 coils (mean number 6.05). The shape and size of coils varied as follows: longest J 6.25 - shortest J 4-3 - longest S 10-20 - shortest S 2-2. The mean time of procedure was 43 minutes (max 180 minutes - min 7 minutes). We did not have any technical complications during the . procedure and no immediate rebleeding occurred. Initial follow-up of the patients showed angiographic full occlusion. Detach Coils appear to be a very precise, reliable and rapid system, with high stability during coil detachment (in very small or very giant aneurysms) in the embolization of intracranial aneurysms, with an interesting aspect concerning the low cost of this new mechanical device.

Chemonucleolysis of lumbar disc herniation with ethanol.

PURPOSE: To demonstrate the efficiency of the treatment of the lumbar disk herniation (LDH) with absolute alcohol. MATERIALS/METHODS: From June 1997 to September 2000, 118 patients with 126 LDH, 69 males and 49 females, aged 19 to 77 (mean age: 51.1 years) were treated with absolute alcohol nucleolysis. In 75 cases, the LDH were parasagittal, in 30 foraminal, in 17 medial and in 4 extraforaminal. In most cases, the sensitive symptoms and motor or reflex abnormalities corresponded to the lumbar disc herniation level. Nucleolysis was made in ambulatory condition and each patient underwent general anesthesia. All procedures were performed in surgical conditions and controlled under digital fluoroscopy. The disc puncture was laterally made at the junction of middle and posterior thirds of the disc, under strict lateral fluoroscopic control. A discogram was obtained before ethanol injection. Injection dose of absolute alcohol was 0.4 ml. The realization time was about 15 minutes. RESULT: Total improvement of symptoms was obtained in 97.55% of cases. Two patients remained with low-back pain and the failure treatment rate was 0.84% (1 case). CONCLUSION: Nucleolysis with ethanol is a very effective, safe and low cost treatment for any kind of LDH, that allows to treat several levels during the same procedure, and can be repeated several times. Nucleolysis with ethanol can be made in ambulatory condition and be proposed to patients who refuse surgical treatment and have allergic background.

Advances in the endovascular treatment of intracranial arteriovenous malformations.

The three treatment options for intracranial arteriovenous malformation are resection, endovascular embolization, and stereotactic radioneurosurgery, in rare cases, the malformation can be eradicated using only one of these options; most cases require a combination of the options, even all three. The most recent advances have been in interventional neuroradiology with the introduction of highdefinition 3D imaging and hyperselective intranidal endovascular embolization using rnicrocatheters and microguidewires, giving marked advantages in terms of rapidity, efficacy, and safety, Nidal devascularization is now much improved, as shown by the increased interval between embolization sessions, while high-field functional magnetic resonance imaging plays a valuable role in the preembolization work-up and postembolization follow-up.

[Efficacy of lumbar chemonucleolysis in the treatment of foraminal and extra-foraminal hernias]. / Efficacité de la chimionucléolyse lombaire dans le traitement des hernies foraminales et extra-foraminales.

A retrospective review of 1,200 nucleolyses performed over a three year period from January 1995 to December 1997 showed 116 discal treatments for foraminal and extra-foraminal localizations. The anatomic localization through the foramen and the intense clinical signs typify these anatomoclinical forms of lumbar hernia. In contrast with complex and disruptive surgical cure, percutaneous nucleolysis offers a precise and rapid method which can be performed in a very short time in outpatients with a success rate of 80%. Most localizations concern L3-L4 and L4-L5 hernias which give the best clinical outcomes.

[Post-traumatic intrasplenic arteriovenous fistula in a child. Spontaneous regression]. / Fistule artério-veineuse intrasplénique post-traumatique chez un enfant. Régression spontanée.

We report on an 11-year-old boy who developed splenic arteriovenous fistula resulting from blunt abdominal trauma. This fistula disappeared spontaneously after 8 months of follow-up without any complication.

Saccular intracranial aneurysms: endovascular treatment with mechanical detachable spiral coils.

PURPOSE: To evaluate endovascular treatment of saccular intracranial aneurysms with mechanical detachable spiral coils. MATERIALS AND METHODS: Fifty-three patients with 56 saccular aneurysms underwent endovascular treatment with spiral coils. All but five had symptomatic subarachnoid hemorrhage staged according to the Hunt and Hess classification as follows: stage IV or V (n = 20), stage III (n = 10), stage I or II (n = 20), and stage 0 (asymptomatic [n = 6]). RESULTS: Forty-seven aneurysms were occluded (100% occlusion) on follow-up angiograms with the following time distribution: 24 months for six aneurysms (six patients), 12 months for 14 aneurysms (11 patients), 6 months for 13 aneurysms (13 patients), 4 months for four aneurysms (four patients), and only immediate postprocedure study for 16 aneurysms (16 patients) (excludes two deaths and one failure). CONCLUSION: In this relatively small group, endovascular treatment with mechanical detachable spiral coils had a success rate of 90%, and it appears to be a rapid, reliable, and relatively safe technique in the treatment of life-threatening subarachnoid hemorrhage.

[Dural fistula of the cavernous sinus. Treatment through an intravenous approach apropos of 4 cases]. / Fistules durales de la loge caverneuse. Traitement par voie endoveineuse à propos de 4 cas.

The authors report 4 cases of symptomatic dural fistula of the carotid cavernous sinus treated by transvenous coils. The objectives of dural fistula treatment are now clearly established and several methods are available. Abstention is the rule for asymptomatic forms, whereas symptomatic forms with ophthalmological complications may respond to manual compression of the jugular vein and the carotid artery, arterial embolization, radiotherapy or venous embolization. Arterial embolization results in complete cure in 72% to 78% of the cases, but it is limited by the meningeal supply of the internal carotid artery, with the microcatheter the transvenous route make it possible to treat the meningeal supply from the internal and external carotids without affecting the arterial system, but this technique is restricted by the anatomy of each patient.

[The role of magnetic resonance angiography in the follow-up of intracranial arteriovenous malformations treated by an intravascular approach]. / Rôle de l'Angio-IRM dans la surveillance des malformations artério-veineuses intra-crâniennes traitées par abord endo-vasculaire.

The purpose of our work was to measure the accuracy and reliability of MR-Angiography in the study and follow-up of intracranial arteriovenous malformations, and in particular to evaluate the results of endovascular treatment. Over an 18-month period 4 patients with such malformations were examined by MR-Angiography. There was an angioma of the corpus callosum, a left parieto-rolandic angioma, a posterior thalamic angioma and a cerebellar angioma. All examinations were performed with a Magneton-Impact 1 Tesla machine (Siemens, Erlangen, Germany), using a head coil, MR-Angiography with time-of-flight sequences and differential arterial and venous saturations. Each patient was examined by MR-Angiography first at the beginning of treatment, then when ambulatory after embolization. The morphological study applied to the afferent vessels, the nidus and the efferent veins. MR-Angiography proved to be very good in identifying the arteries feeding the malformation, and this made it easier to evaluate the reduction of their input after treatment, without having recourse to any arteriography. Beside, analysis of the nidus was facilitated by the judicious arrangement of arterial and venous saturations. In fact, the systematic use of MR-Angiography in the follow-up of intracranial arteriovenous malformations makes it possible to measure, with full reliability, the efficacy of the endovascular treatment under conditions of comfort unequalled in these out-patients, and selective angiography sequences need to be performed only during therapeutic phases.

A comparative study of the anatomical, radiological and therapeutic features of the lumbar facet joints.

An anatomical study of the lumbar apophyseal joints was carried out to facilitate recognition of facet joint lesions, which we now examine routinely by percutaneous arthrography. Special attention was given to the configuration of the different compartments of the joint space and to its relationships with the contents of the intervertebral foramen. The abnormalities seen on lumbar facet joint arthrography are very varied; two major groups should be stressed: synovial fringe hypertrophy and pseudodiverticular synovial ectasia. The percutaneous approach to lumbar facet joint arthrography allows it to be used a therapeutic measure, with injection of anti-inflammatory drugs into the joint space, the beneficial effects of which were confirmed in our series. The precision, efficiency and cost-effectiveness of this outpatient technique justify and should encourage its more widespread application in the diagnosis and treatment of low back pain.

Contribution of discography to the diagnosis and treatment of lumbar disc herniation.

In this study, based on 600 cases of lumbar disc herniation treated by chemonucleolysis, the authors underline the importance of performing good discography and interpreting its results. A discographic classification of intervertebral disc deterioration is suggested. A CT-discographic study is reported and its results are compared with those of standard discography. On the basis of these studies, the authors have established methodological data concerning the efficacy of chemonucleolysis and its evaluation.

[Chemonucleolysis of lumbar intervertebral disk herniation]. / Die Chemonukleolyse des lumbalen Bandscheibenvorfalls.

Chemonucleolysis is an advantageous alternative to surgical treatment of lumbar disc herniation. To achieve the best results the indications must be strictly observed and the procedure itself must be technically perfect. In these circumstances a rapid, noninvasive and less expensive treatment of lumbar disc herniation is possible.

[Superselective angiography of the circumflex arteries in preoperative evaluation of femoral neck fractures]. / L'angiographie supersélective des artéres circonflexes dans l'evaluation pré-opératoire des fractures du col fémoral.

The study of arterial vascularity in the head and neck of the femur is performed as an emergency exploration of femoral neck fractures by means of selective catheterization. The systematization of vascular lesions thus obtained is compared with the anatomical types of fractures. The posteromedial circumflex artery is not injured definitively as a rule, so that conservative osteosynthesis can be preferred to arthroplasty.