Intracranial aneurysms in sickle cell disease: Aneurysms characteristics and modalities of endovascular approach to treat these patients.

INTRODUCTION: The neurological complications of Sickle Cell Disease (SCD) include cerebral infarction and haemorrhage with rarely subarachnoid haemorrhage due to cerebral aneurysms. MATERIALS AND METHODS: In our interventional department, working with SCD referral department, we reported our experience concerning management of adult's patients with cerebral aneurysms. We identified 26 adults with 48 intracranial aneurysms documented by imaging. RESULTS: 18 patients, with 26 cerebral aneurysms were treated by endovascular approach for their aneurysms. No patient was treated by surgical way in our institution. 50% of patients had multiple aneurysms. Locations of aneurysms treated were typical with 70% of cerebral anterior artery and 30% of posterior artery. Three patients suffered from subarachnoid haemorrhage. Two procedure-related complications occurred during the treatment: one thrombo-embolic event with good recovery after medical treatment and one aneurismal perforation leading to the death of patient. Hypercoagulability is a major specific risk in SCD and use of permanent device as stent of flow diverter should be discussed to prevent complications. CONCLUSION: Endovascular management of these aneurysms seems to be a good alternative to treat these patients, with stability of occlusion at follow-up.

Catheter Injected Bone Marrow Mesenchymal Stem Cells Induce Efficacious Occlusion of Arteriovenous Nidus in a Swine Model.

OBJECTIVES: Arteriovenous malformations (AVMs) are complex vascular lesions. Surgical excision is the treatment of choice, but is often not achievable. Embolo-sclerotherapy alone is associated with high recurrence rates. This study tested the hypothesis that seeding hydrogel conditioned bone marrow derived mesenchymatous stem cells (BM-MSCs) in an AVM nidus model induces solid microvascular occlusion through endoluminal tissue growth. METHODS: AVMs were modelled as arteriovenous microvascular nidus, using swine rete mirabile, a plexiform intracranial structure composed of arterial microvessels that extensively anastomose. A right carotid-jugular fistula was created to generate high flow in the rete, and bone marrow was aspirated. At day 14, cultured BM-MSCs marked with a red fluorochrome were incorporated into a hyaluronic acid hydrogel, and injected through a catheter into the rete mirabile, using femoral access. In specific groups microsphere embolisation immediately preceded gel injection. At day 28, the swine were euthanased and the rete mirabile harvested for qualitative and quantitative analysis of microvessel lumen occlusion. RESULTS: Actual transfer of PKH26 labelled cells in rete was confirmed. In a first phase of the study, five swine died as a result of neurological events, prompting reductions of the injected volumes. Twenty-three animals survived until day 28. Injection of BM-MSC loaded hydrogel (n=6) significantly increased the occlusion rate compared with injection of acellular hydrogel (n=7) (10% [range, 10-12%] vs. 26% [range, 20-41%], p=.016). Injection of BM-MSC loaded hydrogel immediately after microspheres (n=6) enhanced the occlusion rate compared with embolic microspheres alone (n=6) (50% [range 46-56%] vs. 22% [range, 15-27%] p=.045). Microsphere injection resulted in vascular luminal thrombus formation. Injection of BM-MSCs induced endoluminal growth of vascular smooth muscle cells with cell proliferation and a dense collagen rich extracellular matrix. CONCLUSION: The luminal occlusion pattern of a microvascular AVM like structure can be changed from thrombus to solid cellular accumulation. The possibility of injecting living cells in a microvascular network, in a chronic survival model, provides new tools for research and treatment of AVMs and other microvascular diseases.

Brain ventricular wall movement assessed by a gated cine MR trueFISP sequence in patients treated with endoscopic third ventriculostomy.

The purpose of this study was to investigate the value of brain ventricular wall movement assessment with a gated cine trueFISP MR sequence for the diagnosis of endoscopic third ventriculostomy (ETV) patency. Sixteen healthy volunteers and ten consecutive patients with noncommunicating hydrocephalus were explored with a MR scanner (Siemens, Avanto 1.5 T) before, 1 week and 3 months after ETV. TrueFISP was evaluated qualitatively (ventricular wall movement and CSF flow through ETV) and quantitatively [distance moved (DMLT) during a cardiac cycle by the lamina terminalis]. The third ventricle volume (TVV) was assessed. Statistical analysis was performed using nonparametric tests. There was no motion of the lamina terminalis (LT) detected on preoperative data. A pulsatile motion of the LT was found for patients with a patent ETV and for controls. DMLT and TVV were correlated (r = 0.79, P = 0.006). A transient dysfunction of ETV was successfully diagnosed on the trueFISP sequence with no motion of the LT or CSF flow observed. The trueFISP sequence appears reliable for the diagnosis of ETV patency and provides non-invasive assessment of the movement of the ventricular wall related to CSF pressure changes.

Thrombectomy for acute basilar artery occlusion by using double Merci retriever devices and bilateral temporary vertebral artery flow reversal. Technical note.

Basilar artery occlusion is a dramatic clinical event with a high mortality rate if patients are treated by standard medical therapy, including anticoagulation agents. The use of intravenous tissue plasminogen activator or intraarterial thrombolysis recanalizes 30-53 and 64%, respectively, of patients with basilar stroke. Mechanical endovascular treatments allow tailored procedures with quicker results and higher recanalization rates. The authors describe a successful mechanical removal of an obstruction in an acute occlusion of the basilar artery tip involving both proximal segments of posterior cerebral arteries in a 20-year-old man. They used 2 Merci retriever devices at the same time, and performed bilateral proximal vertebral artery occlusion for temporary flow reversal and aspiration.

Posterior cervical spinal cord infarction complicating the treatment of an intracranial dural arteriovenous fistula embolization. Case report.

Acute ischemic infarction of the posterolateral bulbomedullary junction occurred in a 28-year-old man who underwent arterial embolization for the treatment of an intracranial dural arteriovenous malformation. The migration of the embolic agent in the posterior spinal artery via a peripheral anastomosis between the middle meningeal artery and the posterior meningeal artery was responsible for this complication. The cast of glue in the radiculopial system at the upper cervical level was visible on computed tomography scanning, and magnetic resonance imaging demonstrated circumscribed signal changes and restricted diffusion in the arterial territory of the bulbomedullary junction. The authors discuss the anatomical, clinical, and technical issues of this rare complication.

Water diffusion compartmentation at high b values in ischemic human brain.

BACKGROUND AND PURPOSE: We studied the evolution of brain water compartments during the early stage of ischemic stroke. METHODS: Diffusion-weighted imaging was performed at 1.5 T in 10 volunteers and 14 patients with stroke. We used a single-shot echo-planar technique with 11 b values of 0-5000 s/mm(2). Regions of interest were selected in the white matter (WM) and striatum of the volunteers and in the ischemic core of the patients. Measurements were fitted on the basis of a biexponential decay with the b factor as follows: S(b) = S(0)[(f(slow) x exp(-b x ADC(slow)) + (f(fast) x exp(-b x ADC(fast))] where S(b) is the signal intensity in the presence of a diffusion gradient, S(0) is the signal intensity without diffusion sensitization, ADC(slow) and ADC(fast) are the respective apparent diffusion coefficients (ADCs) of slow diffusing compartments (SDCs) and fast diffusing compartments (FDCs), and f(slow) and f(fast) the respective contributions to the signal intensity of SDC and FDC. RESULTS: In healthy subjects, FDC represents 74.3 +/- 3.1% of brain water, with ADC(fast) = (124.6 +/- 12.0) x 10(-5) mm(2)/s and ADC(slow) = (15.5 +/- 3.9) x 10(-5) mm(2)/s. In stroke, decreased FDC (49.1% +/- 10.9%; P = 1.05 x10(-5)) and increased ADC(slow) ([22.4 +/- 8.1] x 10(-5) mm(2)/s; P = 8.07 x 10(-3)) were observed, but ADC(fast) was not significantly changed ([135.6 +/- 25.7] x 10 (-5) mm(2)/s; P =.151). CONCLUSION: The restricted diffusion observed in the early stroke is mainly related to a redistribution of water from the FDC to the SDC.

Solitaire FR stent as an adjunctive tool for pipeline stent deployment in the treatment of giant intracranial aneurysms.

BACKGROUND AND IMPORTANCE: The use of flow-diverting stents has gained acceptance during the past few years for the treatment of numerous intracranial aneurysms, especially large or giant ones. However, successful catheterization of the distal parent artery in giant intracranial aneurysms with a microcatheter can be extremely challenging. Forming a microcatheter loop in the aneurysm sac can aid distal catheterization. CLINICAL PRESENTATION: We report the use of a Solitaire FR stent as an adjunctive tool in the successful treatment of 2 giant intracranial unruptured aneurysms with a Pipeline Embolization Device. After having formed a loop inside the aneurysm sac, the microcatheter was anchored distally by a Solitaire FR stent. With the Solitaire FR device opened, the loop in the giant aneurysm sac was completely reduced without loss of the microcatheter position in the distal parent artery. A Pipeline Embolization Device could be delivered in both cases without any difficulty. There were no complications. CONCLUSION: The technique described results in ideal microcatheter alignment with a secure distal position before deployment of a flow-diverting stent.

Efficacity and feasibility of vertebroplasty for severe vertebral fracture: a retrospective study of 12 vertebroplasties.

Vertebroplasty is commonly contraindicated for severe vertebral fractures, or vertebra plana. However, we decided after multidisciplinary staff decision to perform vertebroplasty for few severe vertebral fractures which were still painful after optimal medical treatment. We retrospectively studied the charts of patients who benefited from vertebroplasty for severe vertebral body compression fracture between May 2006 and January 2012 in a rheumatology department. Clinical and biological data were collected and patients were consulted to assess effectiveness of that technique. We performed vertebroplasty of 12 severe vertebral fractures in 10 patients (nine women and one man). Mean age was 74.9±10.7 years. Mean VAS score was 9/10±1.15 before vertebroplasty and 2.4±2 after. Global improvement was 80% and patient satisfaction was 7/10. After vertebroplasty, use of drugs was significantly reduced or even stopped. The complications observed were: three infraclinical cement leakages, one haematoma at the site of the puncture, one atrial fibrillation and one classic pulmonary embolism. Mean follow-up was 28.6±22.3 months. Vertebroplasty is indeed a delicate procedure for severe vertebral fracture but quickly and sustainably effective.

A 6F guide sheath for endovascular treatment of intracranial aneurysms.

INTRODUCTION: Stable insertion of guide catheters via the femoral route can prove difficult because of tortuous vasculature leading to failure of endovascular treatment of intracranial aneurysms. METHODS AND RESULTS: We report our experience using a long braided introducer sheath (6F Terumo Destination) with an inner diameter of 0.087 inches. It allowed the simultaneous use of multiple catheters or adjunctive techniques (balloon-assisted or stent-assisted coiling) while providing excellent support in 60 procedures involving coiling of anterior circulation aneurysms. CONCLUSION: The use of a long introducer sheath, by enhancing stability in the aortic arch and supraaortic vessels, provides another solution to the problem of vascular tortuosity that hinders endovascular treatment of intracranial lesions.