Trans-cranial placement of an amplatzer device to control intractable cardiac failure in an infant with a vein of galen anomaly. A case report.

Neonates presenting with intractable cardiac failure due to vein of Galen aneurysmal malformations (VGAMs) rapidly progress to multisystem organ failure and death if left untreated. Currently the only viable treatment option is endovascular embolization. Although intracranial embolization of a neonate is a high-risk procedure, successful treatment can reverse cardiac failure and prevent neurological complications associated with VGAMs. Embolization via the arterial route is thought to have a better outcome than embolization via the venous system. However, multiple transarterial embolizations in different sessions may well be contraindicated in neonates, because repeat access via the femoral artery, carries a risk of arterial trauma which, in turn, can jeopardize lower limbs. With this case study we show that after repeat failure of arterial embolization, the transcranial placement of an Amplatzer PFO occluder (AGA Medical, Plymouth, USA) in the aneurysm can effectively reduce intrafistular pressure and venous outflow velocity. We also propose a mathematical model that can be used to calculate flow velocity through the aneurysm, which, in turn, could be used to aid clinical decision-making. Unlike some conventional techniques, the placement of an Amplatzer occluder does not pose the risk of completely obstructing venous drainage and therefore does not increase the risk of venous breakthrough hemorrhage. We propose this endovascular technique as a treatment option for high risk neonates in need of emergency embolization of VGAMs, where multiple arterial embolizations failed to control the condition sufficiently.

Initial experience with intracranial stent-graft use. Technical notes.

SUMMARY: We describe our initial experience with the placement of two premounted balloon expandable intracranial Jostent stent-grafts within the intracavernous internal carotid artery for the treatment of a symptomatic large intracavernous aneurysm in one case and a post-traumatic caroticocavernous fistula in the second. Among the initial technical complications we encountered were stent-graft migration and rapidly progressive intragraft thrombosis, with delayed sealing of the stent-graft coverings and exclusion of the pathologies relating to the use of abciximab in both cases. Despite these initial problems both cases had excellent short-term clinical outcomes with angiographic exclusion of both lesions by day three and good clinical and angiographic outcomes at one and two months respectively.

Endovascular treatment of intractable epistaxis--results of a 4-year local audit.

OBJECTIVE: Transcatheter embolisation is an accepted and effective treatment for intractable epistaxis. We analysed our success and complication rates and compared these with results from other published series. DESIGN: Retrospective review. SETTING: Unitas Interventional Unit, Centurion. METHODS: Case record review (57 procedures) and telephonic interviews (36 traceable respondents). OUTCOME MEASURES: A numerical audit of the success and complication rates for embolisation procedures performed during the 4-year period between July 1999 and June 2003. RESULTS: A total of 57 endovascular embolisation procedures were performed for intractable epistaxis in 51 patients during this period. Eight patients (15.7%) developed a re-bleed between 1 and 33 days after embolisation, of whom 5 were reembolised, giving a primary short-term success rate of 86.3% and secondary assisted success rate of 94.1%. Thirty-five of 36 respondents (97.2%) reported no further epistaxis during the long-term follow-up period of 1-47 months. The mortality rate was 0%, the major morbidity rate was 2% (1 stroke) and the minor morbidity rate was 25%. CONCLUSION: Our success and complication rates are acceptable and compare favourably with those reported in other large series.

Distal embolization and local vessel wall ulceration after gastric variceal obliteration with N-butyl-2-cyanoacrylate: a case report and review of the literature.

Repeated endoscopic injections of N-butyl-2-cyanoacrylate mixtures into large gastric varices in a single patient led to two complications: initially, pulmonary embolism, and later local ulceration of the wall of a varix. The latter resulted in massive uncontrollable hemorrhage that ultimately led to a fatal outcome. This case report also analyzes complications reported in the literature during similar endoscopic procedures for gastric varices.

Acute severe epistaxis due to iatrogenic maxillary pseudoaneurysm. Emergency control of haemorrhage by carotid compression and early recurrence after coil embolization.

SUMMARY: Internal maxillary arterial or branch transection is a potential complication of maxillofacial surgery. We describe one such patient who developed acute massive nasal haemorrhage, an episode of which was controlled clinically just prior to performing endovascular embolization by employing the simple but effective clinical manoeuvre of manual carotid arterial compression. Six weeks later the haemorrhage recurred despite a seemingly adequate embolization of the affected arteries with microcoils and Spongistan due to re-establishment of flow through the coils.

Non-aneurysmal perimesencephalic subarachnoid haemorrhage with associated pontine haemorrhagic infarction. A case report and subject review.

SUMMARY: Non-aneurysmal perimesencephalic subarachnoid saemorrhage is characterized by an accumulation of blood in the perimesencephalic and prepontine cisterns identified on sectional imaging together with persistently negative cerebral angiography. Magnetic resonance imaging usually contributes no further information on the possible cause of the bleed but may occasionally show further features including associated parenchymal infarcts such as the pontine haemorrhagic infarct seen in the case described here.

Type D Traumatic Carotido-cavernous Fistula due to Selective Transection of the Inferolateral Trunk(ILT). Diagnosis and Endovascular Treatment.

SUMMARY: A minority of traumatic carotido-cavernous fistulas (CCF) are of the indirect variety, and then usually supplied only by meningeal branches of the ipsilateral external carotid artery (Type C).We describe a case of a Type D CCF due to traumatic injury of the inferolateral trunk (ILT), and describe its angiographic features and endovascular management through both the external and internal carotid arteries following a failed transvenous approach.

Catheter-Directed Intra-Arterial Abciximab Administration for Acute Thrombotic Occlusions during Neurointerventional Procedures.

SUMMARY: Abciximab is one of a new class of platelet aggregation inhibitors that has to date been used mainly in the management of acute coronary ischaemic syndromes or during cardiac intervention for the prevention and treatment of acute vessel occlusion during and after angioplasty or stent placement. More recently, it has begun to play a similar role in neurointerventional work. Its administration during acute stent or vessel occlusions has usually been via systemic intravenous infusion.We describe five cases of acute vessel occlusion during neurointerventional procedures where the abciximab bolus was administered intra-arterially at or close to the site of the occlusion, with rapid complete visual dissolution of the thrombus in four cases and partial dissolution in one, resulting in two patients with no neurological deficits, one with no further neurological deterioration, one with a mild residual thumb paresis and one with a severe neurological deficit.

[Chronic osteomyelitis - a diagnostic dilemma]. / Chroniese osteomiëlitis--'n diagnostiese dilemma.

Infective skeletal lesions can mimic bony tumours. Bony lesions without periosteal reactions in adult patients with normal leucocyte counts will have a different differential diagnosis from that of children with bony lesions and a periosteal reaction. In the latter, osteomyelitis should be distinguished from Ewing's sarcoma and osteogenic sarcoma. Due to the difficult preoperative diagnosis a retrospective study was undertaken which included 14 patients with the histological diagnosis of chronic osteomyelitis but normal leucocyte count and no periosteal reaction. Radiographs showed cavities in 82%, infiltration in 12% and sclerosis in 6% of cases. All patients who underwent skeletal scintigraphy studies showed increased uptake in the lesions. Magnetic resonance showed increased signal intensity in T2 images. Ordinary radiographs are still the most valuable primary investigation for skeletal lesions.

Are clinical differences between black and white stroke patients caused by variations in the atherosclerotic involvement of the arterial tree?

The differences in site and degree of atherosclerotic involvement of various vascular beds and their clinical significance are emphasised in a study of 304 black stroke patients. Detailed clinical examinations, computed tomography (CT), gated blood pool studies, echocardiography and ECG were performed and autopsy studies carried out. CT of the brain showed that non-haemorrhage, i.e. ischaemic lesions, accounted for 71.2% of strokes, a similar figure to that found in white stroke patients. However, carotid bruits (0.62%) and peripheral vascular disease (0.9%) followed by transient ischaemic attacks (1.9%) were found to be uncommon. Similarly, ischaemic heart disease (6.9%) appeared to be less common than the incidence in reported white stroke patients. In 30 patients who came to autopsy, the maximum degree of atherosclerotic stenosis of the extracranial carotid arteries was 21.7% of the lumen diameter. The differences in the site and degree of atherosclerosis in blacks not only give rise to differences in the clinical features of stroke patients but may have an important bearing on their investigation, management and prognosis.

Bizarre parosteal osteochondromatous proliferation of a phalanx.

A rare proliferative osteochondromatous malformation of a proximal phalanx is described. This malformation may mimic the appearance of a sessile osteochondroma or parosteal osteosarcoma on X-rays and may be mistaken for a low-grade osteosarcoma on histology, with disastrous therapeutic consequences. We found that cryotherapy followed by local excision was adequate to remove the tumour.

Giant colonic diverticulum--a radiological diagnostic problem. A case report.

Giant diverticulum of the colon is a rare condition, mentioned only sporadically in the literature and usually presenting on an abdominal radiograph as an air-filled cyst. This poses an interesting clinical and radiological diagnostic problem. A case is presented and a radiological approach suggested.

Embolisation of arteriovenous malformation of the spinal cord. A case report.

An arteriovenous malformation of the spinal cord in a 41-year-old man treated by intra-arterial embolisation is reported. The progressive spastic weakness and severe burning pain responded well to treatment. The carefully calculated use of Ivalon particles is essential and is described. Evoked potentials were used to monitor the status of the spinal cord during the procedure. It is essential that a team of clinicians and radiologists be established at major centres to handle such cases.

[Digital subtraction angiography]. / Berekende subtraksie-angiografie.

Between 10 February 1983 and 9 November 1984 482 patients were investigated by digital subtraction angiography, mainly for carotid arterial disease and problems associated with transplanted kidneys. The use of abdominal compression and antispasmodics are essential to minimize bowel artefacts for intraabdominal arterial examinations. The apparatus is advantageous for interventional radiologists. Images are immediately seen, can be stored on analogue tape, digitalized and obtained with smaller volumes of contrast medium and without arterial catheterization. Movement artefacts, however, can cause problems.

Radionuclide studies in upper gastro-intestinal ulceration--are they reliable? A pilot study of 6 patients.

Endoscopy is at present the diagnostic technique of choice in the evaluation and detection of upper gastro-intestinal tract ulceration. Because of the physical discomfort suffered by patients during endoscopic examination, the search for better and less invasive methods of examination (especially in the unco-operative and seriously ill patient) continues. According to reports from the Orient, sucralfate (Ulsanic; Continental Ethicals) has prominent ulceravid properties. These properties are being used in conjunction with a tagging agent, in this case technetium-99m, as a diagnostic method for the detection and localization of upper gastro-intestinal ulceration. In this pilot study on 6 patients the positive findings of others regarding the specificity and promise of this method could not be confirmed.