Intervening in the Acute Phase of Postradiation Carotid Blowout Syndrome.

Introduction Acute carotid blowout syndrome (aCBS) is a severe complication of head and neck cancer (HNC). It can be defined as a rupture of the extracranial carotid arteries, or one of their branches, that causes life-threatening hemorrhage, and which nowadays can be treated with urgent endovascular intervention. Objective We retrospectively evaluate the endovascular management of aCBS and its outcome in years of survival. Methods Retrospectively, we describe our experience with endovascular control of aCBS in patients treated for HNC. We review the characteristics, pathology, endovascular treatment and morbidity and assess the gain in life years. Results Nine individuals were included in this study. Four patients had been previously diagnosed with laryngeal squamous cell carcinoma (SCC), one with paranasal SCC, one with nasopharyngeal carcinoma and three with oral or maxillary adenocarcinoma. All subjects underwent radiotherapy and surgical excision to different extents. Twelve endovascular procedures were performed for injuries to the internal carotid artery ( n = 3; 25%), external carotid artery ( n = 1; 7%) or one of their branches ( n = 8; 67%). Deconstructive methods were used in nine procedures, and three procedures were mainly reconstructive with deployment of covered stents. Total control of bleeding was achieved in all individuals with no intraprocedural complications. Conclusion Endovascular therapy is an effective alternative for the management of exsanguinating CBS. In our series, this palliative therapy increased the overall patient survival by an estimated 9 months.

Intervening in the acute phase of postradiation carotid blowout syndrome

Introduction: Acute carotid blowout syndrome (aCBS) is a severe complication of head and neck cancer (HNC). It can be defined as a rupture of the extracranial carotid arteries, or one of their branches, that causes life-threatening hemorrhage, and which nowadays can be treated with urgent endovascular intervention. Objective: We retrospectively evaluate the endovascular management of aCBS and its outcome in years of survival. Methods: Retrospectively, we describe our experience with endovascular control of aCBS in patients treated for HNC. We review the characteristics, pathology, endovascular treatment and morbidity and assess the gain in life years. Results: Nine individuals were included in this study. Four patients had been previously diagnosed with laryngeal squamous cell carcinoma (SCC), one with paranasal SCC, one with nasopharyngeal carcinoma and three with oral or maxillary adenocarcinoma. All subjects underwent radiotherapy and surgical excision to different extents. Twelve endovascular procedures were performed for injuries to the internal carotid artery (n = 3; 25%), external carotid artery (n = 1; 7%) or one of their branches (n = 8; 67%). Deconstructive methods were used in nine procedures, and three procedures were mainly reconstructive with deployment of covered stents. Total control of bleeding was achieved in all individuals with no intraprocedural complications. Conclusion: Endovascular therapy is an effective alternative for the management of exsanguinating CBS. In our series, this palliative therapy increased the overall patient survival by an estimated 9 months (AU)

Endovascular reconstruction by means of stent placement in symptomatic intracranial atherosclerotic stenosis.

OBJECTIVE: Patients with intracranial atherosclerosis who fail antithrombotic therapy have a poor prognosis. The high rate of recurrent stroke warrants testing alternative treatments such as intracranial angioplasty. METHODS: We present our experience in the treatment of 104 patients (age range, 54-82 years; mean age, 67 years) with symptomatic intracranial atherosclerotic stenoses despite medical therapy who underwent stent-assisted angioplasty. Patient records were retrospectively analysed for location and degree of stenosis, regimen of antiplatelet agents, devices used, procedure-related complications and adverse events. Clinical (Modified Rankin Scale) and radiographic outcomes were obtained 24 hours, 1 month and 3-6 months after treatment. Sixty-five lesions (62.5%) were located in the posterior circulation. Mean stenosis was 75.4%. RESULTS: In all patients, the angiographic degree of stenosis was reduced to less than 30%. One stent was implanted in 66 patients (63%), and two or more in 38 patients (37%). Modified Rankin Scale (mR) was 1-2 in 67.5% of the cases, 3-4 in 25.9%, 5 in 2.8%, 6 in 3.8%. Procedural morbidity was 5.7% and procedural mortality was 3.8%. Angiographic follow-up was available in 58 patients (55.7%) and the restenosis rate was 12.5%. DISCUSSION: In selected patients, endovascular revascularization of intracranial arteries by means of stent-assisted angioplasty is technically feasible, effective and safe.

Partial aortic obstruction improves cerebral perfusion and clinical symptoms in patients with symptomatic vasospasm.

OBJECTIVE: Stroke studies in animals showed that aortic obstruction increases cerebral blood flow (CBF) and reduces infarct size. In this study we evaluate the safety and efficacy of a device providing partial and transitory aortic obstruction. METHODS: We report the results in 24 selected patients with symptomatic vasospasm by aneurysmal subarachnoid hemorrhage treated by partial and transitory aortic obstruction with a novel device (NeuroFlo, CoAxia, MN). Aneurysms were secured by coils prior to the procedure. We studied the adverse effects related to the aorta-obstructing device, and changes in CBF and neurological outcome. RESULTS: Mean flow velocity increased in both middle cerebral arteries over 15%, and the score in the National Institute of Health Stroke Scale decreased >or=2 point in 20 patients (83%). During the procedure, three patients developed symptoms that were controlled. At 30 days follow-up, three patients had 6 points (unrelated death), three had 3 points, six had 1 point, and 12 had 0 points, in the modified Rankin scale. DISCUSSION: Partial aortic obstruction was safe, the cerebral blood flow increased without inducing significant hypertension and the neurological defects improved in most of the patients. Efficacy with a better level of evidence will be determined by a randomized study.

Percutaneous vertebroplasty: technique and results in 192 procedures.

Percutaneous vertebroplasty with acrylic cement (usually polymethylmethacrylate) consists of injecting cement into vertebral bodies weakened by osseous lesions. The objective of this procedure is to obtain an analgesic effect by mechanical stabilization in destructive lesions of the spine. The three major indications are aggressive vertebral hemangiomas, severe or refractory pain related to osteoporotic vertebral fractures, and malignant vertebral tumors. Complications are infrequent, but occur essentially in patients with vertebral malignant tumors. We present our experience with 148 patients that underwent 192 percutaneous PMMA vertebroplasties for the treatment of painful osteoporotic compression fractures (76 patients, 105 vertebral levels), hemangiomas (31 patients, 43 vertebral levels) and neoplasms (31 patients, 43 vertebral levels). In a vast majority of appropriately selected cases and especially in osteoporotic cases, vertebroplasty constitutes a relatively simple procedure with a very high rate of success.

Carotid stent angioplasty: the role of cerebral protection devices.

Carotid endarterectomy has been validated with results of several randomized controlled trials in which its effectiveness has been demonstrated over that of the best nonsurgical therapy. However, in the past several years, carotid angioplasty with stent placement has emerged as a potential safe and effective alternative to carotid endarterectomy. In this article we examine the current status of carotid angioplasty with the recent introduction of innovative cerebral protection devices and improved endovascular devices. We present a brief description of the current randomized trials evaluating carotid endarterectomy compared to carotid angioplasty as well as our combined experience in 262 patients.

Covered stent as an innovative tool for tumor devascularization and endovascular arterial reconstruction.

A temporal paraganglioma was pre-operatively embolised with particles and due to the fact that the internal carotid artery was encased by the tumor and that multiple petrous feeders precluded safe embolization, we decided to implant a balloon-expandable covered stent. On immediate post-procedural angiography, the arterial diameter was restored and a complete devascularization of the tumor was achieved. The tumor was operated with minimal blood loss and the carotid artery was released from surrounding tumor using the frame of the stent as a surgical limit. Covered stents may become a valuable tool for pre-operative tumor devascularization and arterial reconstruction especially when dealing with hypervascular tumors of the cranial base that encase the carotid artery.

Partially clipped intracranial aneurysm obliterated with combined stent and coil implantation.

PURPOSE: To report a case of endovascular stent placement to assist stable coil deployment in a symptomatic, wide-necked, partially clipped aneurysm. CASE REPORT: A 48-year-old woman presented for endovascular treatment of a symptomatic posterior communicating artery aneurysm remnant that was surgically clipped 10 years ago. A 3.5-mm x 12-mm balloon-expandable stent was placed across the aneurysm orifice followed by complete obliteration of the remnant with coils implanted through the stent mesh. Digital subtraction angiography documented continued patency of the arterial lumen and complete obliteration of the aneurysm at 11 months. CONCLUSIONS: Partial aneurysm clipping may assist or complicate secondary interventional procedures and interfere with correct visualization of the neck. Stent placement obviates the need for the balloon-assist method of coil embolization for wide-necked aneurysm remnants, acting as a mechanical barrier to hold the coils in a very unfavorable anatomy.

Angioplasty and stent placement in intracranial atherosclerotic stenoses and dissections.

BACKGROUND AND PURPOSE: Stent placement has been shown to increase the safety and effectiveness of balloon angioplasty in cervical carotid disease. Here, the authors investigated the feasibility, safety, and short-term outcome of stent-assisted angioplasty for the treatment of intracranial stenoses. METHODS: Thirty-four patients (age range, 12-77 years; mean age, 54 years) with symptomatic intracranial atherosclerotic lesions and dissections that produced stenosis of more than 50% were selected and treated with stents. Eighteen lesions (53%) were located in the anterior circulation, and 16 (47%) were in the vertebrobasilar complex. The mean stenosis was 75%. RESULTS: At follow up, 21 patients (62%) improved clinically, 11 (32%) remained stable, and the condition of two patients (6%) deteriorated. In all patients, the angiographic degree of stenosis was reduced to less than 30%. In 10 patients (29%), two or more stents were implanted: Two stents were implanted in six patients, and three, in four patients. The transient procedural morbidity rate was 12%, and the transient neurologic morbidity rate was 6%. One patient had hemorrhagic transformation due to reperfusion and died, and another patient had a massive myocardial infarction after 5 months. Twenty patients were followed up with angiography for at least 6 months, and none required repeat angioplasty. CONCLUSION: Endovascular revascularization of intracranial arteries by means of stent-assisted angioplasty is technically feasible, effective, and safe in selected patients.

Endovascular reconstruction of intracranial arteries by stent placement and combined techniques.

OBJECT: The authors investigated the feasibility, safety, and short-term outcome of stent treatment for intracranial aneurysms, stenoses, and dissections. METHODS: One hundred twenty-three consecutive patients with intracranial saccular, dissecting, and fusiform aneurysms, atherosclerotic lesions, and dissections were selected for intracranial stent implantation with or without adjunctive coil placement. One hundred eleven patients (mean age 47 years, range 3-73 years) underwent stent treatment; 12 patients (9.8%) were not treated. These 111 patients were divided into four groups: in Group 1 there were 62 patients with saccular aneurysms; Group 2 included nine patients (10 lesions) with dissecting or fusiform aneurysms; in Group 3 there were 36 patients with symptomatic intracranial atheromatous stenoses of more than 50%; and Group 4 included four patients with symptomatic intracranial dissections. All patients underwent computerized tomography scanning and/or magnetic resonance imaging and cerebral digital subtraction angiography preoperatively. Of the 72 aneurysms in Groups 1 and 2, 59 (82%) were treated with combined endovascular stent implantation and endosaccular coil placement. In 67 aneurysms (93%) we achieved complete or nearly complete obliteration. All patients with arterial narrowing achieved residual stenoses of less than 30% postangioplasty. One patient required repeated angioplasty. The morbidity rate in the series was 10.9% and the mortality rate was 6.3%. CONCLUSIONS: These findings indicate that stent treatment is feasible and seems to be an effective modality for arterial reconstruction. This versatile tool allows the treatment of a wide variety of challenging intracranial lesions.

Tratamiento empirico anti-toxoplasma en SIDA y Chagas cerebral: relato de dos casos, revision de la bibliografia y propuesta de un algoritmo / Empirical anti-toxoplasma therapy in cerebral AIDS and Chagas invasion: presentation of 2 cases, bibliography review and proposal of an algorithm

El Tripanosoma cruzi, agente causal de la tripanosomiasis americana o enfermedad de Chagas es endémico en extensas áreas de América del Sur y Central, y existen numerosas comunicaciones documentando la invasión del sistema nervioso central por T. cruzi en pacientes con SIDA. Presentamos dos casos que ilustran claramente que el compromiso neurológico causado por T. cruzi resulta frecuentemente indistinguible de la toxoplasmosis del sistema nervioso central. Como el tratamiento precoz del Chagas neurológico ha sido asociado con una mayor sobrevida, y esta enfermedad es fácilmente diagnosticable mediante la identificación del agente en líquido cefalorraquídeo, proponemos que se realice sistemáticamente el estudio serológico de anticuerpos anti- T. cruzi en todos los pacientes con SIDA y diagnóstico presuntivo de toxoplasmosis cerebral. En aquellos pacientes que sean reactivos para Chagas debería realizarse además el estudio sistemático del líquido cefalorraquídeo. O dicho en otras palabras, la imposibilidad para diferenciar clinicamente el compromiso neurológico por T. cruzi del causado por Toxoplasma gondii hace necesatio replantear el abordaje diagnóstico y terapéutico de las lesiones focales agudas del sistema nervioso central en pacientes con SIDA residentes o procedentes de áreas endémicas de Chagas. (AU)

Tratamiento empirico anti-toxoplasma en SIDA y Chagas cerebral: relato de dos casos, revision de la bibliografia y propuesta de un algoritmo / Empirical anti-toxoplasma therapy in cerebral AIDS and Chagas invasion: presentation of 2 cases, bibliography review and proposal of an algorithm

El Tripanosoma cruzi, agente causal de la tripanosomiasis americana o enfermedad de Chagas es endémico en extensas áreas de América del Sur y Central, y existen numerosas comunicaciones documentando la invasión del sistema nervioso central por T. cruzi en pacientes con SIDA. Presentamos dos casos que ilustran claramente que el compromiso neurológico causado por T. cruzi resulta frecuentemente indistinguible de la toxoplasmosis del sistema nervioso central. Como el tratamiento precoz del Chagas neurológico ha sido asociado con una mayor sobrevida, y esta enfermedad es fácilmente diagnosticable mediante la identificación del agente en líquido cefalorraquídeo, proponemos que se realice sistemáticamente el estudio serológico de anticuerpos anti- T. cruzi en todos los pacientes con SIDA y diagnóstico presuntivo de toxoplasmosis cerebral. En aquellos pacientes que sean reactivos para Chagas debería realizarse además el estudio sistemático del líquido cefalorraquídeo. O dicho en otras palabras, la imposibilidad para diferenciar clinicamente el compromiso neurológico por T. cruzi del causado por Toxoplasma gondii hace necesatio replantear el abordaje diagnóstico y terapéutico de las lesiones focales agudas del sistema nervioso central en pacientes con SIDA residentes o procedentes de áreas endémicas de Chagas.