Flow Diversion Therapy of Remnant and Recurrent Intracranial Aneurysms Treated Surgically.

AIM: To evaluate the safety and efficacy of flow diverter stents (FDSs) for treating remnant or recurrent intracranial aneurysms that were treated surgically. MATERIAL AND METHODS: The patients who were treated with FDSs due to remnant or recurrent intracranial aneurysms after microsurgery were included in the study. The patients' demographics, treatment histories, aneurysm features, complications associated with flow diversion, and neurological and angiographic follow-up findings were evaluated. RESULTS: Twenty patients (eight males) with 20 aneurysms were included in the study. Of 20 aneurysms, 18 (90%) were in the anterior, and two (10%) were in the posterior circulation. The initial treatment methods were clipping in 17 (85%) and wrapping in three (15%) aneurysms. The endovascular procedure was successful in all patients. In three patients (15%), periprocedural and postprocedural complications were encountered. No hemorrhagic complications were detected on cone-beam computed tomography. One patient with a basilary aneurysm died because of brain stem ischemia. The total morbimortality was 5%. The mean length of follow-up was 13.7 ± 7.3 months in 18 patients. The first angiographic follow-up (3-6 months) revealed the complete occlusion in 7 of 11 aneurysms (63.6%). By contrast, 16 aneurysms (94.1%) were occluded at the last angiographic follow-up, one aneurysm (5.9%) was still filling. CONCLUSION: An FDS seems effective, safe, and extremely attractive in treating remnant and recurrent intracranial aneurysms treated surgically.

Long-term clinical and angiographic follow-up results of the dual-layer flow diverter device (FRED) for the treatment of intracranial aneurysms in a multicenter study.

PURPOSE: Our aim was to determine the long-term safety and efficacy of the Flow Re-Direction Endoluminal Device (FRED) in this multicenter study with prospective design. MATERIALS-METHOD: This study included 136 consecutive patients with 155 aneurysms treated between March 2013 and June 2016 in 10 centers. Twenty-two (16.2%) patients presented with rupture of the index aneurysm. Large/giant aneurysms comprised 1/3 of the cohort. Adjuvant coil use during the treatment was 15.5%. The effectiveness measure in the study was the percentage of aneurysms with stable occlusion at follow-up. RESULTS: Vascular imaging follow-up was performed at least once in 131/136 (96.3%) patients with 148/155 (95.5%) aneurysms up to 75 months (mean: 37.3 months; median: 36 months according to latest follow-up), and 102/155(65.8%) aneurysms in 90/136 (66.2%) patients had ≥ 24-month control. According to the latest controls, the overall stable occlusion rate was 91.9% (95% CI, 87.5 to 96.3%). Three out of 148 aneurysms with follow-up were retreated (2%, 95% CI 0.0 to 4.3%). Adverse events were noted in 19/136 (14%, 95% CI, 9 to 21%) patients with a morbidity of 1.5% (95% CI, 0.0 to 3.5%). Mortality was 1/136 (0.7%, 95% CI, 0.02 to 2.2%) and was unrelated to aneurysm treatment. In-stent stenosis (ISS) was detected in 10/131 of the patients with follow-up (7.6%, 95% CI; 3.1 to 12.2%), only one being symptomatic. No adverse events have occurred in any of the patients with follow-up after 24 months, except the one resulting from ISS. CONCLUSION: In the treatment of cerebral aneurysms which were candidates for flow diversion technique, this study showed long-term efficacy of FRED with good safety and occlusion rates.

Temporal bone hemangioendothelioma as a rare vascular tumor in childhood: case report and review of the literature.

BACKGROUND: Hemangiondothelioma is a rare vascular tumor that can occur in the bone. Temporal bone involvement has been reported extremely rare in the literature. CASE: Radiological examination of a one-year-old girl who was admitted due to facial paralysis revealed vascular tumor of the temporal bone and Galen vein aneurysm. Pathological examination showed retiform hemangioendothelioma. She was treated with propranolol, prednisolone, vincristine, and endovascular embolization followed by oral sirolimus. With sirolimus treatment, a partial response was obtained first, then the tumor remained stable and sirolimus treatment was discontinued. No progression was observed in the disease after discontinuation of treatment. CONCLUSION: In this article, a case of hemangioendothelioma originating from the temporal bone is discussed in the light of other case reports in the literature.

A rare concurrence: gelastic seizures in a patient with right temporal nongalenic pial arteriovenous fistula.

INTRODUCTION: Gelastic seizures are the type of seizures that are most commonly seen in childhood and should be excluded definitely in the differential diagnosis of hypothalamic hamartomas. This seizure type may be accompanied by refractory seizures, cognitive decline, and early puberty. However, etiology may also include other causes different than hypothalamic hamartomas. The seizure may also arise from temporal and frontal region, in addition to hypothalamus. Different clinical findings may be observed based on origin and areas of spread. CONCLUSIONS: In this article, we report a case of gelastic seizure that has been observed by a different cause other than hypothalamic hamartoma which was reported for the first time in the literature.

Stent-Assisted Coil Embolization of Posttraumatic Dissecting Carotid Aneurysm Causing Ophthalmoplegia.

BACKGROUND: Ophthalmoplegia secondary to a traumatic dissecting aneurysm in the cavernous segment of internal carotid artery (ICA) is a relatively rare entity. Anticoagulant or antiplatelet therapy is the preferred treatment option for carotid dissections. However, endovascular interventions are noninvasive and alternative methods to surgery, especially in cases of aneurysms that do not respond to medical therapy. CASE REPORT: We report of a 19-year-old man presenting with left-sided, total ophthalmoplegia after a traffic accident. Magnetic resonance imaging (MRI) and digital subtraction angiography (DSA) revealed a dissection beginning at the cervical segment of internal carotid artery (ICA) together with a dissecting aneurysm in the cavernous segment. A stent was placed in the narrowed and dissected segment of ICA, and the dissecting aneurysm of the cavernous segment was successfully managed with a stent-assisted coil embolization. After the endovascular treatment of the aneurysm, a full recovery of cranial nerve function was achieved. CONCLUSIONS: Immediate diagnosis and appropriate therapy of dissecting aneurysms is necessary for good clinical outcomes in cases of ophthalmoplegia.

Bilateral thalamic lesions: A pictorial review.

Bithalamic lesions are uncommon, however, both focal and systemic disorders may present bilateral abnormalities in the thalamus in different acute and chronic clinical situations. Neuroimaging, in particular magnetic resonance imaging, plays an essential role in diagnostic approach. Imaging features such as signal alterations, diffusion restriction or contrast enhancement are helpful in characterization of these abnormalities. The location of the lesions may provide key information because some pathologies typically involve a certain part of the thalamus. In addition to thalamic findings, neuroimaging findings in other parts of the brain associated with the clinical and laboratory information should be taken into account to make a correct diagnosis.

Ruptured superior gluteal artery pseudoaneurysm with hemorrhagic shock: Case report.

Pseudoaneurysm of the superior gluteal artery (SGA) is very rare and the most common causes are blunt or penetrating pelvic traumas. Although pseudoaneurysm can be asymptomatic at the time of initial trauma, it can be symptomatic weeks, months, even years after initial trauma. We present a case of a ruptured superior gluteal artery pseudoaneurysm with hemorrhagic shock twenty days after a bomb injury in the Syria civil war. In addition, we review the anatomy of the SGA, clinical presentation and pitfalls of pseudoaneurysm, and imaging and treatment options.

Comparison of diagnostic accuracy of Doppler USG and contrast-enhanced magnetic resonance angiography and selective renal arteriography in patients with atherosclerotic renal artery stenosis.

BACKGROUND: There are many systemic complications of conventional selective renal arteriography (SRA), such as contrast-mediated nephropathy. Contrast-enhanced magnetic resonance angiography (CE-MRA) and renal artery Doppler ultrasonography (DUSG) have been used increasingly for renal artery stenosis (RAS). The aim of this study was to evaluate the accuracy of CE-MRA and DUSG as used for diagnosis of RAS. MATERIAL AND METHODS: We divided 130 consecutive patients investigated for resistant hypertension into 2 groups based on age: group 1 was patients <60 years old and group 2 was patients >60 year. DUSG, CE-MRA, and SRA were performed in group 1 and group 2 patients. RESULTS: Seventy-two patients (24 males [M], 48 females [F]) in group 1, and 58 patients (26 M, 32 F) in group 2 were included in the study. In the evaluation of clinically significant renal artery stenosis with DUSG, in group 1 the overall sensitivity was 83.33% and overall specificity was 81.82%, and in group 2 they were 69.23% and 0%, respectively, when compared with SRA. In the evaluation of clinically significant renal artery stenosis with CE-MRA, the overall sensitivity and specificity were 92.31% and 36.36%, respectively, in group 1 and 100.00% and 73.33%, respectively in group 2, when compared with SRA. CONCLUSIONS: CE-MRA is an accurate, non-invasive method for the diagnosis of RAS in patients above 60 years of age and DUSG may be the choice of diagnostic method for RAS in patients under 60 years of age.

The effect of insulin therapy on biomechanical deterioration of bone in streptozotocin (STZ)-induced type 1 diabetes mellitus in rats.

AIMS: To investigate the effect of insulin therapy on biomechanical properties of bone in streptozotocin (STZ)-induced type 1 diabetes mellitus (T1DM) in rats. METHODS: A total of 28 male Wistar-Albino rats (12-week-old; 210-300g) were divided into 4 groups (n=7 for each) including control [C; no treatment], sham [Sh; distilled water i.p., for 8 weeks], diabetes [T1DM; 65mg/kg of STZ, single i.p.] and diabetes+insulin treatment [T1DM+I; 65mg/kg of STZ, single i.p.+insulin; 2-4UI/day/rat, i.p., for 8 weeks] groups. Body weight, blood glucose levels (BGLs), bone mineral density (BMD) and geometric/mechanical properties of bone tissue were evaluated. RESULTS: BGLs in diabetic rats were significantly increased compared to non-diabetic rats, while the body weights were decreased (p<0.05). Femur length and cross-sectional area of femur were significantly decreased in both T1DM and T1DM+I groups (p<0.05). The significant reduction obtained in BMD in T1DM rats compared with C and Sh (p<0.05) groups was reversed by insulin treatment (p<0.05). Displacement, absorbed energy, maximum load, ultimate stress and toughness were significantly decreased inT1DM and T1DM+I groups compared to C and Sh groups (p<0.05). CONCLUSIONS: In conclusion, insulin treatment seems to be ineffective in restoration of biomechanical deterioration of bone specific to STZ-induced T1DM.

Development of high-output heart failure after correction of central venous occlusion: a case report.

Temporary or permanent central venous catheter (CVC) insertion has been performed frequently for hemodialysis treatment. One of the most important long-term complications of CVC is the central venous occlusion (CVO). Treatment of CVO consists of percutaneous angioplasty (PTA), PTA and stent implantation, or surgical procedure for resistant occlusions. Clinical outcome and long-term results of the revascularization procedures are well documented. However, there is no clear information about acute medical complications of the procedures. High-output heart failure (HOHF) is associated with several diseases including chronic anemia, psoriasis, systemic arteriovenous fistula, sepsis, hypercapnia, multiple myeloma, and hyperthyroidism. Herein, we report a case of chronic kidney disease with CVO that developed acute HOHF immediately after the revascularization procedure (PTA and stenting).

Deterioration of bone quality by streptozotocin (STZ)-induced type 2 diabetes mellitus in rats.

Patients with diabetes mellitus (DM) have various skeletal disorders and bone quality can be impaired in DM leading to fractures. Wistar albino male rats (270-300 g; n = 16) were assigned randomly to nondiabetic and diabetic rats (single dose intravenous injection of 45 mg/kg streptozotocin). All rats in each group were perpetuated for 8 weeks, and blood glucose levels as well as body weights were measured once weekly. Biomechanical measurements were performed at the mid-diaphysis of the left femur with tensile test. Extrinsic and intrinsic properties were measured or calculated. Bone mineral density (BMD) was also evaluated and measured by dual-energy X-ray absorptiometry. Cross-sectional area of the femoral shaft was evaluated by computerized tomography. Blood glucose levels in diabetic rats were significantly increased compared to that of the nondiabetic rats, while the body and femur weights were decreased (P < 0.05). In respect to the BMD, cross-sectional area and femur length, there were no statistically significant differences between the nondiabetic and diabetic rats (P > 0.05). The maximum load, ultimate stress, and toughness endpoints in diabetic rats were significantly decreased compared to that of the nondiabetics (P < 0.05). There were no statistically significant differences between the nondiabetic and diabetic rats with regard to the displacement and stiffness (P > 0.05). Femurs of diabetic rats had less absorbed energy than that in nondiabetics (P < 0.05). Ultimate strain was lower in diabetic rats than that in nondiabetics, while the elastic modulus was higher (P > 0.05). The bone quality of rats is decreased by streptozotocin-induced type 2 diabetes mellitus.

Ectopic kidney with varied vasculature: demonstrated by CT angiography.

An ectopic kidney was found incidentally in a 20-year-old male patient during the abdominopelvic CT angiography. It was situated on the right side at the abdominopelvic junction, partly in the abdomen at the level of the intervertebral disc between L3 and L4 superiorly and partly in the greater pelvis at the level of the promontorium and close to the inferior border of the sacroiliac joints. It was supplied by two arteries which were nearly in the same caliber, and each of which branched from the common iliac arteries both close to the aortic bifurcation. There were two renal veins. The larger one which was emerging from the lateral part of the ectopic kidney was draining into the inferior vena cava. The smaller one which was the only hilar vessel of the ectopic kidney was draining into the left common iliac vein. The orthotopic left kidney was also supplied by two arteries from the abdominal aorta. Ectopic kidneys pose a problem for any planned surgical intervention given their anomalous blood supply. Ectopic position and varied vasculature can predispose to iatrogenic trauma during interventional radiological and laparoscopic procedures, and emergency operations.

Successful treatment of enterocutaneous fistula in a hemodialysis patient with somatostatin.

Although cysticercosis is the most common parasitic disease affecting the central nervous system, spinal cysticercosis is rare. A rare form of spinal cysticercosis involving the whole spinal canal is presented. A 45-year-old Korean male had a history of intracranial cysticercosis and showed progressive paraparesis. Spinal magnetic resonance scan showed multiple cysts compressing the spinal cord from C1 to L1. Three different levels (C1-2, T1-3, and T11-L1) required operation. Histopathological examination confirmed cysticercosis. The patient improved markedly after surgery.

An extremely rare bifurcation pattern of the caudal abdominal aorta: case report demonstrated by angiography.

An extremely rare bifurcation pattern at the caudal abdominal aorta was encountered on the pelvic angiography and MR angiography of a male patient. Instead of dividing into two common iliac arteries, the caudal abdominal aorta first gave the right external iliac artery at the level of the last lumbar arteries, then bifurcated into a right internal iliac artery and a left common iliac artery. The median sacral artery originated at this anomalous bifurcation. This high origin of the right external iliac artery and separate branching of these right iliac vessels from the abdominal aorta are important during the interventions in the region. We present the angiography findings and discuss the embryological origin of this unusual and unreported congenital anomaly.

Deterioration of bone quality by long-term magnetic field with extremely low frequency in rats.

The aim of our study was to investigate the effects of long-term (45 days) magnetic field (50 Hz, 1 mT; MF) on femur biomechanical parameters of rats. Bone mineral density (BMD) and histological investigation were also evaluated. For this purpose, twenty-four 8-week-old, Wistar-Albino female and male rats were assigned randomly to female control (FC) and MF-exposed rats (F-MF); male control (MC) and MF-exposed rats (M-MF). BMD was measured by dual-energy X-ray absorptiometry. Cross-sectional area of the femoral shaft was evaluated by computerized tomography. Biomechanical measurements were performed at the mid-diaphysis of the left femur with tensile test. Maximum load, displacement, stiffness, energy absorption capacity (structural properties); ultimate stress, ultimate strain, elastic modulus and toughness (material properties) were calculated. Diaphysial cortical bone thickness was measured by using histological method from the right femur. In respect to the cortical thickness of the rats' femurs, there was statistically significant interaction between the gender and group (P<0.05), while the BMD and cortical area were not (P>0.05). The BMD, cortical thickness and area values of the femurs of MF-exposed rats (F-MF, M-MF) were significantly decreased in comparison to that of the controls (FC, MC) (P<0.05). There were no statistically significant differences between the control and the MF-exposed rats in respect to the femur length (P>0.05). There were no statistically significant interaction between the gender and group with regard to the maximum load, displacement, stiffness, ultimate stress, ultimate strain, elastic modulus and toughness endpoints, while the energy absorption capacity was significant (P<0.05). Maximum load, displacement and stiffness values of MF-exposed rats were significantly decreased compared to that of the controls (P<0.05). Femurs of M-MF rats had less absorbed energy than that in controls (P<0.05). Ultimate stress and elastic modulus parameters were significantly decreased in MF-exposed rats in comparison to that of the controls (P<0.05). Ultimate strain was higher in MF-exposed rats than that in controls (P>0.05). The mean of toughness was decreased in MF-exposed rats compared to that of the controls (P>0.05). In conclusion, the bone quality of rats is decreased by magnetic field exposure.

[Determining the biomechanical quality of normal and osteoporotic bones in rat femora through biomechanical test and finite element analysis]. / Normal ve osteoporotik siçan femurunda kemigin biyomekanik kalitesinin biyomekanik testle ve sonlu elemanlar analizi ile belirlenmesi.

OBJECTIVES: This study aimed to determine the biomechanical quality of cortical bone in normal and osteoporotic rat femora with the use of biomechanical analysis and finite element analysis. METHODS: Fourteen young adult female Sprague-Dawley rats weighing 225-250 g were randomized into two groups equal in number. One group underwent bilateral ovariectomy under ketamine anesthesia. Fourteen weeks after ovariectomy, bone mineral density was measured by dual energy X-ray absorptiometry in two groups and the rats were sacrificed under high-dose ketamine anesthesia for removal of all the femora. The right femora were subjected to biomechanical tension tests. In the left femora, cortical bone sections were visualized by computed tomography and finite element analysis was performed on computer-generated three dimensional images using the ANYSIS 9.0 software. Deformation, stress, and strain values obtained by the two analyses were compared. RESULTS: Compared to the control group, bone mineral density decreased by 29%, and decreases in deformation, stress, and strain values were 39%, 51%, and 64%, respectively, in the ovariectomized rats (p<0.05). No significant differences were found between the results of biomechanical measurements and finite element analysis (p>0.05). CONCLUSION: Our data suggest that finite element analysis can be used in vivo to determine biomechanical quality of bone in osteoporotic patients.

Paraganglioma of the skull base: a case report.

Paragangliomas are rare benign neuroendocrine tumors derived from the extra-adrenal paraganglia of the autonomic nervous system. Here, we described a new case of a 75-year-old woman with paraganglioma arising in the middle and posterior cranial fossa with extended destruction of the skull base and clivus. She was admitted to our department with the complaint of severe respiratory distress due to vocal cord paralysis. We discussed its clinical, radiological, histopathological features and treatment modalities in the light of the current literature.

Low-exposure cadmium is more toxic on osteoporotic rat femoral bone: mechanical, biochemical, and histopathological evaluation.

This study aimed to investigate the effects of low-exposure Cd on normal and osteoporotic bone. For this purpose, 12-week-old Sprague-Dawley female rats were assigned randomly to a control group, a Cd group, and an ovariectomy (OVX)+Cd group. OVX+Cd rats underwent bilateral ovariectomy via ventral incision. Twelve weeks after ovariectomy, cadmium chloride (CdCl(2)) was given to rats (Cd and OVX+Cd groups) as intraperitoneal (ip) injection of 0.5mg/kg three times a week for 18 weeks and distilled water was given to control group via ip route for 18 weeks. Bone mineral density (BMD) was measured at mid-diaphysis femoral region by dual-energy X-ray absorbsiometry. Cross-sectional area of the femoral shaft was evaluated by computerized tomography. Biomechanical measurements were performed at the mid-diaphysis of the left femur. Collagen fibers were evaluated at light microscopic level. BMD, cortical thickness, cortical area, and femur length were not changed in Cd and OVX+Cd groups in comparision to controls. In the OVX+Cd group, strength, displacement, energy, stress, strain, and toughness were significantly lower than those of the control group. The Cd concentration of bone was significantly increased in the OVX+Cd group compared to that in the control group. Collagen fiber intensity was decreased in all groups except control group. The results of the present study indicate that the administration of low-dose Cd does not affect normal bone biomechanical parameters, but it has a significant effect on osteoporotic bone.