Interobserver variability in retreatment decisions of recurrent and residual aneurysms.

BACKGROUND AND PURPOSE: The degree of variation in retreatment decisions for residual or recurrent aneurysms among endovascular therapists remains poorly defined. We performed a multireader study to determine what reader and patient variables contribute to this variation. MATERIALS AND METHODS: Seven endovascular therapists (4 neuroradiologists, 3 neurosurgeons) independently reviewed 66 cases of patients treated with endovascular coil embolization for ruptured or unruptured aneurysm. Cases were rated on a 5-point scale recommending for whether to retreat and a recommended retreatment type. Reader agreement was assessed by intraclass correlation coefficient and by identifying cases with a "clinically meaningful difference" (a difference in score that would result in a difference in treatment). Variables that affect reader agreement and retreatment decisions were examined by using the Wilcoxon signed-rank test, Pearson χ(2) test, and linear regression. RESULTS: Overall interobserver variability for decision to retreat was moderate (ICC = 0.50; 95% CI, 0.40-0.61). Clinically meaningful differences between at least 2 readers were present in 61% of cases and were significantly more common among neuroradiologists than neurosurgeons (P = .0007). Neurosurgeons were more likely to recommend "definitely retreat" than neuroradiologists (P < .0001). Previously ruptured aneurysms, larger remnant size, and younger patients were associated with more retreat recommendations. Interobserver variability regarding retreatment type was fair overall 0.25 (95% CI, 0.14-0.41) but poor for experienced readers 0.14 (95% CI, 0-0.34). CONCLUSIONS: There is a large amount of interobserver variability regarding the decision to retreat an aneurysm and the type of retreatment. This variability must be reduced to increase consistency in these subjective outcome measurements.

Recurrent intracranial stenosis induced by the Wingspan stent: comparison with balloon angioplasty alone in a single patient.

We present a case in which angioplasty alone and stent-assisted angioplasty were performed in the same patient to treat medically refractory intracranial stenoses. This elderly patient with presumed intracranial atherosclerotic disease underwent angioplasty alone for his anterior cerebral artery stenosis. Stent-assisted angioplasty was used for treatment of his ipsilateral middle cerebral artery stenosis. Follow-up angiography at 4 months documented severe recurrent stenosis confined only to the stented portion of the middle cerebral artery.

Transorbital puncture for the treatment of cavernous sinus dural arteriovenous fistulas.

This report describes a series of patients for whom dural arteriovenous fistulae (DAVFs) of the cavernous sinus were successfully embolized using a percutaneous, transorbital technique to directly cannulate the cavernous sinus. A vascular access needle and catheter are percutaneously advanced along the inferolateral aspect of the orbit to access the cavernous sinus via the superior orbital fissure. Safe and effective embolization is achieved without the need for a surgical cut-down.

Balloon-assisted coiling of intracranial aneurysms: evaluation of local thrombus formation and symptomatic thromboembolic complications.

BACKGROUND AND PURPOSE: Remodeling balloons are used to assist in endovascular coiling of aneurysms. We evaluated our experience with balloon-assisted coiling (BAC) in an attempt to determine whether this technique increased the rate of thrombus formation or symptomatic thromboembolic complications. MATERIALS AND METHODS: In 3 years, we treated 221 patients with intracranial aneurysms. Statistical analysis was performed to assess whether BAC increased the rate of thrombus formation or symptomatic thromboembolic complications. Patient demographics, aneurysm size, location, neck width, antiplatelet therapy, and rupture status were evaluated. RESULTS: We detected no statistically significant difference in rates of thrombus formation (14% versus 9% with and without BAC, respectively, P=0.35) or symptomatic thromboembolic events (7% versus 5% with and without BAC, respectively, P=0.76), though our power to detect small differences was limited. There was also no correlation with age, sex, rupture status, aneurysm size, or location. There was a significant increase in the rates of thrombus formation (6% versus 16%, P=0.02) and symptomatic thromboembolic complications (3% versus 10%, P=0.04) in aneurysms that were classified as narrow- or wide-necked, respectively. The use of clopidogrel was associated with a decrease in the rate of complications (P=0.01). CONCLUSION: In this series, we detected no significant increase in the rates of either intraprocedural thrombus formation or symptomatic thromboembolic events in patients treated with BAC. Larger studies are required to confirm our observations. Wide-necked aneurysms were independently associated with increased rates of thrombus formation and symptomatic thromboembolic complications, whereas the use of clopidogrel was protective (P=0.01).

Endovascular treatment of epistaxis in patients with hereditary hemorrhagic telangiectasia.

BACKGROUND AND PURPOSE: The treatment of epistaxis in patients with hereditary hemorrhagic telangiectasia can be very challenging. The purpose of our study was to evaluate our experience with endovascular epistaxis embolization in patients with hemorrhagic hereditary telangiectasia and to compare this with our experience in patients treated for idiopathic epistaxis. MATERIALS AND METHODS: Over a 6-year period, we treated 22 patients with epistaxis by using endovascular embolization. Twelve of 22 patients had hereditary hemorrhagic telangiectasia; 10 patients had idiopathic epistaxis. The angiographic findings, efficacy of treatment, and complications for both groups were compared. RESULTS: Patients with hereditary hemorrhagic telangiectasia had angiographic abnormalities in 92% of cases compared with only 30% in the idiopathic epistaxis group. Compared with a group of 10 patients treated for other causes of epistaxis, those with hereditary hemorrhagic telangiectasia required significantly more re-embolization treatments or additional surgical procedures because of continued or recurrent bleeding episodes after embolization (P=.03). Complications were rare; a single patient in the idiopathic epistaxis group had a self-limited groin hematoma and postembolization facial pain. CONCLUSION: Endovascular embolization of epistaxis is a safe procedure that can be useful for patients with severe acute epistaxis or chronic persistent bleeding. Patients who undergo endovascular embolization for epistaxis related to hereditary hemorrhagic telangiectasia require repeat embolization and subsequent surgical procedures more often than those with idiopathic epistaxis.

Vertebroplasty, first 1000 levels of a single center: evaluation of the outcomes and complications.

BACKGROUND AND PURPOSE: Percutaneous polymethylmethacrylate (PMMA) vertebroplasty has become a common procedure for treatment of pain and disability associated with vertebral compression fractures. We reviewed the experience with our first 1000 consecutively treated vertebral compression fractures in an attempt to demonstrate both the short- and long-term safety and efficacy of percutaneous vertebroplasty. MATERIALS AND METHODS: The first 1000 compression fractures treated by vertebroplasty at our institution were identified from a comprehensive prospectively acquired vertebroplasty data base. All patients treated with vertebroplasty were included, regardless of the underlying pathologic cause. Chart reviews of the procedure notes, imaging studies, clinical visits, and follow-up telephone interviews were performed for each patient. Evaluation at each follow-up time point included pain response (subjective and visual analog pain score), change in mobility, change in pain medication usage, and modified Roland-Morris Disability Questionnaire. Statistical analysis was performed on the pain response and change in the Roland-Morris score at each follow-up time point. Significant procedure-related complications that occurred from the time of the procedure were also specifically extracted from the patients' charts. RESULTS: There was a dramatic improvement in all the evaluated parameters following percutaneous vertebroplasty. The improvement in pain, mobility, medication usage, and Roland-Morris score was noticed immediately after the procedure and persisted through the 2-year follow-up. There was a low rate of complications from the procedure, the most common being rib fractures. CONCLUSION: According to our results, practitioners can quote a high success rate and low complication rate for vertebroplasty when making treatment recommendations for painful spinal compression fractures.

Follow-up MR imaging in patients with pyogenic spine infections: lack of correlation with clinical features.

BACKGROUND AND PURPOSE: Follow-up MR imaging examinations are increasingly used to monitor response to treatment in patients with spine infection. We aim to describe follow-up MR imaging examination findings 4-8 weeks after diagnosis and initiation of treatment of spine infections and to compare with clinical findings. MATERIALS AND METHODS: Thirty-three patients with spinal infection and available baseline and 4-8-week follow-up MRIs were included in this retrospective cohort study. Baseline and follow-up MR imaging were graded by 2 neuroradiologists blinded to clinical characteristics and outcome. Clinical findings and outcomes were independently obtained by retrospective review of the medical record. RESULTS: Compared with baseline MR imaging examinations, follow-up MR imaging more frequently demonstrated vertebral body loss of height (26/33 [79%] versus 14/33 [47%]; P < .001) and less frequently demonstrated epidural enhancement (19/32 [59%] versus 29/33 [88%]; P = .008), epidural canal abscess (3/32 [9%] versus 15/33 [45%]; P = .001), and epidural canal compromise (10/32 [31%] versus 19/33 [58%]; P = .008). Most follow-up MR imaging examinations demonstrated less paraspinal inflammation and less epidural enhancement compared with baseline. However, vertebral body enhancement, disk space enhancement, and bone marrow edema more often were equivocal or appeared worse compared with baseline. Twenty-one of 32 (66%) follow-up MR imaging examination overall grades were considered improved, 5 (16%) were equivocal, and 6 (19%) were worse. No single MR imaging finding was associated with clinical status. CONCLUSION: Soft tissue findings, not bony findings, should be the focus of clinicians interpreting follow-up MR imaging results. No single MR imaging parameter was associated with the patients' clinical status.

Outcomes of patients receiving long-term corticosteroid therapy who undergo percutaneous vertebroplasty.

BACKGROUND AND PURPOSE: The purpose of this study was to determine the efficacy and rate of complications in patients undergoing percutaneous vertebroplasty (PVP) for vertebral compression fractures as a result of secondary osteoporosis caused by long-term corticosteroid use compared with patients with primary osteoporosis treated with PVP. MATERIALS AND METHODS: A retrospective review of all patients undergoing PVP was conducted to identify patients who also received long-term corticosteroid therapy. Outcomes including pain, periprocedural complications, and frequency of new fractures in patients receiving corticosteroids were compared with control patients undergoing PVP for primary osteoporosis. RESULTS: Sixty-eight patients receiving long-term corticosteroid therapy underwent 79 PVP procedures. Patients treated with corticosteroids undergoing PVP were significantly younger and more likely to be male compared with control subjects. Patients receiving long-term corticosteroid treatment experienced significant pain relief immediately postprocedure and at 1 week, 1 month, 6 months, 1 year and 2 years postprocedure (P < .0001 at all time points). Patients receiving corticosteroids experienced similar decreases in pain from baseline compared with control subjects at all follow-up time points (P > .05). The complication rate for patients receiving corticosteroids was 4.4% compared with 3.4% for control subjects (P = .60). Patients on long-term corticosteroid treatment did not have an increased risk of new fractures after PVP compared with control subjects (P = .68). CONCLUSIONS: Percutaneous vertebroplasty performed for vertebral compression fractures as a result of long-term corticosteroid therapy is as safe and effective in relieving pain as PVP performed in patients with vertebral compression fractures as a result of primary osteoporosis.

Use of the ulnar artery as an alternative access site for cerebral angiography.

Although the common femoral artery is the easiest and most widely accepted access site for cerebral angiography, atherosclerotic, aortoiliac, or femoral artery disease can preclude this approach. We describe our experience using the ulnar artery access site in a patient with bilateral aortoiliac occlusive disease. This article may be useful to neuroradiologists who encounter difficulty with other arterial access sites. A description of the technique and a review of the pertinent literature are provided.

Acute vertebral compression fractures in patients with multiple myeloma: evaluation of vertebral body edema patterns on MR imaging and the implications for vertebroplasty.

The presence of edema on MR imaging is a common finding in acute or subacute vertebral body compression fractures. Compression fractures can present in patients with benign osteoporosis, metastases, multiple myeloma, or hemangiomas. We present 2 patients with multiple myeloma who had symptomatic acute and subacute compression fractures documented on imaging studies without associated edema on MR imaging evaluation.

Bovine aortic arch variant in humans: clarification of a common misnomer.

The term "bovine arch" is widely used to describe a common anatomic variant of the human aortic arch branching. This so-called bovine aortic arch has no resemblance to the bovine aortic arch. We describe the most common human aortic arch branching patterns and compare these with the bovine aortic arch.

Subsequent vertebral fractures after vertebroplasty: association with intraosseous clefts.

BACKGROUND AND PURPOSE: Patients with vertebral fractures containing intraosseous clefts may represent a distinct subgroup of vertebroplasty patients, yet the development of subsequent vertebral fractures in this population has not been explored. We tested the hypothesis that after vertebroplasty for intraosseous clefts, subsequent fractures would occur earlier and more frequently than after treatment of non-cleft-containing fractures. METHODS: We retrospectively reviewed 362 patients treated with vertebroplasty for osteoporotic fractures. The location, frequency, and timing of subsequent fractures were compared between 2 subgroups: group 1, patients treated at fractures containing clefts, and group 2, treated patients without clefts. A vertebra-by-vertebra analysis was used to compare the relative risk and timing of subsequent fractures adjacent to vertebrae with or without clefts. RESULTS: Group 1 included 63 patients treated at 65 vertebrae and group 2 included 250 patients treated at 399 vertebrae. Group 1 demonstrated a nearly twofold increased risk of subsequent fracture (odds ratio [OR], 1.90; 95% confidence interval [CI], 1.04-3.49, P = .037). At the vertebral level, the relative risk of subsequent fracture was 2.02 (95% CI, 1.46-2.58; P = .013) times greater adjacent to a treated cleft. Fractures adjacent to any treated level occurred significantly sooner than nonadjacent fracture (P = .0004). The presence of a cleft was not significantly associated with the timing of subsequent fractures. CONCLUSIONS: Patients with osteoporotic vertebral fractures containing clefts are at increased risk for subsequent fractures and treatment of these clefts is associated with increased rates of adjacent fracture. There is no significant difference in the timing of subsequent fractures based on the presence of a cleft.

The radial artery access site for interventional neuroradiology procedures.

The radial artery access site offers many advantages in neuroangiography. Right vertebral artery access is readily obtained from a right radial artery approach. As with cardiology procedures, neuroradiology procedures may necessitate the use of lytic therapy or platelet inhibitors. Sheath removal can be done without reversal of anticoagulation or concerns about major bleeding complications. We report our experience in using the radial artery access site for interventional neuroradiology cases. Practical considerations and technical details are offered.

Radiation exposure to the primary operator during endovascular surgical neuroradiology procedures.

Endovascular surgical neuroradiologists can receive a substantial amount of occupational radiation exposure. We evaluated the amount of radiation exposure that results from the practice of performing hand injections during digital subtraction angiography (DSA). The primary operator can significantly decrease the radiation dose by leaving the room for DSA procedures. However, the total radiation dose for the primary operator is relatively low and is certainly within allowable regulatory limits when extrapolated to a yearly dose.

Transarterial coil embolization of the venous component of aggressive type 4 dural arteriovenous fistulas.

We report 2 patients with aggressive intracranial dural arteriovenous fistulae that were repaired via percutaneous, transarterial coil embolization of the venous outlets.

A modified vertebroplasty approach for spine biopsies.

There are various techniques available for percutaneous biopsy of suspected diskitis/osteomyelitis. Our technique has evolved as our experience with percutaneous vertebroplasty has grown. By using a transpedicular approach, we angle a bone biopsy needle in an exaggerated caudocranial trajectory to allow eventual access across the disk space above. This approach permits sampling of the disk space, as well as both adjacent vertebral endplates. We describe our percutaneous modified vertebroplasty approach for biopsy of suspected diskitis/osteomyelitis.

Percutaneous sacroplasty using CT fluoroscopy.

Sacral insufficiency fractures frequently cause significant pain and limit activities of daily living in patients with osteoporosis. Percutaneous vertebroplasty is a common procedure to alleviate the pain associated with thoracic and lumbar vertebral compression fractures. The sacral percutaneous vertebroplasty procedure (sacroplasty) has recently been introduced as an alternative to medical management of osteoporotic sacral insufficiency fractures. We describe our CT fluoroscopy technique in performing percutaneous sacroplasty.

Cerebral Aneurysm Perforations during Treatment with Detachable Coils. Use of Remodelling Balloon Inflation to Achieve Hemostasis.

SUMMARY: Perforation of intracranial aneurysms during endovascular treatment with platinum microcoils is a well-known and serious complication reported to occur in 2-4% of patients. Inflation of a remodelling balloon across the aneurysm neck or within the proximal parent vessel is an additional technique that theoretically might be useful to reduce flow within the aneurysm and achieve hemostasis. In the case reports that follow, we present our experience using this technique for managing intraprocedural aneurysm rupture.

Angioplasty of an idiopathic intracranial arterial stenosis.

SUMMARY: Treatment of symptomatic intracranial atherosclerotic stenosis usually involves maximizing medical therapy. In patients with medically refractory symptoms despite maximum pharmacologic therapy, intracranial angioplasty and/or stenting has become an accepted treatment option. The use of percutaneous transluminal angioplasty (PTA) for idiopathic intracranial stenoses has not been reported to date.We describe a case of idiopathic intracranial stenosis which was refractory to medical therapy and was successfully treated with percutaneous transluminal angioplasty. The presenting symptoms included multiple episodes of aphasia and right-sided weakness as well as a left basal ganglia infarct. The patient underwent treatment with two intracranial angioplasty procedures. There was a recurrence of the stenosis and symptoms following the first procedure. However, after a second treatment with a slightly larger balloon, flow in the MCA normalized. Furthermore, the symptoms attributed to her MCA stenosis had essentially resolved. This case suggests that patients with medically refractory idiopathic intracranial stenosis can be successfully treated with percutaneous transluminal angioplasty.