Endoscopic third ventriculostomy in an infant with vein of Galen aneurysmal malformation treated by endovascular occlusion: Case report and a review of literature.

INTRODUCTION: Vein of Galen aneurysmal malformations (VGAMs) can, through multiple mechanisms, complicate with hydrocephalus (HCP). It is generally agreed that management strategies in this scenario should focus on endovascular embolizations. Treatment options for non-responders, however, have been only scarcely reported upon. CASE PRESENTATION: We present a nine-month-old boy with a mural type VGAM complicated by HCP. Despite endovascular occlusion of the sole feeder, the child exhibited hydrocephalus progression prompting an Endoscopic Third Ventriculostomy (ETV). This procedure restored a cerebrospinal fluid (CSF) circulation otherwise impaired by aqueduct obstruction. Later, a new feeder arose and a second embolization was ultimately needed in order to achieve VGAM regression. Throughout four years of follow up, the child attained all developmental marks. DISCUSSION/CONCLUSION: VGAMs are prone to hydrocephalus development as there is both an underlying venous congestion and a mechanical, obstructive component. Although there is a rationale for addressing both components, the underlying AV shunts and subsequent venous pressure elevations usually determine failure of traditional CSF shunting strategies. It is therefore challenging to manage HCP in patients who failed to improve following endovascular embolizations. For such cases, ETV stands as an elegant minimal invasive alternative with potential to provide a more physiologic drainage route and thus better allow for neurological development.

Torcular dural sinus malformations: a single-center case series and a review of literature.

INTRODUCTION: Torcular dural sinus malformations (tDSMs) are rare vascular pathologies with various anatomoclinical pictures and prognosis. We analyzed our case series and corroborated the complexity of this rare unit by a review of literature. CASE SERIES: From 2003 to 2018, we treated four tDSMs patients. The evolution of three postnatally diagnosed cases of similar angioarchitecture contrasted with a fourth antenatally diagnosed case with significant torcular thrombosis. All patients were examined by computed tomography, magnetic resonance imaging, CT angiography, and MRI angiography. Three patients underwent digital subtraction angiography with embolization of feeders. Unusual pathological images were depicted. CONCLUSIONS: Early diagnosis along with embolization of feeders and lake could improve the outcome for tDSM patients with dural arteriovenous shunts. Ventriculoperitoneal shunt implantation before endovascular treatment led to significant worsening of both clinical presentation and MRI picture. For patients who persist with hydrocephalus despite the endovascular approach, we suggest endoscopic third ventriculostomy as a first-line treatment option. Antenatally diagnosed patients with thrombosed lakes constitute a prognostically better group of patients. Spontaneous thrombosis and remodelation of the lake can, however, still leave neurological sequelae, as observed in our patient.

Endovascular treatment of acute basilar artery occlusion: time to treatment is crucial.

AIM: To evaluate the safety and efficacy of multimodal endovascular treatment (EVT) of acute basilar artery occlusion (BAO), including bridging therapy [intravenous thrombolysis (IVT) with subsequent EVT], to compare particular EVT techniques and identify predictors of clinical outcome. MATERIALS AND METHODS: This retrospective, multi-centre study comprised 72 acute ischaemic stroke patients (51 males; mean age 59.1 ± 13.3 years) with radiologically confirmed BAO. The following data were collected: baseline characteristics, risk factors, pre-event antithrombotic treatment, neurological deficit at time of treatment, localization of occlusion, time to therapy, recanalization rate, post-treatment imaging findings. Thirty- and 90-day outcomes were evaluated using the modified Rankin scale with a good clinical outcome defined as 0-3 points. RESULTS: Successful recanalization was achieved in 94.4% patients. Stepwise binary logistic regression analysis identified the presence of arterial hypertension (OR = 0.073 and OR = 0.067, respectively), National Institutes of Health Stroke Scale (NIHSS) at the time of treatment (OR = 0,829 and OR = 0.864, respectively), and time to treatment (OR = 0.556 and OR = 0.502, respectively) as significant independent predictors of 30- and 90-day clinical outcomes. CONCLUSION: Data from this multicentre study showed that multimodal EVT was an effective recanalization method in acute BAO. Bridging therapy shortens the time to treatment, which was identified as the only modifiable outcome predictor.

Carotid endarterectomy and carotid artery stenting: changing paradigm during 10 years in a high-volume centre.

BACKGROUND: We analysed the results of internal carotid artery (ICA) stenosis treatment at our institution over the last 10 years according to treatment modalities (carotid endarterectomy [CEA] vs carotid artery stenting [CAS]). Furthermore, we compared our results of treatment prior to the EVA-3S study being implemented into our practice (2003-2007) and after that (2008-2012). METHOD: During the years 2003-2012, a total of 1,471 procedures were performed for ICA stenosis. CEA was done in 815 cases and CAS in 656 cases. The primary outcome was disabling stroke (mRS > 2) or myocardial infarction (MI) within 30 days after treatment. Secondary outcomes were frequency of transient ischaemic attacks (TIAs), minor strokes (stroke without impaired activities of daily living [ADL]) and any other significant complication. Comparisons of the results before and after 2008 were performed. RESULTS: Major mortality and morbidity were divided according to treatment groups; reached 1.0 % in the CEA group and 3.0 % in the CAS group, p = 0.004. Minor stroke was recorded at 1.8 % and 2.7 % in the CEA and CAS, p = 0.245. TIAs in 1.0 % (CEA) and 4.7 % (CAS), p < 0.001. Any complication in 11.9 % (CEA) and 13.3 % (CAS), p = 0.401. In the overall results (i.e. CEA and CAS together), we found in 2008-2012 a decrease of incidence of TIAs (from 30/840 to 9/631, p = 0.011) and any complications (from 120/840 to 64/631, p = 0.017). CONCLUSIONS: CEA performed in a high-volume centre is a safe procedure in properly indicated patients. In all subgroup analyses, CEA fared better than or at least of equal benefit as CAS. Since 2008, the frequency of TIAs and other complications decreased significantly. This study supports an idea of CEA being the first choice of treatment and CAS being reserved for strictly selected cases, such as re-stenosis after a previous carotid procedure, carotid dissection, ICA stenosis after radiotherapy, previous major neck surgery, contralateral cranial nerve palsy or tandem stenosis.

[Late complication of surgical repair of aortic coarctation: ruptured pseudoaneurysm of the aorta treated by thoracic endovascular aortic repair]. / Complication tardive d'un traitement chirurgical par interposition prothétique d'une coartation aortique: rupture d'un faux anévrisme anastomotique traitée par implantation endoluminale d'endoprothèse couverte.

Aortic coarctation is a frequent congenital defect requiring early surgical treatment. Late complications of these surgical procedures can be fatal as in the case of a ruptured anastomotic pseudoaneurysm. We present a case of a 49-year-old man presenting with hemorrhagic shock due to this complication who was successfully treated by endovascular techniques with implantation of two stent grafts. This case illustrates the fact that endovascular aortic repair is feasible, certainly less invasive and very efficient for this type of complication when used in an experienced center.

[Multidisciplinary cooperation in the management of serious bleedings complicating necrotizing pancreatitis--a case review]. / Multioborová spolupráce pri osetrení závazného krvácení komplikující prubeh nekrotizující pankreatitidy--kazuistika.

Acute necrotising pancreatitis is connected with a high complication rate. The most serious ones are hemorrhagic complications with bleeding from vascular structures erosions. Authors report a case of endovascular treatment of surgically untreatable lesion of portal vein. In this case stentgraft was successfully implanted to cover the erosion and stop the bleeding. Percutaneous transhepatic route was used.

[Ophthalmic complications after the embolization of the internal carotid artery--a case report]. / Ocní komplikace po embolizaci v povodí arteria carotis interna--kazuistika.

The case report concerns about a 53 years old lady with Rendu-Osler-Weber disease, who was referred to our Department with the orbital apex syndrome after embolization of the internal carotid artery (ICA) due to repeating epistaxis. Immediately after the surgical procedure concerning the left-sided ICA, the patient complained about sharp hemicrania and pain of the ipsilateral eye, and diminished vision as well. The neurological and ophthalmologic examinations found decreased vision and limited movement of the eyeball on the left side. The patient was handed over to our Department inpatient care after one week after the surgery with clinically expressed syndrome of the left orbital apex--amaurosis, ptosis, total ophthalmoplegia, and protrusion of the eyeball. During the stay in the hospital, the progression of scotomas of the visual field with remaining concentric visual field on the right side (i.e. contralateral to the procedure) was found. The central vision of the right eye remained 20/20. The patient was treated by means of corticosteroids systemically as well as locally. The signs gradually subsided; during the control stay in hospital after three weeks after the surgery, the movements were limited in the far periphery only; slight ptosis and internal ophtalmoplegia remained; no protrusion of the eyeball was present; the amaurosis of the left eye remained permanent. In the visual field of the right eye, the concentric restriction disappeared and slight depression in the nasal half of the visual field remained only.

Chordoid meningioma: presentation of two case reports, review of the literature, and plea for data standardisation.

Chordoid meningioma is a rare variant of meningioma with histological features resembling those of chordoma. This tumour should have a greater risk of recurrence and aggressive growth (WHO grade II). So far, 92 such tumours have been described in the literature. We report two cases of chordoid meningioma occurring in adult female patients. In our two patients (aged 28 and 60 years with chordoid meningioma of the convexity and left-sided outer sphenoid wing, respectively) we centred on some rarely discussed aspects of the tumour. MRI scans showed no edema in the vicinity of either of the two meningiomas, whereas selective angiography of ACI and ACE revealed a dural type of vascular supply to the two neoplasms. In both cases, the tumour was removed by radical surgery (Simpson grade I resection) with a normal post-operative course. Both women (one 2 years post-surgery and one 4 years post-surgery) are now free from any signs of relapse on MRI and with normal neurological findings. The vascular endothelial growth factor (VEGF) expression was low in either case (5 and 40%, respectively). We regard the factors under consideration in our study (i.e. absence of edema, dural supply, low VEGF expression and radical Simpson grade I resection) as an important contribution to the discussion of the biological behaviour of chordoid meningioma.

Preoperative neuroimage findings as a predictor of postoperative neurological deficit in intracranial meningiomas.

BACKGROUND: The present study aimed to find radiological parameters that can provide indirect information on the invasive growth of meningioma relevant enough to predict the likely risk of postoperative neurological deficit. MATERIAL/METHODS: The cohort consisted of 40 consecutive adult patients (from January 2004 till May 2005) with comparable general condition parameters (age 18-75 years, KRS 70-100, ASA 1-2) with meningiomas solely attacking brain tissue with the whole of their volume. The Pearson chi-square test was used for statistical evaluation. RESULTS: Radical resection of the meningioma was attained in 33 (82.5%) patients and subtotal resection in 7 (17.5%). Ten (25%) patients at 7 days after the operation had neurological findings which were worse than before. Seven were found to have a new neurological deficit and there were three cases of progression of the existing neurological symptoms. Three patients (7.5%) were worse off neurologically than before the operation as long as 3 months after surgery, while seven had their neurological condition restored ad integrum. All of the ten patients with postoperatively worsened neurological findings had their meningiomas localised in the eloquent area. A correlation was found between the eloquent area and neurological deficits, and also between the presence of peritumoral oedema (small, medium, large) and neurological deficits. Interdependence was detected between a discernible tumour-brain interface and the absence of oedema, between a discernible tumour-brain interface and a dural type of vascular supply, and between the dural type of vascularisation and an absence of oedema. CONCLUSIONS: As follows from the outcomes, meningioma growth in the eloquent area and the presence of peritumoral oedema are the two adverse parameters predicting the development of postoperative neurological deficits. In contrast, dural types of vascularisation, a visible tumour-brain interface, meningioma growing in a non-eloquent area, and the absence of peritumoral oedema are favourable predictive parameters. To go by the results, in the presence of the last two parameters the patient need not be exposed to the risks of invasive selective angiography.

Ruptured cerebral aneurysm patients treated by clipping or coiling: comparison of long-term neuropsychological and personality outcomes.

BACKGROUND AND PURPOSE: A prospective study was conducted to compare the neuropsychological outcome of surgical versus endovascular treatment in patients with cerebral aneurysms. METHODS: From April 2001 to 2005, 211 patients with ruptured cerebral aneurysms were treated at the senior author's institution. Of these 211 patients, 75 that were able and willing to undergo neuropsychological assessment 1 year after treatment of their aneurysm were enrolled in the study. Thirty-five patients were treated surgically and 40 by endovascular therapy. Standardized neuropsychological and personality tests were employed to assess cognitive and personality functions. One neurosurgical team using the same treatment protocols treated all patients. RESULTS: The two groups of patients did not differ significantly with respect to age, gender, concurrent diseases, Hunt and Hess grade, Fisher grade, frequency of complications, vasospasms and hydrocephalus development. No differences in performance on neuropsychological and cognitive tests (AVLT, TMT and WAIS-III) and personality variables and mood scales (TCI, BDI and SMS) were found one year postoperatively. If a full IQ as defined by WAIS-III and 1SD below the mean is considered as the main measure of cognitive deficits, 5.4% of the sample suffered from cognitive deficits. There were no differences between clipped and coiled patients (t=0.03; p=0.97). CONCLUSIONS: The differences in the neuropsychological assessment of patients treated by either coiling or clipping were small and non-significant. Given the small number of patients in the study, however, we suggest the need for further research with a larger sample size and the use of a randomized design before drawing any firm conclusions.

The role of MRI in the assessment of polymyositis and dermatomyositis.

OBJECTIVES: Acute inflammation in idiopathic inflammatory myopathies (IIM) causes oedema that can be visualized by magnetic resonance imaging (MRI). The inflammatory infiltrate in IIM is thought to be frequently in a focal distribution. The aim of this study is to better evaluate the relationship of MR image of thigh muscles to clinical and histological parameters in patients with IIM. METHODS: MRI-short tau inversion recovery (STIR) technique was used to distinguish between affected and non-affected muscles. Computer tomography (CT)-controlled targeted needle biopsy was used for sampling. The intensity of muscle oedema, its extent and total assessment on MRI were evaluated with 10 cm visual analogue scale. The intensity of inflammatory infiltrate was assessed using 5-point grading system. The second MRI and muscle biopsy were performed after the time interval of treatment. RESULTS: MR scans, muscle biopsy and clinical examination were performed in 29 patients with polymyositis (PM) and dermatomyositis (DM). Paired MRI-affected and MRI-non-affected biopsy samples were obtained from 17 cases. In six cases, the biopsy was available for comparison before and after period of treatment. At the initial examination, it was the intensity of oedema on MRI that was associated with clinical status. Mean intensity of MRI findings significantly decreased in 10 patients where the MRI was available also after treatment. The mean intensity of inflammatory infiltrate in PM/DM patients was 2.5 +/- 0.7 for MRI-affected and 1.7 +/- 0.6 for MRI-non-affected muscles (P < 0.001). Mean intensity of inflammatory infiltrate in the MRI-affected muscles in the first examination (n = 6) was 2.2 +/- 0.8 and did not significantly decrease in the second examination in samples taken after the treatment (2.0 +/- 0.9). CONCLUSION: It is mainly the signal intensity in MR scan, which is associated with disease activity in the acute presentation of PM/DM. Muscle biopsy guided by positive MRI finding contains significantly more inflammatory cells than the biopsy taken from MRI non-affected sites. However, even in parts of muscles, which look unaffected on MR scan, the inflammatory cells can be found. The intensity on MR scans decreases significantly after the treatment, but the histologically detected inflammation does not change substantially.

Intracranial meningioma surgery outcome--the impact of preoperative neuroimaging.

The present study is aimed at finding radiological parameters which could provide indirect information on invasive growth of meningioma, relevant enough to predict the possible risk of postoperative neurological deficit development. The cohort was composed of 40 consecutive adult patients of comparable general condition parameters (age 18-75 years, KRS 70-100, ASA 1-2) with meningiomas attacking with the whole of their volume solely the brain tissue. As follows from the outcome, meningioma growth in the eloquent area and the presence of peritumoral oedema are the two adverse parameters predicting the development of postoperative neurological deficit. In contrast, dural type of vascularisation, visible tumour-brain interface, meningioma growing in a non-eloquent area and the absence of peritumoral oedema are favourable predictive parameters. According to our results, if the last two of those parameters are present, the patient need not to be exposed to the risks of invasive selective angiography.

[Intracranial meningiomas; standard diagnostic procedure and results of surgical treatment]. / Nitrolební meningiomy; standardní diagnostický postup a vý1sledky operacní lécby.

The aim of the study is to define radiological parameters which may indirectly indicate invasive expansion of a meningioma and thus forecast potential risks of postoperative neurological deficits. The study group includes 40 adult patients in comparable physical conditions (age 18-75, CRS 70-100, ASA 1-2) with meningiomas, affecting the brain tissue only. The results indicate that unfavorable parametres, predicting potential postoperative neurological deficits include: growth of a meningioma in eloquent regions and presence of a peritumoral oedema. Positive parametres, indicating that no neurological deficit would arise, include: dural supply, visible brain-tumor barrier, non-eloquent location of a meningioma and absence of a peritumoral oedema. The study results suggest that provided the two last parametres are present, a patient need not be exposed to risks of invasive selective angiography.

[Intracranial meningiomas--criteria for selection of the optimum therapeutic modality]. / Nitrolební meningiomy; kritéria pro výber optimální léebné modality.

The authors present their own proposal for a standard diagnostic procedure algorithm in intracranial meningiomas, which they used in their prospective, non-randomized longitudinal study in a group of 30 subjects within a year. The following four criteria were assessed in each patient: age, physical condition according the ASA classification, location of the meningioma on the MRI (superficial, the scull base) and the growth invasivity using selective DSA (ACI+ACE) and MRI (the vascularization type, the oedema index and the change in the oedema signal intensity in 3.5 hours). The criteria helped to establish the optimum therapeutic procedure for each patient: embolisation without a follow-up surgery (2 subjects), observation (2 subjects), pre-operative embolisation (5 subjects) and surgery without preceeding embolisation (21 subjects). This study did not assess the intracranial meningiomas treatment outcome. It highlights significance of the diagnostic procedures standardization in order to establish their optimum therapeutic modality.

The expression of cyclooxygenase-1, cyclooxygenase-2 and 5-lipoxygenase in inflammatory muscle tissue of patients with polymyositis and dermatomyositis.

OBJECTIVE: To describe cyclooxygenase-1 (COX-1), cyclooxygenase-2 (COX-2) and 5-lipoxygenase (5-LOX) expression in muscle tissue in patients with idiopathic inflammatory myopathies (IIM) - dermatomyositis (DM) and polymyositis (PM) and to find out if any differences between affected and non-affected muscles detected by MRI exist. METHODS: Samples of muscle tissue from 7 patients with dermatomyositis (DM) and from 4 with polymyositis (PM) were obtained by needle biopsy from affected and non-affected sites distinguished by magnetic resonance imaging. In situ hybridization with antisense mRNA probes was employed to detect COX-1, COX-2 and 5-LOX mRNA. RESULTS: Expression of COX-1, COX-2, and 5-LOX mRNA was found in all samples - in the muscle cells, inflammatory cells and in vessels. COX-1 mRNA expression predominated in the inflammatory cells and vessels and was higher in affected than in non-affected sites detected by MRI (mean intensity 3.22+/-0.67 vs. 2.0+/-0.87; p = 0.0006). The expression of COX-2 mRNA was high mainly in inflammatory cells and/or vessels and was increased in MRI-detected affected tissues (3.5+/-0.88; 1.9+/-1.1; p = 0.003), as was the expression of COX-2 mRNA in muscle cells (2.1+/-1.0 vs. 1.3+/-1.0; p = 0.021). 5-LOX mRNA was largely expressed in muscle cells from MRI-detected affected sites and the signal intensity was higher in comparison with samples taken from non-affected tissues detected by MRI (3.22+/-0.7 vs. 1.67+/-0.7; p = 0.0007). CONCLUSION: Expression of COX-1, COX-2 and 5-LOX mRNA was observed for the first time in muscle tissues from IIM patients. This expression was increased in affected tissues detected by MRI, which may suggest a role of COX-1, COX-2, and 5-LOX in the pathogenesis of IIM.

Cyclosporine A versus methotrexate in the treatment of polymyositis and dermatomyositis.

OBJECTIVE: To determine the effectiveness and tolerance of treatment with cyclosporine A (CyA) or methotrexate (MTX) added to corticosteroids in patients with severe, active polymyositis (PM) and dermatomyositis (DM). PATIENTS AND METHODS: Thirty-six patients (20 with DM, 16 with PM) were enrolled into the study and randomized in MTX (n = 17) and CyA (n = 19) groups. Muscle endurance and functional test (MEFT), clinical assessment (CA), global patient's assessment (GPA), muscle MRI, serum CK, myoglobin, IL-1Ra, and autoantibody status were used to assess the response to therapy after 1, 3, and 6 months. RESULTS: Significant improvement in MEFT, CA, GPA, and muscle MRI was found in both groups. Patients treated with MTX showed insignificantly better response than patients with CyA. CK levels in the MTX group decreased significantly after 1, 3, and 6 months, whereas a significant reduction in the CyA group was first observed after 6 months. IL-1Ra serum levels significantly dropped in the CyA group after two weeks, whereas in the MTX group the significant decrease was first seen after 3 months of treatment. Good correlation was found between each of the clinical parameters (MEFT, CA, and GPA), none of them showed any correlation with CK or IL-1Ra levels. CONCLUSIONS: Administration of MTX or CyA added to corticosteroids was associated with clinical and laboratory improvement. Changes in CK and IL-1Ra levels were not associated with parameters of clinical disease severity measured in this study.

[Comparison of the results of CT examination and surgical findings in blunt injuries of the liver and spleen]. / Porovnání záveru CT vysetrení s operacními nálezy u tupých poranení jater a sleziny.

In the course of 24 months (July 1 1996 till June 30, 1998) after CT examination of the abdomen 23 patients were subjected to laparotomy or laparoscopy as injury of the liver or spleen was assumed. Conclusions of CT are in the literature considered one of the necessary prerequisites of possible conservative treatment of the mentioned injuries, their accuracy and reliability is however not unequivocal. On comparison of the CT and surgical finding in the above patients at the time of examination the positive CT finding was correct in 17 of 19 cases, i.e. in 89%. Four patients were on count of clinical signs of intraabdominal injury operated despite a negative CT, in two of them liver injury was found in the obl. lig. falciforme. The overall accuracy was 83%. During the second assessment the overall accuracy increased to 87%. CT, using the A.A.S.T. classification underrated injury on average by 0.45 degree. In the authors' opinion CT of the abdomen is indicated in multiple injuries and severe associated injuries in case of circulatory stability as it makes it possible to examine effectively within a short time also other injured areas. It should always be made, using contrast.