Flow dynamics in acute ischemic stroke due to embolic occlusion of a fetal posterior cerebral artery treated with endovascular thrombectomy - report of two cases.

The fetal variant of the posterior cerebral artery (fPCA) conserves a major blood flow from the anterior to the posterior cerebral circulation via a strong persistent caudal portion of the embryonic internal carotid artery. We present two cases where endovascular treatment in acute ischemic stroke was complicated by this flow diversion. Though direct thrombectomy of the fPCA using a stent retriever was feasible and successful in both cases outcome remained unfavourable due to a continuous redirection of embolic material into the posterior circulation. Knowledge of flow dynamics in a fPCA is important for endovascular treatment in acute ischemic stroke.

Procedural sedation and analgesia for percutaneous trans-hepatic biliary drainage: Randomized clinical trial for comparison of two different concepts.

Procedural sedation and analgesia (PSA) is important during painful dilatation and stenting in patients undergoing percutaneous trans-hepatic biliary drainage (PTBD). A prospective, nonblinded randomized clinical trial was performed comparing different analgesic regimens with regard to the patient's comfort. Patients were randomly assigned to two treatment groups in a parallel study, receiving either remifentanil or combined midazolam, piritramide, and S-ketamine. The primary study endpoint was pain intensity before, during, and after the intervention using the numerical rating scale (0, no pain; 10, maximum pain). The secondary study endpoint was the satisfaction of the interventional radiologist. Fifty patients underwent PTBD of whom 19 (38.0%) underwent additional stenting. During intervention, the two groups did not differ significantly. After the intervention, the need for auxiliary opioids was higher (12.5% vs 7.7%; p = 0.571) and nausea/vomiting was more frequently observed (33.4% vs 3.8%; p = 0.007) in patients with remifentanil than in patients with PSA. Overall, 45 patients (90.0%) needed additional administration of non-opioid analgesics during postinterventional observation. Remifentanil and combined midazolam, piritramide, and S-ketamine obtained adequate analgesic effects during PTBD. After the intervention, medications with antiemetics and long-acting analgesics were more frequently administered in patients treated with remifentanil (EudraCT No. 2006-003285-34; institutional funding).

Anterocentral Portal in Ankle Arthroscopy.

BACKGROUND: The anterocentral portal is not a standard portal in anterior ankle arthroscopy due to its proximity to the anterior neurovascular bundle. However, it provides certain advantages, including a wide field of vision, and portal changes become redundant. The purpose of this study was to evaluate the neurovascular complications after anterior ankle arthroscopy using the anterocentral portal. METHODS: We retrospectively identified patients who had undergone anterior ankle arthroscopy with an anterocentral portal at our institution from 2013 to 2018. Medical record data were reviewed and patients were invited for clinical follow-up, where a clinical examination, quantitative sensory testing for the deep peroneal nerve, and ultrasonography of the structures at risk were performed. A total of 101 patients (105 arthroscopies) were identified and evaluated at a mean follow-up of 31.5 ± 17.7 months. RESULTS: Leading indications to surgery were heterogeneous and included anterior impingement (48.6%), osteochondral lesions of the talus (24.8%), chronic ankle instability (14.3%), and fractures (8.6%). The overall complication rate was 7.6%, and no major complications were observed. In 1.9% (2/105) of the cases, the complications were associated with the anterocentral portal and included injury to the medial branch of the superficial nerve (1/105) and to the deep peroneal nerve (1/105). Injury to the deep peroneal nerve was associated with a loss of detection and nociception. There were no injuries to the anterior tibial artery. In 41.9% (44/105) of the cases, only 1 working portal was used in addition to the anterocentral portal, and in 19% (20/105) the anterolateral portal could be avoided. Ultrasonography confirmed the integrity of the deep peroneal nerve, the medial branch of the superficial peroneal nerve, and the anterior tibial artery in all patients. Patients with nerve injuries associated with the anterocentral portal showed no signs of neuroma or pseudoaneurysm. CONCLUSION: Using a standardized technique, the anterocentral portal in ankle arthroscopy is safe with a low number of neurovascular injuries and can be recommended as a standard portal. The anterolateral portal remains associated with a high number of injuries to the superficial peroneal nerve. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Aortic stent graft placement under extracorporeal membrane oxygenation in severe multiple trauma.

Placement of an aortic stent graft under extracorporeal membrane oxygenation was the life-saving procedure in a case of severe head trauma and traumatic aortic dissection after injured by a railroad engine. Timely access to neurosurgery, heart surgery, and radiology providing minimal invasive interventions increase the chances of a favorable outcome.

Continuous intra-arterial nimodipine infusion in refractory symptomatic vasospasm after subarachnoid hemorrhage.

INTRODUCTION: Vasospasm still is a major cause of morbidity after aneurysmal subarachnoid hemorrhage. The purpose of this report is to describe the successful management of severe refractory vasospasm with continuous intra-arterial nimodipine (IAN) treatment. CASE DESCRIPTION: A 72-year old right handed woman was admitted with non-traumatic SAH WFNS grade 1. Cerebral computed tomography demonstrated thick blood filling of the basal cisterns, and intraventricular hemorrhage. Cerebral angiogram failed to detect a vascular abnormality. After an uneventful initial course the patient developed symptomatic left middle cerebral artery vasospasm with aphasia and corresponding restriction in diffusion weighted images in the left frontal lobe. Bolus IAN only transiently improved cerebral circulation and clinical signs and symptoms. Continuous-IAN was started and led to full clinical recovery and normalisation of MRI diffusion restrictions. DISCUSSION AND CONCLUSIONS: Continuous selective intra-arterial infusion of nimodipine may be an option in selected patients with symptomatic vasospasm refractory to conventional treatment after careful consideration of benefits and procedure-related risks.

The influence of gender on patency rates after iliac artery stenting.

OBJECTIVE: The purpose of this study was to investigate the influence of gender on the long-term outcome after iliac artery stenting and to assess gender-specific differences of the influence of risk factors on treatment success and patency rates. METHODS: Between January 2000 and December 2006, 404 percutaneous transluminal angioplasties with primary stent deployment for symptomatic iliac artery occlusive disease were performed at our center. These included 128 interventions in women and 276 interventions in men. RESULTS: Whereas average age was significantly higher (65.9 ± 12.9 years; P = .007) and arterial hypertension more frequent (60.9% vs 49.3%; P = .032) in women, hyperuricemia (7.0% vs 14.1%; P = .047) and a positive smoking status (61.7% vs 74.3%; P = .014) were more frequently observed in men. Fontaine stage was more advanced (stages III and IV) in women than in men (P = .028; P < .001). Technical success was 97.7% in women and 99.3% in men. Overall complication rate was higher in women compared with men (P = .002), mostly caused by access site hematomas (4.7% vs 0.4%) and pseudoaneurysms (8.6% vs 2.5%). Patients were followed up for 45.0 ± 33.3 months. Restenosis developed in 16.8% of cases in women and in 14.6% of cases in men and was treated in 73.7% by an endovascular approach. Primary patency rates at 1, 3, 5, and 7 years were 90.3%, 77.2%, 60.2%, and 46.4% in women and 89.9%, 71.5%, 63.6%, and 59.7% in men, respectively (P = .524; log-rank, .406). Secondary patency rates were 97.2%, 91%, 81.5%, and 70.3% in women and 97.1%, 89.1%, 82.6%, and 78% in men, respectively (P = .959; log-rank, .003). Multivariate analysis identified lower age as the only independent risk factor for recurrent disease in both groups. Age-defined subgroup analysis showed a restenosis/reocclusion rate of 23.9% in men and 22.1% in women older than 63.5 years (P = .861) but 32.1% in men and 49.1% in women younger than that (P = .034). CONCLUSIONS: Our data suggest that although women are older and present with a more advanced stage of peripheral arterial occlusive disease, endovascular therapy is equally effective irrespective of gender. Surprisingly, the subgroup of young female patients had a specifically poor outcome.

Long-term outcome after surgical and endovascular management of true and false subclavian artery aneurysms.

Subclavian artery aneurysm is a rare but serious disease due to the risk of thrombosis, embolization, rupture and compression of adjacent structures. Treatment consists of surgical and endovascular techniques. Up to now few long-term follow-up results have been reported. In our study the results from 15 patients treated for subclavian artery aneurysms were evaluated. Eleven patients underwent open surgical reconstruction, four patients were treated endovascularly. After a mean follow-up period of 77 months (83 months for the open surgical group, 38 months for the endovascular group), 10 of 11 open surgical reconstructions and all primarily implanted stent grafts were patent. Secondary intervention was necessary in two patients. Thirty-day mortality for both treatment groups was 0%. Subclavian artery aneurysm-related symptoms disappeared in six out of 10 patients after the treatment. Long-term outcomes with good technical results, patency rates and low periprocedural morbidity could be shown in both treatment groups.

Transcatheter embolization for the management of acute active inferior epigastric artery hemorrhages.

PURPOSE: To report a retrospective review of all patients who were admitted to the interventional radiology unit at our hospital for transcatheter arterial embolization (TAE) of an acute active hemorrhage of the inferior epigastric artery. METHODS: From 1996 to 2012, 52 consecutive patients (26 men; mean age 63±15 years) with hemodynamically relevant active abdominal wall hematoma were admitted for TAE of the inferior epigastric artery. Of these, 19 patients had spontaneous hemorrhage due to use of anticoagulants, 18 due to abdominal trauma, and 15 due to an iatrogenic complication. All superselective embolizations were performed using a coaxial catheter technique with a 0.018-inch microcatheter introduced through the diagnostic macrocatheter. Various embolization methods, alone or in combination, were applied, including primarily microcoils and polyvinyl alcohol particles. RESULTS: Primary technical success was achieved in 47/52 (90%) patients; the remainder needed a second embolization session (secondary success 100%). The mean puncture-to-hemostasis time was 65.4±35 minutes. No patient developed a large hematoma or pseudoaneurysm at the puncture site. The 30-day mortality was 19% (n=10) and the total cumulative mortality rate was 23% (n=12). Over a mean 67-month follow-up of 39/40 survivors (1 lost to follow-up), no complications from the embolization procedure, such as abdominal wall ischemia, were observed. There were no differences in outcomes based on etiology of the hemorrhage. CONCLUSION: In selected patients with acute active hemorrhage of the IEA in the anterior abdominal wall, TAE is a fast, safe, minimally invasive, and reliable method with a high technical success rate and no long-term complications.

Resolution of biliary stricture after living donor liver transplantation in a child by percutaneous trans-hepatic cholangiography and drainage: a case report.

INTRODUCTION: Intra-hepatic cholestasis arising from biliary strictures is a frequent complication in pediatric patients after liver transplantation. Minimally invasive procedures such as percutaneous drainage placement and balloon dilation are the preferred diagnostic and therapeutic modalities. CASE PRESENTATION: We report the case of a 12-month-old Caucasian boy with biliary atresia who was initially treated with hepatoportoenterostomy. In the following months, he developed biliary cirrhosis, accompanied by cystic bile retention, recurrent bile duct infections and malabsorption. Six months after the initial surgical intervention, he underwent living donor liver transplantation. Within two months, the hepatico-jejunostomy became occluded leading to progressive intra-hepatic cholestasis. Under sonographic guidance, external drainage of bile was accomplished by percutaneous trans-hepatic cholangiography and drainage. In total, our patient underwent 12 interventions under general anesthesia until balloon dilatation of the hepatico-jejunostomy was successfully performed. Finally, our patient's general condition improved and he gained weight. CONCLUSIONS: Minimally invasive techniques are preferred to surgical revisions and justify even multiple attempts. Interventions under general anesthesia, though not without risks, are still reasonable. Co-operation with parents and multidisciplinary approach to complication management by the involved surgeon, radiologist, pediatrician and anesthesiologist are important.

High dose erythropoietin increases brain tissue oxygen tension in severe vasospasm after subarachnoid hemorrhage.

BACKGROUND: Vasospasm-related delayed cerebral ischemia (DCI) significantly impacts on outcome after aneurysmal subarachnoid hemorrhage (SAH). Erythropoietin (EPO) may reduce the severity of cerebral vasospasm and improve outcome, however, underlying mechanisms are incompletely understood. In this study, the authors aimed to investigate the effect of EPO on cerebral metabolism and brain tissue oxygen tension (PbtO2). METHODS: Seven consecutive poor grade SAH patients with multimodal neuromonitoring (MM) received systemic EPO therapy (30.000 IU per day for 3 consecutive days) for severe cerebral vasospasm. Cerebral perfusion pressure (CPP), mean arterial blood pressure (MAP), intracranial pressure (ICP), PbtO2 and brain metabolic changes were analyzed during the next 24 hours after each dose given. Statistical analysis was performed with a mixed effects model. RESULTS: A total of 22 interventions were analyzed. Median age was 47 years (32-68) and 86 % were female. Three patients (38 %) developed DCI. MAP decreased 2 hours after intervention (P < 0.04) without significantly affecting CPP and ICP. PbtO2 significantly increased over time (P < 0.05) to a maximum of 7 ± 4 mmHg increase 16 hours after infusion. Brain metabolic parameters did not change over time. CONCLUSIONS: EPO increases PbtO2 in poor grade SAH patients with severe cerebral vasospasm. The effect on outcome needs further investigation.

Endovascular popliteal thrombectomy using the self-expanding, retrievable Solitaire recanalization device.

PURPOSE: To present an initial peripheral application of the self-expanding, detachable, fully-retrievable Solitaire FR Recanalization Device for endovascular thrombectomy in the lower leg of a patient with acute peripheral limb ischemia. CASE REPORT: A 79-year-old woman with a long history of peripheral arterial occlusive disease and a femoropopliteal bypass graft presented with sudden grade IIb ischemia of the left lower leg. Conventional antegrade angiography identified total thrombotic occlusion of the tibioperoneal trunk below the distal femoropopliteal bypass anastomosis; the bypass itself was not occluded. When suction thrombectomy was unsuccessful, a 4×20-mm self-expanding, retrievable Solitaire stent was deployed. The thrombus was retrieved, with immediate recanalization of the tibioperoneal trunk and no sequela. Clinical signs of ischemia resolved, and after 6 months of follow-up, no reocclusion had occurred. CONCLUSION: Developed as a tool to retrieve clots causing acute ischemic stroke, the Solitaire FR Recanalization Device may also have a place in treating patients with acute below-the-knee thrombotic arterial occlusion in whom suction thrombectomy had failed. The Solitaire stent may be an additional endovascular option that can result in successful treatment of acute limb ischemia and avoid more expensive surgical procedures in selected cases.

Incidence and treatment of local stenosis or occlusion at the vascular access site leading to limb ischemia and new-onset intermittent claudication after percutaneous interventions: implications of vascular closure devices.

OBJECTIVE: Vascular access site complications (ASCs) are an ongoing hazard of percutaneous interventions (PI). We analyzed incidence, indication, and results of operative repair of access site complications leading to acute limb ischemia (ALI) or new-onset severe claudication (CI) in our institution during an 8-year period. METHODS: Retrospective analysis: demographic parameters, details of coronary or vascular intervention, use of a vascular closure device (VCD), clinical presentation, diagnosis and therapy. ENDPOINTS: perioperative outcome (death, limb loss, and need for re-operation/intervention) and length of hospital stay. For comparison of annual operation rates, patients were grouped by the years 2001 to 2004 (no use of VCD) and 2005 to 2008 (selective use of a VCD; in all cases: Angio-Seal), and Chi-Square-test was applied. RESULTS: Fifty-one patients (19 female; median age: 64.5 years) underwent repair of arterial ASCs causing ALI (n = 32) or new-onset severe CI (n = 19) after 58,453 catheter interventions (overall rate: 0.087%; ALI: 0.055%; CI: 0.032%). Corresponding with more widespread VCD use, the annual number of ALI and new onset CI increased significantly (P < 0.001). PERIOPERATIVE OUTCOME: 30 day mortality was 4%. No limb loss occurred. Re-operations were indicated in 10 patients (20%) for: hematoma (n = 5), local infection (n = 3), revision of fasciotomy (n = 1), and repeated thrombectomy (n = 1). Median length of postoperative hospital stay: 7 days (range: 1-28). CONCLUSION: ALI and new-onset severe CI due to access site complications after PI are rare, however, they are potentially threatening life and limb. The use of VCDs results in an overall increase of ischemic complications.

Angiopoietin-1 is associated with cerebral vasospasm and delayed cerebral ischemia in subarachnoid hemorrhage.

BACKGROUND: Angiopoietin-1 (Ang-1) and -2 (Ang-2) are keyplayers in the regulation of endothelial homeostasis and vascular proliferation. Angiopoietins may play an important role in the pathophysiology of cerebral vasospasm (CVS). Ang-1 and Ang-2 have not been investigated in this regard so far. METHODS: 20 patients with subarachnoid hemorrhage (SAH) and 20 healthy controls (HC) were included in this prospective study. Blood samples were collected from days 1 to 7 and every other day thereafter. Ang-1 and Ang-2 were measured in serum samples using commercially available enzyme-linked immunosorbent assay. Transcranial Doppler sonography was performed to monitor the occurrence of cerebral vasospasm. RESULTS: SAH patients showed a significant drop of Ang-1 levels on day 2 and 3 post SAH compared to baseline and HC. Patients, who developed Doppler sonographic CVS, showed significantly lower levels of Ang-1 with a sustained decrease in contrast to patients without Doppler sonographic CVS, whose Ang-1 levels recovered in the later course of the disease. In patients developing cerebral ischemia attributable to vasospasm significantly lower Ang-1 levels have already been observed on the day of admission. Differences of Ang-2 between SAH patients and HC or patients with and without Doppler sonographic CVS were not statistically significant. CONCLUSIONS: Ang-1, but not Ang-2, is significantly altered in patients suffering from SAH and especially in those experiencing CVS and cerebral ischemia. The loss of vascular integrity, regulated by Ang-1, might be in part responsible for the development of cerebral vasospasm and subsequent cerebral ischemia.

Multimodal neuromonitoring in a patient with aneurysmal subarachnoid hemorrhage associated with aortic coarctation.

BACKGROUND: Aortic coarctation (AC) rarely remains undiagnosed until adulthood. Intracranial aneurysms and spontaneous subarachnoid hemorrhage (SAH) are more frequent in patients with AC than in the general population. METHODS: The purpose of this report is to describe the management of a poor grade SAH patient with previously undiagnosed AC using advanced monitoring techniques of the brain and the cardiovascular system. RESULTS: A 28-year-old man with previously unknown AC was admitted with aneurysmal SAH WFNS grade 5. Head computed tomography demonstrated thick blood filling the basal cisterns, mild hydrocephalus, and global cerebral edema. The ruptured aneurysm of the anterior communicating artery was successfully coiled on the same day. Echocardiography revealed high grade isthmus stenosis with a pressure gradient of 60 mm Hg. Hospital course was complicated by prerenal failure and severe vasospasm. Neuromonitoring data (cerebral metabolism, brain tissue oxygenation, cerebral blood flow and intracranial pressure) were used as endpoint to define the optimal blood pressure to meet the cerebral metabolic and oxygen demand in each phase. CONCLUSIONS: Cerebral aneurysm rupture associated with coarctation of the aorta is rare. The aim of this report is to call attention to AC in, particularly, young patients presenting with SAH and to discuss advanced multimodal neuromonitoring techniques used to optimize intensive care management.

A case of a traumatic trigeminal-cavernous fistula occluded by coil embolization.

BACKGROUND: A trigeminal artery as the most common persisting embryonic carotid-basilar anastomosis is found in up to .2% of adults. In rare instances, trigeminal-cavernous fistulas develop either spontaneously or after a trauma. RESULTS: We present a 16-year-old patient with a traumatic trigeminal-cavernous fistula (Saltzmann type 2), which was successfully treated by interventional occlusion of the persistent trigeminal artery. After intervention, clinical symptoms (chemosis, right-temporal bruits, and sixth nerve palsy) resolved. DISCUSSION: In this case, fistula occlusion was achieved by coil embolization with only 4 coils placed directly at the rupture point of the trigeminal artery but not into the cavernous sinus. Thus, the cavernous sinus was preserved in function and structure. Special anatomy and interventional peculiarities of this unique case are described in detail.

Endovascular repair of isolated iliac artery aneurysms.

PURPOSE: To retrospectively evaluate a 12-year experience with endovascular repair of isolated iliac artery aneurysm (IAA). METHODS: From August 1997 through July 2009, 91 patients (81 men; mean age 71 years, range 31-90) underwent endovascular treatment for isolated IAA at our department. Of these, 77 patients received stent-grafts either alone or in combination with coils or an Amplatzer vascular plug (n = 2); 1 patient received a Smart stent combined with coils, and 13 patients were treated with coil embolization only. The aneurysms were classified according to location: type I = common iliac artery (CIA), type II = internal iliac artery (IIA), type III = CIA and IIA, and type IV = external iliac artery with/without CIA and/or IIA involvement. RESULTS: Primary technical success was 90.1% for all aneurysm types and 93.6%, 80%, 88.8%, and 93.3% for types I, II, III, and IV, respectively. Secondary technical success was 96.7% for all types and 97.8%, 95%, 100%, and 93.3%, respectively, for each type. Clinical success was 93.4% for all types and 97.8%, 85%, 100%, and 86.7%, respectively, by type. Complications in 18 (19.8%) patients included 7 type I endoleaks, 3 type II endoleaks, 2 enlarged aneurysm sacs (incomplete embolization), 5 cases of buttock claudication, and 2 stent-graft thromboses. Two patients were converted to open surgery; 10 underwent secondary interventions. Mortality rates were 1.1% (n = 1) at 30 death days and 23.1% (n = 21) over a mean follow-up of 45.9 months (no aneurysm-related death). Cumulative overall survival was 97.7% at 1 year and 47.6% at 10 years. Freedom from aneurysm-related complications was 88.6% at 1 year and 83.5% at 5 years. CONCLUSION: Endovascular repair of isolated IAA is a safe and minimally invasive alternative to surgery. However, it may be associated with several complications and must, therefore, be carefully planned.

Endovascular management of inadvertent subclavian artery catheterization during subclavian vein cannulation.

PURPOSE: To retrospectively review a 9-year experience with endovascular management of inadvertent subclavian artery catheterization during subclavian vein cannulation. MATERIALS AND METHODS: From June 2000 through July 2009 (109 months), 13 patients underwent endovascular management of inadvertent subclavian artery catheterization. All catheters were still in situ, including one 7-F catheter, six 8-F catheters, and six large-bore 10-11-F catheters. Treatment was performed with an Angio-Seal device (n = 6) or balloon catheters (n = 7) and by additional stent-graft placement (n = 4). RESULTS: Mean follow-up was 27.3 months (range, 0.4-78 months). The 30-day mortality rate was 7.7% and the late mortality rate was 46.1%. Primary technical success was achieved in nine patients (69.2%), in four with the use of a compliant balloon catheter and in the other five with an Angio-Seal device. Complications required additional stent-graft placement in four patients (30.8%), one because of stenosis after Angio-Seal device deployment and three as a result of insufficient closure of the puncture site by balloon tamponade. Stent-graft repair was successful in all four patients, for a primary assisted technical success rate of 100%. CONCLUSIONS: Endovascular techniques offer a less invasive alternative to surgery. The present limited experience shows that the use of the Angio-Seal device is not without risks, whereas balloon tamponade is not always reliable in closing the puncture site. Stent-graft placement may be required in patients in whom balloon tamponade fails or in whom the use of the Angio-Seal device is contraindicated.

Transcatheter arterial embolization for the management of iatrogenic and blunt traumatic intercostal artery injuries.

OBJECTIVE: The purpose of this retrospective study was to evaluate transcatheter arterial embolization (TAE) for the management of iatrogenic and blunt traumatic intercostal artery (ICA) injuries associated with hemothorax and clinical deterioration. METHODS: From May 1999 through April 2007, 24 consecutive patients (17 men, 7 women; mean age 53 years) presenting with active ICA hemorrhage underwent TAE mainly by means of coils combined with polyvinyl alcohol (PVA) particles. Eleven of them had blunt traumatic injuries (group A, n = 11) and 13 had iatrogenic injuries (group B, n = 13). In all patients, ICA injuries resulted in acute bleeding with clinical deterioration and hemothorax. Before discharge, all patients underwent clinical examination, laboratory tests, and chest x-ray. After discharge, no specific follow-up protocol was required, and the patients were questioned on their state of health at regular intervals and underwent CT or chest x-ray as needed. RESULTS: Primary technical success (PTS) was achieved in 21 of 24 patients (87.5%). In group A, it was achieved in all but one patient (90.9%) and in group B in 11 of 13 patients (84.6%). A total of three patients needed secondary interventions, which failed in one of them, amounting to a secondary technical success rate (STS) of 8.3%. The total cumulative mortality rate was 37.5% (n = 9). In group A, it was 9.1% (n = 1) and in group B, it was 61.5% (n = 8). 30-day-mortality was 9.1% in group A, where one patient died due to multiple severe associated injuries, and 30.8% (n = 4) in group B, where one patient died due to treatment failure and three patients due to severe comorbidities. During follow-up, no more deaths occurred in group A, while in group B, four more patients died due to severe comorbidities, amounting to a late mortality rate of 30.8%. No technical complications and no complications such as chest wall or spinal cord ischemia were observed. The mean observation period was 44.6 months in group A and 23.8 months in group B. CONCLUSION: TAE of ICAs is a minimally invasive, safe, and reliable treatment option to control massive intrathoracic hemorrhage, especially in patients with serious comorbidities and/or multiple injuries. However, it should be performed only by experienced interventionalists and exact knowledge of the anatomic features of the affected artery and of collateral pathways is mandatory to avoid complications.

Traumatic fistula between the middle meningeal artery and the sphenoparietal sinus.

PURPOSE: Post-traumatic fistulas between the middle meningeal artery and the cranial venous system are extremely rare. We describe clinical presentation and successful endovascular management of a case of post-traumatic fistula between the middle meningeal artery and the sphenoparietal sinus. METHODS: A 53-year-old man was admitted with multiple brain contusions and a temporoparietal fracture after a head trauma. On day 3 after trauma he developed unilateral signs of a cavernous sinus syndrome. Digital subtraction angiography showed a fistula between the middle meningeal artery and the sphenoparietal sinus. RESULTS: The fistula was occluded by endovascular coil embolization, resulting in complete remission of the clinical symptoms. CONCLUSION: A high index of suspicion is necessary to detect subtle signs of venous congestion of the cavernous sinus in an intubated patient. Angiography is the diagnostic modality of choice and should include the selective investigation of the external carotid artery vascular territory. Endovascular therapy provides minimal invasive and definitive treatment of this rare condition.

Intra-arterial haemodynamic changes during cerebral three-dimensional rotational angiography.

Three-dimensional rotational angiography (3DRA) is useful for detecting, classifying and planning treatment for intracranial aneurysms. Prolonged contrast material (CM) injection, required for 3DRA, might cause blood pressure changes in the selectively catheterized artery. The purpose of this study was to assess the extent and clinical relevance of haemodynamic changes in the selected artery during 3DRA. Twenty-five consecutive patients with intracranial aneurysms were prospectively examined with 3DRA (18 ml, 3 ml/s power injector) for planning treatment. Intra-arterial pressure was measured in the internal carotid or vertebral artery by using a pressure guidewire. Mean and systolic blood pressure acquired by the guidewire (Pd) and fractional flow reserve (FFR) were measured before, during and after CM injection. The extent of Pd and FFR changes was evaluated by Student's t-test and linear regression analysis and their clinical relevance with the limits-of-agreement analysis. Mean systolic Pd and FFR increased significantly (P<0.001) from 105.2+/-22 mmHg and 0.98+/-0.04, respectively, at the baseline to 118.1+/-23 mmHg and 1.09+/-0.12, respectively, during injection and decreased thereafter to baseline. The correlation between mean and systolic Pd during injection and at baseline was moderate (r(2)=0.47 and 0.63, respectively) but remained significant (P=0.001 and <0.001, respectively). Moderate bias and range of agreement were found for systolic Pd (12.8+/-29.2 mmHg) and FFR (0.1+/-0.24). Selective CM injection during 3DRA causes a temporary but clinically tolerable increase in blood pressure and pressure gradient.