Reconstructive endovascular treatment of fusiform or ultrawide-neck circumferential aneurysms with multiple overlapping enterprise stents and coiling.

BACKGROUND AND PURPOSE: Fusiform aneurysms and ultrawide-neck circumferential aneurysms are still some of the most challenging lesions. The aim of this study was to investigate the efficacy and feasibility of the use of multiple overlapping Enterprise stents with coiling for the treatment of fusiform or ultrawide-neck circumferential aneurysms. MATERIALS AND METHODS: Twelve consecutive patients (9 men and 3 women; mean age, 56 years) with fusiform (n = 5) or ultrawide-neck circumferential (n = 7) aneurysms were treated with 2-3 overlapping Enterprise stents and coiling. The feasibility of this procedure and the clinical and angiographic outcomes of this technique were retrospectively evaluated. RESULTS: All patients were successfully treated by using this technique without any complications. Posttreatment angiographic results revealed grade 4 occlusion of the aneurysm in 6, grade 3 in 4, and grade 2 in 2 patients. Clinical follow-up was performed in all patients (mean, 16 months; range, 5-24 months). Nine patients had an mRS score of 0. Two had an mRS score of 1, one of whom had an initial mRS score of 2 due to the mass effect of a giant aneurysm; the other had a recurrent aneurysm presenting with SAH 5 years after clipping. Angiographic follow-up was performed in 10 patients at 6-20 months posttreatment. Nine had stable or improved occlusion, while 1 had a minor recurrence. CONCLUSIONS: In this small series, multiple overlapping Enterprise stents with coiling were a feasible and effective option for the treatment of fusiform and ultrawide-neck circumferential aneurysms. Further experience and follow-up are required to document the long-term efficacy of this treatment.

Embolisation of indirect carotid-cavernous sinus dural arterio-venous fistulae using the direct superior ophthalmic vein approach.

Indirect carotid-cavernous sinus dural arterio-venous fistulae (cDAVF) can be treated by transarterial and/or transvenous embolisation. This study evaluated patients with cDAVF who underwent transvenous embolisation using the direct superior ophthalmic vein (SOV) approach. Between January 2004 and October 2006, eight cDAVF in seven patients were embolised using direct surgical exposure of the SOV when access to the cDAVF via transarterial or transfemoral venous routes was not feasible. Medical records and imaging studies were retrospectively reviewed. The seven patients consisted of four females and three males from 43 to 65-year-old (mean age, 54.4 years). Six cDAVF lesions were located on the left side and two on the right. All fistulae were successfully embolised and showed clinical improvement. One patient presented after treatment with transient venous congestion on the brain stem, which was relieved by osmotic diuretics and steroids. Direct surgical exposure of the SOV for transvenous embolisation of cDAVF can be effective if the facial vein, inferior petrosal sinus, and internal jugular vein are thrombosed. This approach is easy, safe, and effective when performed by a multidisciplinary team.

Phenytoin-induced lingual tonsil hyperplasia causing laryngeal obstruction.

The effects of phenytoin sodium on lymphoid tissue have been known for some time. However, its effect on the lymphoid tissue of Waldeyer's ring is unreported in the otolaryngology literature. We present the case of a 78-year-old woman who was treated with phenytoin for generalized tonic-clonic seizures for 4 months and who subsequently developed lingual hyperplasia that caused laryngeal obstruction eventually requiring a tracheotomy. Of note, no history of airway compromise or difficulty with intubation from a prior operation 20 years ago was reported; these findings suggest that the lingual tonsillar hyperplasia was a consequence of phenytoin therapy and not a preexisting condition. The findings of histopathologic evaluation were consistent with lymphoid hyperplasia without evidence of malignancy. We also report our operative management and follow-up of this rare condition.

Selection of treatment modalities for cerebral arteriovenous malformations: a retrospective analysis of 348 consecutive cases.

The objective was to establish the selection criteria for the optimal management modalities for cerebral arteriovenous malformations. We analysed the complications and late outcomes in 348 consecutive cases (132 microsurgical resections, 202 stereotactic radiosurgeries, 8 embolisations only, 6 combined treatments) managed at Yonsei University Hospital from 1988 to 1997. Files for all patients were analysed. The outcome was classified into good for the patients who returned to their previous job with or without neurological deficits, fair for the patients who were unable to return to work but performed daily activities independently with minor deficits, and poor for the patients who were performing dependent daily activities with major deficits. The outcome of microsurgery was considered good in 108 patients (81.8%), fair in 18 (13.6%), poor in 4 (3.1%), and 2 (1.5%) patients died. Initial insults and haemodynamic complications were the major cause of an unfavourable outcome. The cumulative occlusion rate of the nidus after radiosurgery was 10.2% within 12 months, 75.3% within 24 months, and 89.8% within 36 months. Perilesional imaging changes with neurological deficits (4 permanent and 6 transient, 4.8%) and haemorrhage (16 patients, 7.7%) during the latent interval were the major cause of an unfavourable outcome (1 poor, 4 dead after radiosurgery). Postradiosurgery bleeding occurred frequently within 6 months (6 patients), and between 13 and 24 months (8 patients). In conclusion, selection of treatment modality for cerebral AVMs depends on the preoperative evaluation of the risk/benefit ratio in each case. Microsurgical removal, which eliminates the risk of bleeding immediately, is preferred for lesions in non-eloquent areas. Radiosurgery is an effective treatment modality for small lesions in eloquent areas, but has a substantial risk of haemorrhage during the latency period. Results of this study suggest that microsurgical removal should be considered for lesions in eloquent areas with high haemorrhage risk, such as prior haemorrhage, medium to large size lesion, and single deep venous drainage.

Emergency surgical recanalisation of A1 segment occluded by a Guglielmi detachable coil.

We describe a case of A1 segment occlusion caused by a tangled Guglielmi detachable coil (GDC) during an endovascular treatment for a ruptured anterior communicating aneurysm. Immediate surgical recanalisation of the occluded artery and clipping of the aneurysm rescued the patient. This case demonstrates that an emergency surgical team, as well as an operating room, should be available during any complicated intra-aneurysmal procedure, so that timely surgical intervention could be carried out without delay.

Management of poor-grade patients with ruptured intracranial aneurysm.

To formulate treatment strategies for poor-grade patients after aneurysmal subarachnoid hemorrhage (SAH), medical records were analyzed for 166 patients who were in Hunt and Hess Grade IV or V among 588 consecutive cases with ruptured intracranial aneurysm admitted during the past 5 years. Causes of unfavorable outcome (poor or dead) in those 166 patients were evaluated to improve the management outcome. Overall management results of the 166 poor-grade patients were favorable (good or fair) in 71 (42.8%), unfavorable in 95 (78 dead, 17 poor). Direct clipping was performed in 90 patients, and the results were favorable in 69 (76.7%) and unfavorable in 21 (23.3%). Surgery was not done in 76 patients because 41 were moribund on arrival, 15 deterioration due to rebleeding, 7 severe brain swelling, 5 serious medical illness, one severe delayed ischemic deficit (DID), and one cerebral infarction following angiography, and 6 refused surgery. Seven patients survived in non-surgery group (2 fair, 5 poor). Direct effects of aneurysm rupture (34.8%) and early rebleeding (34.8%) were the major causes of unfavorable outcome in Grade IV patients, while it was direct effect of aneurysm rupture (91.8%) in Grade V patients. It is suggested that as rebleeding is the only preventable cause of unfavorable outcome, urgent management is necessary to prevent rebleeding, especially for Grade IV patients. Grade IV patients should be treated aggressively with direct clipping for non-complex aneurysms or for patients with hematoma, and coil embolization for complex aneurysms without hematoma.

The protective effects of alpha-melanocyte stimulating hormone on canine brain stem ischemia.

OBJECTIVE: To evaluate the influence of alpha-melanocyte stimulating hormone (alpha-MSH), an anti-inflammatory antagonist of the production and action of proinflammatory cytokines, 26 dogs were divided into four groups and exposed to isolated, reversible brain stem ischemia in the presence or absence of alpha-MSH treatment. METHODS: Brain stem auditory evoked potentials (BAEPs) and regional cerebral blood flow were measured during ischemia and for 5 hours after reperfusion. Group I was composed of five dogs that underwent surgical preparation only. Group II was composed of seven dogs that were exposed to 20 minutes of ischemia without treatment. Group III was comprised of seven dogs exposed to 20 minutes of ischemia with alpha-MSH treatment before and during ischemia. Group IV was composed of seven dogs exposed to 20 minutes of brain stem ischemia with alpha-MSH treatment only during reperfusion. RESULTS: During the ischemic period, BAEPs were abolished in all animals within 10 minutes. With reperfusion, the BAEPs increased to approximately 36% of baseline in Group II dogs that received no treatment. However, this increase was approximately 63% in animals that received alpha-MSH both before and during ischemia (Group III). In Group IV dogs that received alpha-MSH only during reperfusion, BAEPs were increased approximately 10 to 14% more than in Group II during the late reperfusion period. CONCLUSION: The improved recovery of BAEPs in dogs treated with alpha-MSH suggests that this peptide may have neuroprotective effects in brain stem ischemia and reperfusion injury. This effect may be caused by an antagonistic action of alpha-MSH on cytokine-induced ischemic brain damage.