Can the degree of coronary collateralization be used in clinical routine as a valid angiographic parameter of viability?

The success rate of percutaneous coronary artery intervention (PCI) of chronic total occlusion (CTO) lesions have increased in the recent years. However, improvement of function is only possible when significant myocardial viability is present. One of the most important factors of maintaining myocardial viability is the opening and development of collaterals. Our hypothesis was that with a higher degree of collaterals more viable myocardium is present. In 38 patients we compared the degree of collaterals, evaluated with a conventional coronary angiogram (CCA) and graded by the Rentrop classification to transmural extent of the scar obtained in a viability study with magnetic resonance (MRI). We found a statistically significant association of the degree of collaterals determined with Rentrop method and transmural extent of the scar as measured by CMR (p = 0.001; Tau = -0.144). Additionally, associations showed an increase in the ratio between viable vs. non-viable myocardium with the degree of collaterals. Our study suggests that it may be beneficial to routinely grade the collaterals at angiography in patients with CTO as an assessment of myocardial viability.

Endovascular treatment of unruptured aneurysms of cavernous and ophthalmic segment of internal carotid artery with flow diverter device Pipeline.

BACKGROUND: Intra-arterial treatment of aneurysms by redirecting blood flow is a newer method. The redirection is based on a significantly more densely braided wire stent. The stent wall keeps the blood in the lumen of the stent and slows down the turbulent flow in the aneurysms. Stagnation of blood in the aneurysm sac leads to the formation of thrombus and subsequent exclusion of the aneurysm from the circulation. The aim of the study was to evaluate flow diverter device Pipeline for broad neck and giant aneurysm treatment. METHODS: Fifteen patients with discovered aneurysm of the internal carotid artery were treated between November 2010 and February 2014. The majority of aneurysms of the internal carotid artery were located intradural at the ophthalmic part of the artery. The patients were treated using a flow diverter device Pipeline, which was placed over the aneurysm neck. Treatment success was assessed clinically and angiographically using O'Kelly Marotta scale. RESULTS: Control angiography immediately after the release of the stent showed stagnation of the blood flow in the aneurysm sac. In none of the patients procedural and periprocedural complications were observed. 6 months after the procedure, control CT or MR angiography showed in almost all cases exclusion of the aneurysm from the circulation and normal blood flow in the treated artery. Neurological status six months after the procedure was normal in all patients. CONCLUSIONS: Treatment of aneurysms with flow diverter Pipeline device is a safe and significantly less time consuming method in comparison with standard techniques. This new method is a promising approach in treatment of broad neck aneurysms.

Endovascular versus operative treatment of cerebral aneurysms: a comparison of results from a low-volume neurosurgical centre.

BACKGROUND: Subarachnoid haemorrhage is a debilitating disease. The treatment options include surgical clipping or endovascular embolisation. Still, many controversies exist about which method is more convenient. METHODS: In the retrospective study from January 2006 to December 2013, 129 patients with subarachnoid haemorrhage were analysed. They were classified according to the WFNS grade and Fisher scale. The diagnosis of intracranial aneurysms was based on computerised tomographic angiography and digital subtraction angiography. All patients received the standard therapy against vasospasm. The treatment outcome was evaluated with Glasgow Outcome Scale. RESULTS: Of 129 patients, surgery was employed in 40, endovascular obliteration in 86 patients and 3 patients received both forms of treatment. Four factors were statistically significant for worse results in the univariate analysis: the age, WFNS grade, Fisher grade and the presence of clinical vasospasm. In the multivariate analysis, only the age, WFNS grade and the presence of clinical vasospasm remained statistically significant for the outcome. There was a trend towards better outcome for the patients that had endovascular treatment compared with patients who were treated surgically, although the difference was not statistically significant. CONCLUSIONS: Although the endovascular embolisation in relation to the surgical clipping is becoming a more popular treatment method for ruptured cerebral aneurysms it cannot offer reliable endovascular exclusion in all types of aneurysms. Based on our experience, it is therefore necessary to look at these two methods as complementary that may both be used separately or in combination for the well-being of the patient.

Treatment of tongue cavernous haemangioma with direct puncture and sclerotization with ethanol.

BACKGROUND: Haemangiomas of tongue are rare type of malformations. They can be treated mostly conservatively but in some cases they need more aggressive treatment with preoperative intra arterial embolization and surgical resection. Lesions of tongue that are localized superficially can also be treated with direct puncture and injection of sclerosing agent (absolute ethanol). CASE REPORT: We present a case of a 48 years old female patient, where we performed embolization of cavernous haemangioma with mixture of absolute ethanol and oil contrast. After the procedure the patient received analgetics and antioedematous therapy. After the sclerotization the planed surgery was abandoned. Control MRI examinations 6 and 12 months after the procedure showed only a small remnant of haemangioma and no signs of a larger relapse. CONCLUSIONS: In our case the direct puncture of haemangioma and sclerotherapy with ethanol proved to be a safe and effective method to achieve preoperative devascularization of the lesion. Direct puncture of the lesion is not limited by the anatomy of the vessels or vasospasm, which can occur during the intra-arterial approach.

Embolization of spinal dural arteriovenous fistula via the retrocorporeal artery: case report.

BACKGROUND AND IMPORTANCE: The goal of spinal dural arteriovenous fistula (DAVF) treatment is to permanently occlude the proximal draining vein and the fistula itself, which can be achieved by open surgery or endovascular treatment. The endovascular approach is currently the primary treatment, but it requires the presence of an access as close to the site of the fistula as possible. This case illustrates that the retrocorporeal artery may be an alternative option in case of previous embolization failure with proximal occlusion of the radicular arteries. CLINICAL PRESENTATION: A 54-year-old man presented with an 18-month history of progressive paraparesis secondary to right L2 spinal DAVF. The first endovascular treatment failed to achieve occlusion of the fistula via the ipsilateral L2 and L3 radicular arteries. Given the proximal occlusion of these feeders during the first embolization, the dilated retrocorporeal arteries were approached via the contralateral L2 and L3 radicular arteries. Complete occlusion of the fistula was achieved with Onyx in a single session with progressive improvement of preoperative neurological deficit. CONCLUSION: The retrocorporeal artery may provide a safe alternative approach to spinal DAVFs in cases in which a conventional endovascular approach failed, thus avoiding invasive surgical treatment.

Quantitative evaluation of the tibial tunnel after anterior cruciate ligament reconstruction using diffusion weighted and dynamic contrast enhanced MRI: a follow-up feasibility study.

OBJECTIVE: The aim of the study was to evaluate the feasibility of two quantitative MRI methods: diffusion weighted imaging (DWI) and dynamic contrast enhanced imaging (DCEI), for follow-up assessment of the tibial tunnel after reconstruction of the anterior cruciate ligament (ACL). MATERIALS AND METHODS: Twenty-three patients were examined by MRI at 1 and 6 months following ACL reconstruction. DWI and DCEI were utilized for evaluating the region of interest (ROI) within the proximal part of the tibial tunnel. From the resulting apparent diffusion coefficient (ADC) maps, ADC values were calculated. DCEI data were used to extract the enhancement factor (f(enh)) and the enhancement gradient (g(enh)) for the same ROI. RESULTS: Calculated ADC as well as the f(enh) and g(enh) had diminished to a statistically significant extent by 6 months after ACL reconstruction. The average ADC value diminished from 1.48 (10(-3) mm(2)/s) at 1 month to 1.30 (10(-3) mm(2)/s) at 6 months after reconstruction. The average f(enh) value decreased from 1.21 at 1 month to 0.50 at 6 months and the average g(enh) value decreased from 2.01%/s to 1.15%/s at 6 months, respectively. CONCLUSION: The study proved feasibility of DWI and DCEI for quantitative assessment of the tibial tunnel at 1 and 6 months after ACL reconstruction. Both methods have the potential for use as an additional tool in the evaluation of new methods of ACL reconstruction. To our knowledge, this is the first time quantitative MRI has been used in the follow-up to the ACL graft healing process.

Adult metachromatic leukodystrophy: a new mutation in the schizophrenia-like phenotype with early neurological signs.

OBJECTIVES: The adult type of metachromatic leukodystrophy can manifest itself as motor or as psycho-cognitive form, the latter is very similar to schizophrenia. We report on two sisters with adult metachromatic leukodystrophy who display symptoms of both forms. METHODS: Presented are genotype analyses and 4-year follow-up data regarding clinical manifestations as well as neurocognitive and neuroimaging results for two adult sisters with metachromatic leukodystrophy. RESULTS: Whereas the younger sister developed disorganized schizophrenia-like symptoms, the other exhibited schizophrenia-like, negative symptoms. In both sisters, neurological signs were already present at the onset of the disease and progression towards dementia was documented within 1-2 years. In peripheral leukocytes, the activity of arylsulphatase A was reduced to 2 and 5% of the mean normal activity in both women. Genotype analysis revealed compound heterozygosity for a known severe splice site mutation, (c.459+1G>A) together with two known polymorphisms, [(c.937G>T), (p.Trp193Asp)] and [(c.1530C>G), (p.Thr391Ser)], and a novel missense mutation, (c.1194C>T). The latter results in the exchange of a conserved polar amino acid, threonine 279, to hydrophobic isoleucine (Thr279Ileu), which could not be found among >100 control alleles. A family analysis identified T279I as the paternal allele, whereas (c.459+1G>A) as well as the two polymorphisms were inherited from the mother. This is consistent with a disease-causing effect of the novel mutation. CONCLUSIONS: The novel mutation, T279I detected in our patients, correlates with a specific phenotype with schizophrenia-like symptoms, neurological signs and cognitive impairment early in the course of the disease and a relatively fast progression towards dementia. This is in contrast to previous reports on adult metachromatic leukodystrophy patients with the psycho-cognitive phenotype who did not show any neurological signs for decades, however, most of these patients were heterozygous for another specific missense mutation, I179S.

Treatment of ruptured intracranial aneurysms: report from a low-volume center.

BACKGROUND: The aim of this retrospective analysis was to present our experience and results in treating subarachnoid hemorrhage due to ruptured intracranial aneurysms at a neurosurgical department with a small annual number of cases (i.e. a low-volume center) and to discover which factors could influence treatment and reliably predict the outcome of hemorrhage. METHODS: All patients with aneurysmal subarachnoid hemorrhage treated at our department between 1973 and 2003 were retrospectively analyzed. We performed 293 operations and 21 endovascular procedures. In the majority of patients we excluded the aneurysm from circulation by placing a clip on the aneurysmal neck. Relevant data were obtained on patients' performance, imaging studies, treatment and outcome. RESULTS: According to the Hunt & Hess grade, the majority of patients were in groups 1 or 2. Perioperative mortality was 3%. Postoperative mortality due to complications related to subarachnoid hemorrhage was 10%. Vasospasm was detected in 18% of patients and was a direct cause of death in 5%. The outcome was good in 68% (grades 4 or 5 on the Glasgow outcome scale). In multivariate analysis, the Hunt & Hess grade, age and clinical vasospasm all had important predictive value for the outcome. CONCLUSIONS: The results of treatment in our series of patients fall within reported norms and are comparable to results from other low-volume centers. For successful treatment of aneurysmal subarachnoid hemorrhage, fast diagnosis, correct surgical or endovascular treatment and proper intensive pre- and postoperative care are of utmost importance.

Endovascular treatment of a direct post-traumatic carotid-cavernous fistula with electrolytically detachable coils.

Carotid-cavernous fistulae are abnormal communications between the internal carotid artery and venous compartments of the cavernous sinus. Fistulae are uncommon but well-documented sequelae of craniofacial trauma. The characteristic clinical presentation includes ocular pain, chemosis, exophthalmus and visual disturbances. We report on a 28-year-old man with a history of severe craniocerebral injury, including multiple craniofacial fractures resulting from a fall from a height of approximately 6 meters, who was surgically treated one year ago. Two months before presentation, the patient began to exhibit progressive chemosis, proptosis, eyelid swelling, diplopia and exophthalmus. Computerized tomography and computerized tomographic angiography revealed findings consistent with a carotid-cavernous fistula of the right side of the cavernous sinus with dilatation of the right ocular vein. Digital subtractional angiography of the right internal carotid artery revealed a fistula between the cavernous part of the artery and the right cavernous sinus. There was only minimal blood flow in the supraclinoid part of the internal carotid artery because of the high pressure within the fistula. Our decision was to try to occlude the fistula by means of endovascular embolization. The origin of the fistula in the internal carotid artery was successfully obliterated with seven electolytically detachable coils. Control digital subtractional angiography at the end of the procedure demonstrated minimal residual flow through the fistula. Two months after the treatment, angiographic control revealed complete obliteration of the fistula. Clinical examination showed total resolution of signs and symptoms of a carotid-cavernous fistula. Endovascular transarterial embolization of carotid cavernous fistulae is a widely accepted, safe and successful treatment option. In the case that we describe we occluded the fistula and right cavernous sinus with electrolytically detachable coils that we could place into the sinus. Other endovascular treatment options include the use of detachable balloons, stent placement, transvenous embolization or surgical ligation of the fistula.

[Endovascular treatment of intracranial artery aneurysms in the posterior cerebral circulation]. / Endovaskuläre behandlung intrakranieller aneurysmen im hinterhirnkreislauf.

The purpose of the study was to determine the safety and effectiveness of electrolytically detachable platinum coils in the endovascular treatment of ruptured and unruptured aneurysms in the posterior cerebral circulation. The aneurysms were occluded with electrolytically detachable platinum coils. Six patients with posterior cerebral circulation aneurysms were treated. Four patients suffered a subarachnoid hemorrhage, in two patients the aneurysms were detected incidentally, in one due to mass effect. In all six patients, the diameters of the aneurysms were less than 12 mm and were therefore classified as small aneurysms. Complete occlusion (100%) was achieved in 4 patients, the rate of occlusion in the other two patients was estimated at 75% in one case and at 90% in the other. The clinical outcome in five patients was excellent, without any additional neurological deficit. One patient died five weeks after the procedure due to respiratory complications. At the time of endovascular treatment, she had been graded clinically as grade 5 according to Hunt and Hesse. None of the patients experienced any recurrence of hemorrhage during the follow up period of 12 months. Endovascular occlusion of posterior cerebral artery aneurysms with detachable coil system is an effective alternative therapy to established surgical treatment and could become the treatment of choice. The method is minimally invasive and there is no need for skull trepanation.

Endovascular treatment of arteriovenous malformation in a child.

Arteriovenous malformations are direct communications between the arterial and venous circulations without the usual passage through the capillary net. They are the most frequent type of malformations of the intracranial circulation and the second most frequent cause of intracranial hematomas or hemorrhage. We report on a 7-year-old girl with intracerebral hematoma following acute rupture of an arteriovenous malformation. The girl experienced a spontaneous headache and later became unconscious. At the time of admission to the hospital, her neurological status scored 5 on the Glasgow Coma Scale. Computerized tomography of the brain revealed a round hyperdense lesion in the left frontoparietal region. Digital subtractional angiography of the left internal carotid artery confirmed the suspicion of an arteriovenous malformation with one main feeding artery: a distal branch of the left anterior cerebral artery. The nidus was round and about 2 cm in diameter. The venous drainage was of the superficial type, flowing into the left superior sagittal sinus. After consultation with a neurosurgeon, we decided to treat the arteriovenous malformation by means of an endovascular technique. A flow-guided catheter was placed close to the nidus. Control angiography before embolization revealed the proper position for the injection of embolic material. We used the conventional mixture of acrylic polymerization glue, Lipiodol oil contrast medium and particles of tantalum powder. Control angiography at the end of the procedure revealed complete occlusion of the malformation. There were no signs of potential new feeding arteries that could appear as a result of changed hemodynamic conditions after embolization. Endovascular treatment of arteriovenous malformations could become the treatment of choice for these lesions, especially in combination with radiosurgery. The established microsurgical treatment is very effective but carries a higher risk of hemorrhagic complications.

Recurrent giant invasive thoracolumbar schwannoma.

Giant invasive spinal schwannoma is a new term proposed by Sridhar in 2001 for a particularly aggressive type of benign spinal schwannoma. Only a few cases have been published, the majority of these located in the lumbosacral spine, two in the thoracic and only one in the cervical spine. A rare case of such a tumor is presented. The tumor predominantly occupied level L1 and partially levels T12 and L2, and recurred 13 years after the first seemingly radical excision of a benign melanotic schwannoma. The highly vascularized tumor was radically excised using the dorsal approach, and a Sokon transpeduncular fixation was performed. Carter's lateral thoraco-abdominal access allowed the retroperitoneal and intravertebral expansions of the tumor to be removed and L1 corpectomy to be accomplished. Ventral vertebral stabilization was achieved with a titanium cage. After the operation, the pain in the patient's left leg subsided. Three years after the management, he is still pain-free, able to walk freely and to resume his usual daily activities.