Embolization of Intracranial Dural Arteriovenous Fistulas Using PHIL Liquid Embolic Agent in 26 Patients: A Multicenter Study.

BACKGROUND AND PURPOSE: The introduction of liquid embolic agents has revolutionized endovascular approach to cranial vascular malformations. The aim of the study was to retrospectively assess the efficacy and safety of Precipitating Hydrophobic Injectable Liquid (PHIL), a new nonadhesive liquid embolic agent, in the treatment of patients with cranial dural arteriovenous fistulas. The primary end point was the rate of complete occlusion of dural arteriovenous fistulas. Secondary end points included the incidence of adverse events and clinical status at 3-month follow-up. MATERIALS AND METHODS: This was a retrospective multicenter study. Twenty-six consecutive patients with dural arteriovenous fistulas (de novo or previously treated) treated by injection of PHIL only or with PHIL in combination with other embolization products (such as Onyx or detachable coils) were included in the study. Recruitment started in August 2014 and ended in September 2015. RESULTS: Twenty-two (85%) patients were treated with PHIL only, with 3 patients treated with both PHIL and Onyx, and 1, with both PHIL and coils. Immediate complete angiographic occlusion was achieved in 20 (77%) patients. Of the 6 patients with residual fistulas, 3 were retreated with PHIL and 1 achieved angiographic cure. An adverse event was seen in 1 patient who developed worsening of preexisting ataxia due to acute thrombosis of the draining vein. CONCLUSIONS: PHIL appears to be safe and effective for endovascular treatment of cranial dural arteriovenous fistulas. Short-term angiographic and clinical results are comparable with those of Onyx, with the added advantage of easier preparation and improved homogeneous cast visualization. The use of iodine as a radio-opacifier also produces considerably less artifacts on CT compared with tantalum-based embolic materials.

Manual thromboaspiration technique as a first approach for endovascular stroke treatment: A single-center experience.

BACKGROUND: For intracranial large vessel occlusion in acute ischemic stroke (AIS), a high degree of revascularization in the minimal amount of time predicts good outcomes. Recently, different studies have shown that the direct aspiration first pass technique (ADAPT technique) for AIS obtains high recanalization rates, fast interventions and low costs when it works as first attempt. This study retrospectively describes revascularization efficacy, duration of procedure, intra and post-procedural complications, early and after 90-days clinical outcome in a group of patients who underwent ADAPT as the primary endovascular approach, eventually followed by stent retriever thrombectomy, for recanalization of large vessels in the anterior circulation. MATERIALS AND METHODS: We analyzed clinical and procedural data of patients treated from April 2014 to August 2015. Recanalization was assessed according to the Thrombolysis in Cerebral Infarction score. Clinical outcome was evaluated at discharge and after 3 months (modified Rankin Scale, mRS). RESULTS: Overall, 71 patients (mean age of 69.7 years) were treated. Sites of occlusion were anterior circulation (including seven tandem extracranial-intracranial occlusions). In 39 patients i.v. rtPA was attempted. Recanalization of the target vessel was obtained in 87.3% of cases whereas direct aspiration alone was successful in 46/71cases (64.8%) with an average puncture-to-revascularization time of 43.1 minutes. Symptomatic intracranial hemorrhage occurred in 7.8% and embolization to new territories in 5.6%. In total, 38 patients (53.5%) had a good outcome at 90 days follow-up. CONCLUSIONS: In our series, the manual thromboaspiration technique has been shown as fast and safe, with good rates of vessel revascularization in 87.3% of patients and neurological outcome <3 mRS in 53.5% of patients.

A sonographic quantitative cutoff value of cerebral venous outflow in neurologic diseases: a blinded study of 115 subjects.

BACKGROUND AND PURPOSE: The autonomic nervous system maintains constant cerebral venous blood outflow in changing positions. Alterations in cerebral autoregulation can be revealed by postural changes at quantitative color Doppler sonography. The aim of this study was to reach an optimal cutoff value of the difference between the cerebral venous blood outflow in the supine and seated positions that can discriminate healthy controls from patients with multiple sclerosis and those with other neurologic diseases and to evaluate its specificity, sensitivity, and diagnostic accuracy. MATERIALS AND METHODS: One hundred fifteen subjects (54 with MS, 31 healthy controls, 30 with other neurologic diseases) underwent a blinded quantitative color Doppler sonography evaluation of cerebral venous blood outflow in the supine and sitting positions. An optimal difference value between the supine and sitting positions of the cerebral venous blood outflow cutoff value was sought. RESULTS: The difference value between supine and sitting positions of the cerebral venous blood outflow was ≤ 503.24 in 38/54 (70.37%) patients with MS, 9/31 (29.03%) healthy controls, and 13/30 (43.33%) subjects with other neurological diseases. A difference value between supine and sitting positions of the cerebral venous blood outflow at a 503.24 cutoff reached a sensitivity at 70.37%, a 70.96% specificity, a 80.85% positive predictive value, and a 57.89% negative predictive value; the quantitative color Doppler sonography parameters yielded significant differences. The difference value between supine and sitting positions of cerebral venous blood outflow ≤ 503.24 assessed the significant difference between MS versus other neurological diseases. CONCLUSIONS: Alteration of cerebral venous blood outflow discriminated MS versus other neurologic diseases and MS versus healthy controls. The difference value between supine and sitting positions of cerebral venous blood outflow ≤ 503.24 was statistically associated with MS.

Endovascular treatment of brain arteriovenous malformations using a liquid embolic agent: results of a prospective, multicentre study (BRAVO).

OBJECTIVES: To evaluate the safety and efficacy of a new liquid embolic agent in brain arteriovenous malformation (bAVMs) embolisation. METHODS: A prospective, multicentre series was conducted at 11 interventional centres in Europe to evaluate embolisation of bAVMs with the new liquid embolic agent. Technical conditions, complications, clinical outcome and anatomical results were independently analysed. RESULTS: From December 2005 to December 2008, 117 patients (72 male; 45 female, aged 18-75 years) were included. Clinical presentation was mostly haemorrhage (34.2 %) and seizures (28.2 %). Most AVMs were located in the brain hemispheres (85.5 %). AVMs were <3 cm in 52.1 % of patients and ≥ 3 cm in 47.9 %. Morbidity was observed in 6/117 patients (5.1 %), related to haemorrhagic events in 2 cases and non-haemorrhagic complications in 4 cases. Five patients (4.3 %) died in relation to the treatment (bleeding in 4 patients and extensive venous thrombosis in 1). Complete occlusion of the AVM by embolisation alone was obtained in 23.5 % of patients. Complementary treatment was performed in 82.3 % of patients with partial AVM occlusion, mostly radiosurgery. CONCLUSIONS: In this prospective, multicentre, European, observational series, the new liquid embolic agent proved to be suitable for BAVM embolisation, with acceptable morbidity and mortality and good efficacy. KEY POINTS: • Numerous interventional techniques have been used to embolise brain arteriovenous malformations (AVMs). • This prospective multicentre study demonstrates the suitability of a liquid embolic agent. • The safety of treatment using Onyx is acceptable. • Such embolisation leads to complete AVM occlusion in 23.5 % of patients.

Direct percutaneous venous puncture and embolization of giant perimedullary arteriovenous fistulas.

PMAVFs are rare entities that are formed by a direct communication between an artery that feeds the spinal cord and a vein. The goal of treatment is to occlude the shunt; this is done endovascularly either from an arterial or a venous approach. When these approaches are not possible, direct percutaneous puncture of the draining veins may be attempted to embolize the arteriovenous shunt directly.

Percutaneous treatment of cervical disk hernias using gelified ethanol.

This study investigates the efficacy of chemonucleolysis using RGE in the treatment of cervical disk hernias in a small sample of patients who had cervical diskogenic or radicular pain secondary to disk herniations. Results were satisfactory in 89.5% patients, with no adverse events recorded during the procedure or after. The use of RGE shows promising results and might be a feasible and safe alternative in the treatment of cervical disk hernias.

Hemiplejia y afasia transitorias no tromboembólicas: ¿neurotoxicidad por contraste angiográfico? / A case of temporary nonthrombotic hemiplegia and aphasia due to neurotoxicity from angiographic contrast material?

Se presenta el caso de una mujer de 75 años, que desarrolló hemiplejia, afasia y disminución del nivel de conciencia, súbitamente, 3h después de una embolización de aneurisma cerebral. La embolización transcurrió sin complicaciones, con control angiográfico final normal. La tomografía computarizada (TC) craneal postembolización mostró hiperdensidad cortical y de los surcos de la convexidad; hallazgos que desaparecieron en una nueva TC realizada 4h después. Una arteriografía cerebral 24h postembolización presentaba retraso del parenquimograma hemisférico izquierdo respecto del derecho, sin oclusiones vasculares. El déficit neurológico persistió 72h, y se resolvió después, tan súbitamente como se instauró, espontánea y completamente. Éste es uno de los pocos casos descritos de déficit neurológico transitorio en relación con la administración de contraste iodado, fuera de la circulación posterior (ceguera cortical). Cuando se producen síntomas neurológicos tras un tratamiento endovascular cerebral, es fundamental distinguir este excepcional cuadro, probablemente tóxico, de las posibles complicaciones isquémicas del procedimiento (AU)

We present the case of a 75-year-old woman who suddenly developed hemiplegia, aphasia, and reduced consciousness three hours after embolization of a cerebral aneurysm. No complications occurred during embolization and the findings at end-procedure angiography were normal. Cranial computed tomography (CT) after embolization showed hyperdensity of the cortex and sulci of the convexity; another CT examination performed four hours later showed these findings had disappeared. Cerebral arteriography 24h after embolization showed delayed blood flow to the parenchyma of the left hemisphere compared to the right but no vascular occlusion. The neurological deficit lasted 72h and resolved spontaneously and completely as suddenly as it developed. This is one of the few cases of temporary neurological deficit related to iodinated contrast administration to be reported outside the posterior circulation (cortical blindness). When neurological symptoms occur after endovascular procedures in the brain, it is fundamental to distinguish this rare clinical syndrome of probable toxic origin from possible ischemic complications of the procedure (AU)

[A case of temporary nonthrombotic hemiplegia and aphasia due to neurotoxicity from angiographic contrast material?]. / Hemiplejia y afasia transitorias no tromboembólicas: ¿neurotoxicidad por contraste angiográfico?

We present the case of a 75-year-old woman who suddenly developed hemiplegia, aphasia, and reduced consciousness three hours after embolization of a cerebral aneurysm. No complications occurred during embolization and the findings at end-procedure angiography were normal. Cranial computed tomography (CT) after embolization showed hyperdensity of the cortex and sulci of the convexity; another CT examination performed four hours later showed these findings had disappeared. Cerebral arteriography 24h after embolization showed delayed blood flow to the parenchyma of the left hemisphere compared to the right but no vascular occlusion. The neurological deficit lasted 72 h and resolved spontaneously and completely as suddenly as it developed. This is one of the few cases of temporary neurological deficit related to iodinated contrast administration to be reported outside the posterior circulation (cortical blindness). When neurological symptoms occur after endovascular procedures in the brain, it is fundamental to distinguish this rare clinical syndrome of probable toxic origin from possible ischemic complications of the procedure.

Total occlusion of a conus medullaris pial arteriovenous malformation obtained with one session of superselective embolization.

The authors report about a case of the endovascular treatment of a pial arteriovenous malformation (AVM). The lesion was located on the conus medullaris. This injury is a rare spinal AVM. The diagnostic management and surgical treatment was chosen with a collaboration between neurosurgeons and neuroradiologists. The diagnostic management was based on clinical validation and magnetic resonance with angiographic technique as a gold standard. With regard to the surgical treatment of spinal AVM, endovascular and radiotherapy is a decision which should be taken multidisciplinarily. The treatment is crucial in resolving this lesion. The authors describe the case of a 38-year-old girl with clinical findings of progressive radiculomedullary ischemic process caused by the presence of spinal AVM. The angiographic images showed a pial AVM of the conus medullaris fed by an anterior radiculomedullary artery (Adamckiewiz artery) originated from a left T11 dorsospinal artery and by a posterior radiculopial artery originated from the left L1 artery. The draining veins were posterior pial veins, and accessory anterior subpial veins. Even if the first treatment of a pial arteriovenous malformation (AVM) of conus medullaris can be the surgical treatment for posterior localization, a neurointerventional angiographic and modern materials make it possible to reach pial AVMS of conus medullaris avoiding surgery. The authors describe a successful treatment of conus medullaris arteriovenous malformation with a one session of superselective embolization.

Medium-term results using the leo self-expanding stent in the treatment of complex intracranial aneurysms.

The preliminary experience with the Leo microstent in combination with detachable coils for the treatment of patients with wide-necked cerebral aneurysms is reported, and the technical complications and recommendations for optimum placement and deployment are discussed. Thirty.two patients identified as harboring wide-necked aneurysm were selected for stent-assisted coiling. Aneurysms were paraophthalmic-cavernous in 13 cases, eight were located at the posterior communicating artery, four at the basilar artery, three at the vertebral arteries, two at the posterior cerebral arteries, one at the right middle artery, and one at the right posterior inferior cerebellar artery. After appropriate antiplatelet therapy, the Leo stent was delivered to the aneurysm site and positioned without difficulty, except in four cases requiring the use of steam to shape the tip of the Vasco microcatheter. Angiographic follow-up was undertaken at six months in 32 patients, at one year in 27 patients, and at two years in 20 patients. Stent placement in the desired position with complete or near complete occlusion of the aneurysm was feasible in all patients. In one patient, the stent was slightly displaced during microwire manipulation for aneurysm microcatheterization. Two-year angiography in 20 patients showed 18 complete occlusions and two aneurysms with a minimal residual neck. The Leo stent represents a significant advancement in the vascular treatment of intracranial aneurysms providing high radial force and an easy delivery system i.e., it is a feasible, secure and effective system.

Models of epithelial histogenesis.

Epithelial tissues emerge from coordinated sequences of cell renewal, specialization and assembly. Like corresponding immature tissues, adult epithelial tissues are provided by stem cells which are responsible for tissue homeostasis. Advances in epithelial histogenesis has permitted to clarify several aspects related to stem cell identification and dynamics and to understand how stem cells interact with their environment, the so-called stem cell niche. The development and maintenance of epithelial tissues involves epithelial-mesenchymal signalling pathways and cell-matrix interactions which control target nuclear factors and genes. The tooth germ is a prototype for such inductive tissue interactions and provides a powerful experimental system for the study of genetic pathways during development. Clonogenic epithelial cells isolated from developing as well mature epithelial tissues has been used to engineer epithelial tissue-equivalents, e.g. epidermal constructs, that are used in clinical practise and biomedical research. Information on molecular mechanisms which regulate epithelial histogenesis, including the role of specific growth/differentiation factors and cognate receptors, is essential to improve epithelial tissue engineering.

Management of spinal dural arteriovenous fistulae with emphasis on an endovascular approach.

Spinal arteriovenous shunts are rare and present at a rate of approximately 1:10 with cerebral arteriovenous shunts. Spinal dural arteriovenous fistulas (SDAVF) are the most common type of spinal vascular malformation in the adult and account for about 60% of all, with a marked male predominance (5:1). Endovascular treatment has gained force as the treatment of choice in recent years. We reviewed the patients sent to our service at Clinica del Rosario in Madrid and Hospital General de Cataluña in Barcelona between January 1991 and December 2005 with a diagnosis of SDAVF made clinically or by imaging for possible endovascular treatment. Location, presenting symptoms, and clinical outcome according to treatment were analyzed. A total of 104 patients were diagnosed and treated for a SDAVF, 85 were men and 19 women aged between 23 and 79 years (average 58). Seventy-six were treated with embolization alone (73%), 21 with a combination of endovascular therapy and surgery (20.1%) and seven patients had surgery alone (6.7%). Of the embolization group, 62 patients were cured (81.5%), 11 improved (14.4%) and three (3.9%) worsened. Of the group with combined therapy, 13 (61.9%) were cured, five (23.8%) improved and three (14.2%) worsened. Among the surgery group, four (57.2%) were cured and three (42.8%) worsened. Endovascular approach with liquid adhesive is gaining more acceptance as the treatment of choice for SDAVF if the conditions allow a super selective catheterization of the shunt. These patients benefit most when diagnosis is made early in the course of the pathology and have a better chance of a complete remission of symptoms.

Radial approach in the treatment of supraaortic arterial lesions.

SUMMARY: Radial approach (mainly right) has been used in the treatment of 67 supraaortic lesions including 56 carotid, nine vertebral and two subclavian artery stenoses. This approach offers new possibilities and solves most of the remaining technical difficulties or impossibilities encountered in the endovascular treatment of supraaortic lesions. The current technique is described. The results of this first series have been very satisfactory without complication. MR angiography allows selection of patients suitable for radial approach.

Lumbosacral liposuction. A new tool for the treatment of low back pain.

SUMMARY: To obtain a better active contention of the lumbosacral spine, a new technique of liposuction of the fat surrounding the atrophied paraspinal muscles is described. A preliminary series of 40 patients presenting low back pain symptoms is presented. The technique, performed on an out patient basis is well tolerated.The MR follow-up controls regularly showed an expansion of the paraspinal muscles. The overall results obtained on this preliminary non uniform series showed encouraging results with 77.5% of very good or good results.

Stimulation of osteoblast growth by an electromagnetic field in a model of bone-like construct.

The histogenesis of bone tissue is strongly influenced by physical forces, including magnetic fields. Recent advances in tissue engineering has permitted the generation of three dimensional bone-like constructs. We have investigated the effects of electromagnetic stimulation on human osteoblast cells grown in a hydrophobic polyurethane scaffold. Bone-like constructs were stimulated by pulsed electromagnetic fields in a bioreactor. Proliferation, bone protein expression and calcified matrix production by osteoblasts were measured using histochemical methods. In stimulated cultures, the number of cells was significantly higher compared to static (control) cultures. In both stimulated and control cultures, cells were immunoreactive to osteoblast markers, including type-I collagen, osteocalcin and osteopontin, thus suggesting that the expression of bone-related markers was maintained throughout the in vitro experiments. Morphometric analysis of von Kossa-stained sections revealed that stimulation with electromagnetic field significantly increased matrix calcification. The data lend support to the view that the application of a magnetic field can be used to stimulate cell growth in bone-like constructs in vitro. This finding may be of interest for the production of biomaterials designed for clinical applications.

Differential distribution of elastic tissue in human natural skin and tissue-engineered skin.

Tissue-engineered skins (TES), manufactured by epidermal and dermal equivalents, are now being used in biological, pharmacotoxicological and clinical applications. It is thus interesting to know to what extent artificial organs are similar to natural counterparts. Elastic fibres are important constituents of the extracellular matrix of natural skin (NS). The aim of our study was to investigate the possible occurrence and distribution of elastic tissue in a model of human TES using different histochemical techniques, including classical Orcein and Fuchsin-Resorcin methods and immunohistochemistry, at both light and electron microscopical levels. Immunoperoxidase and high resolution immunogold methods were used. In NS, classical staining techniques and elastin-immunohistochemistry revealed a well-organized network of elastic fibres. High resolution immunocytochemistry revealed an intense labelling in the amorphous component of elastic fibres. Fibres of different diameters were immunostained. In TES, no stained elastic fibres were observed using classical staining techniques, and the interpretation of immunoperoxidase observations was not clear-cut. In contrast, immunogold staining at the electron microscopical level provided specific labelling of elastin-like immunoreactive material in the dermal equivalent. However, ultrastructural immunocytochemistry revealed that elastic tissue organization in TES was poor compared to that in NS. This study demonstrates that elastic fibres are a component of the extracellular matrix in this model of TES and suggests that fibroblasts of the dermal equivalent are engaged in matrix secretion. Nevertheless, the level of extracellular matrix organization in TES is low compared to NS. Moreover, this study also suggests that different models of bilayered TES may differ with respect to extracellular matrix organization. These aspects should be considered when TES is used in biological and pharmacotoxicological studies. A better understanding of the factors influencing extracellular matrix formation in TES is necessary to achieve further development of skin generation in vitro.

Endovascular treatment of a cavernous sinus dural arteriovenous fistula by transvenous embolisation through the superior ophthalmic vein via cannulation of a frontal vein.

We describe a new approach for transvenous embolisation of cavernous sinus dural arteriovenous fistulae through the superior ophthalmic vein (SOV), i.e., via percutaneous cannulation of a frontal vein. Modern neurointerventional angiographic materials make it possible to reach the SOV in this way without puncturing it in the orbit or a surgical exposure. Orbital phlebography should still be in the repertoire of interventional neuroradiology units in large centres.

"Protected" wallstenting of atheromatous stenoses at the carotid bifurcation.

SUMMARY: Atheromatous stenoses at the carotid bifurcation were treated by angioplasty and Wallstenting with cerebral protection obtained in most cases by temporary occlusion of the internal carotid artery. 287 carotid stenoses were treated in 233 patients. The stenosis was symptomatic in 79% of cases. All patients presented either a stenosis of >70% with significant impairment of the cerebral circulation (281 cases) or a symptomatic ulcerated plaque (six cases). A self-mounted protection system was used in 177 cases, the Percusurge Guardwire protection device in 98 cases an EPI filter in 12 cases. There was a contralateral internal carotid occlusion in 13% of cases. A combined stenting (vertebral, siphon, subclavian) was performed in 14% of cases. A Rolling membrane Wallstent was used in 84 patients, a first generation Easy Wallstent in 38 cases, a "Carotid" Easy Wallstent 35 in 55 cases and monorail 14 in 110 cases. Full opening of the stenosis was obtained in 98% of patients with correction of the arterial curve and improvement of the cerebral vascular supply. There were 0.7% cases with transient symptomatic neurological complications and 2% with permanent sequelae mainly related to avoidable inadequacy in flushing or to the insufficient radial force of the first generation Easy Wallstent. There were no per and one post-procedural cardiac complication (0.6%) in the s165 cases performed with the "Carotid" Easy Wallstent. Follow-up angiograms showed 0.7% of restenoses. Still in evolution, endovascular treatment of atheromatous stenoses at the carotid bifurcation with cerebral protection and stenting is a promising alternative technique to surgery. The association of Carotid Easy Wallstent 14 monorail and Percusurge Guardwire appears to be currently satisfactory.

[Hemangiomas and superficial vascular malformations of the face and neck]. / Hemangioma y malformaciones vasculares superficiales de la cara y del cuello.

Hemangiomas and superficial vascular anomalies of the head and neck form what usually calls the angiomas. Many terms exist in the literature for that reason the classification of the ISSVA, admitted by most of the doctors, helps us in naming the different anomalies. The processing of this pathology needs a multidisciplinary collaboration with doctors of different specialties. The evolution of the radiological, surgical techniques of laser, and who knows, of the research, allows to hope us to cure some of the particularly dangerous anomalies like the arteriovenous malformations. We presented here the different technics used in 2001 in the management of hemangioma and superficial vascular anomalies insisting on a multidisciplinary approach.

Cell proliferation and differentiation in a model of human skin equivalent.

Recent advances in culturing technology has permitted the production of organotypic models that may be referred to as human skin equivalents (HSE). We have studied histochemical, ultrastructural, and kinetic aspects of an HSE composed by an epidermal equivalent and a dermal equivalent separated by a basement membrane. Only keratinocytes and fibroblasts were present in the epidermal and dermal equivalents, respectively; cells of other lineages were lacking. Keratinocyte stratification and differentiation seemed similar to natural skin. Evidence is shown that such an HSE may also release growth factors such as vascular endothelial growth factor that are believed to play a role in skin grafting. The distribution of cycling cells as well as the values of the growth fraction are comparable to those observed in natural skin. Although the absence of several cells populations that reside in natural skin is a remarkable feature of this HSE, the high levels of tissue organization and cell differentiation lead us to believe that such an HSE may be considered a candidate substitute of human skin in biological, pharmacologic, and clinical applications.