Lobar embolization for treatment of diffuse pulmonary arteriovenous malformations in hereditary hemorrhagic telangiectasia: a case report.

Pulmonary arteriovenous malformations (PAVMs) are abnormal communications between pulmonary arteries and pulmonary veins that are most commonly associated with hereditary hemorrhagic telangiectasia (HHT). The authors report a case of lobar artery embolization for the treatment of diffuse PAVMs in a patient with HHT who was experiencing recurrent transient ischemic attacks despite anticoagulation and multiple previous embolizations. The right lower lobar and interlobar arteries were embolized to achieve complete occlusion of multiple PAVMs in the right lower lobe and right middle lobe. In conclusion, lobar embolization can be considered for the relief of neurologic symptoms in patients with diffuse PAVMs.

Blunt cerebrovascular injuries: diagnosis and management outcomes.

BACKGROUND: Blunt cerebrovascular injury (BCVI) to the carotid and vertebral arteries is a potentially devastating injury in trauma patients. The optimal management for BCVI has not been standardized. At our institution, 64-slice multi-detector computed tomographic angiography (CTA) has been used as the initial screening exam for BCVI in patients who met predefined screening criteria. The purpose of this study is to review the incidence of CTA-diagnosed BCVI in at-risk patients and to evaluate the treatment and clinical outcome of patients with BCVI. METHODS: This study included trauma patients with a positive diagnosis of BCVI on CTA during a 41-month study period. The medical records and relevant radiographic findings were retrospectively reviewed. RESULTS: Twenty seven of 222 blunt trauma patients evaluated with CTA had a positive diagnosis of BCVI, with an occurrence rate of 12.2%. Traumatic brain injury (72.2%) and basal skull fractures (55.6%) were the most frequent associated injuries with carotid trauma while 100% of blunt vertebral injuries occurred in the setting of cervical fractures. Fourteen (51.8%) patients received medical therapy; Eleven (40.7%) patients received conservative treatment. Endovascular treatment was attempted in a single case of vertebral arteriovenous fistula. BCVI-related stroke was found in four patients (14.8%), one of whom developed an infarct while on medical treatment. CONCLUSIONS: BCVI is found in a significant portion of blunt trauma patients with identifiable risk factors, and screening CTA has high diagnostic yield in detecting these lesions. Medical therapy is the mainstay of treatment at our institution; however, BCVI-related stroke may occur despite treatment.

Use of diffusion-tensor imaging in traumatic spinal cord injury to identify concomitant traumatic brain injury.

OBJECTIVE: To characterize and differentiate cerebral white matter (WM) changes related selectively to traumatic brain injury (TBI) or spinal cord injury (SCI) in patients with SCIs in order to improve diagnostic accuracy of TBI in people with SCI. DESIGN: Diffusion-tensor imaging (DTI)-derived fractional anisotropy (FA) data in WM tracts were compared between a healthy control and 2 patient groups. Between-subject comparisons of FA were performed using region of interest (ROI) analysis and tract-based spatial statistics. SETTING: A large, urban inpatient SCI program. PARTICIPANTS: Three groups: SCI and concomitant TBI (SCI with TBI, n=7); SCI without TBI (SCI only, n=15); and healthy control subjects (n=12). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: FA was used as a measure of cerebral WM integrity. RESULTS: ROI analyses showed reduced FA in the genu and splenium of the corpus callosum and forceps minor in patients with SCI with TBI compared with both healthy controls and patients with SCI only. ROI analyses did not show evidence of FA differences in patients with SCI only compared with controls. Tract-based spatial statistics did not demonstrate between-group differences in FA. CONCLUSIONS: DTI is a sensitive tool to detect TBI-related WM damage in patients with SCI who have suffered concomitant TBI. No WM abnormalities on DTI could be attributed to SCI alone, although this finding should be further explored in future studies. Therefore, DTI may be a valuable tool to identify TBI in the SCI population. Further research to produce normative FA values is needed to allow identification of TBI in individual patients with SCI.

Tumor effects on cerebral white matter as characterized by diffusion tensor tractography.

BACKGROUND: Diffusion tensor MRI fiber tractography (DTT) is the first non-invasive in vivo technique for delineating specific white matter (WM) tracts. In cerebral neoplasm, DTT can be used to illustrate the relationship of the tumor with respect to adjacent WM trajectories. METHODS: Fiber tractography was used in this study to assess tumor-induced changes in WM trajectories in three cases of cerebral neoplasm: glioblastoma multiforme, meningioma, and anaplastic astrocytoma. RESULTS: Three patterns of WM alteration were identified: 1) disruption, 2) displacement, and 3) infiltration. Tumor disruption of WM tracts was observed in glioblastoma multiforme, which terminated fibers crossing the corpus callosum. In meningioma, DTT illustrated bulk displacement of the corticospinal tract in the affected hemisphere as well as preservation of the deviated axons. In anaplastic astrocytoma, fiber tracking demonstrated disruption of WM tracts at the tumor origin as well as intact axons through areas of tumor infiltration. CONCLUSIONS: Fiber tracking results correlated with the clinical and histopathological features of the tumor. Larger case series will be required to determine if fiber tracking can add accuracy to existing imaging methods for grading tumors.