Alessandro Pedicelli

3D rotational angiography for the diagnosis and preoperative assessment of intracranial aneurysms: preliminary experience

PurposeThe aim of this study was to assess the value of the systematic use of 3D rotational angiography (3DRA) in the diagnosis and preoperative evaluation of cerebral aneurysms with a view to planning endovascular embolisation.Materials and methodsThirty-five consecutive aneurysms (20 incidental and 15 after subarachnoid haemorrhage) were studied and treated by means of 3DRA over a 1-year period. All rotational studies were conducted by selective cannulation of the vessel supplying the lesion (internal carotid artery or vertebral artery) with a single injection of 20 cc of contrast agent after diagnostic angiography in anterior-posterior (AP) and laterolateral (LL) views. Three-dimensional reconstructions were generated within a mean time of 5 min, and coil embolisation was performed on the basis of the 3D images.ResultsThree-dimensional RA enabled accurate definition of site, orientation, morphology and size of the sac and its relationship with the parent arteries and helped us choose the most appropriate angulation of the C-arm for guiding and controlling the embolisation procedure. Furthermore, the technique allowed us to detect six aneurysms for which conventional imaging had yielded equivocal results.ConclusionsBased on our experience before RA equipment became available and in agreement with the literature, we believe that 3DRA improves the identification of all lesions and helps refine the choice of the most suitable embolisation material and technique. Three-dimensional RA requires substantially fewer projections and thus reduces radiation dose and volume of contrast material to the patient. The use of 3DRA most likely results in a shorter procedure time and fewer risks and complications for the patient.RiassuntoObiettivoValutare l’utilità dell’impiego sistematico dell’angiografia rotazionale 3D (3DRA) nella diagnostica preliminare al trattamento endovascolare degli aneurismi cerebrali, ai fini della pianificazione della procedura.Materiali e metodiSono stati studiati e trattati consecutivamente 35 aneurismi (20 occasionali e 15 dopo emorragia subaracnoidea) con 3DRA in 32 pazienti in un anno. Lo studio rotazionale è stato sempre eseguito mediante cateterizzazione selettiva del vaso afferente (carotide interna o arteria vertebrale) con singola iniezione di 20 cc di MdC dopo angiografia diagnostica nelle due proiezioni ortogonali. Sono state effettuate ricostruzioni 3D con tempi di post-processing mediamente di 5 minuti, e sulla base di queste è stata eseguita l’embolizzazione con spirali.RisultatiMediante la 3DRA in ogni caso è stato possibile definire in maniera accurata la sede, l’orientamento, la morfologia e le dimensioni della sacca, il rapporto con i vasi parenti e la scelta dell’idonea angolazione dell’arco a C ai fini della guida e del controllo dell’embolizzazione. La tecnica ha permesso inoltre di individuare 6 aneurismi di dubbia interpretazione alla diagnostica tradizionale.ConclusioniIn base alla nostra esperienza precedente alla disponibilità di un angiografo rotazionale, e in accordo con i dati della letteratura, riteniamo che la 3DRA consenta di individuare con maggiore accuratezza tutte le lesioni e di scegliere con maggiore precisione il materiale più idoneo per la procedura, la tecnica di embolizzazione, nonché di ridurre sensibilmente il numero di proiezioni e quindi la dose di esposizione e di mdc al paziente, con una verosimile riduzione dei tempi di trattamento, dei rischi e delle complicanze.

Angio-Architectural Features of High-Grade Intracranial Dural Arteriovenous Fistulas: Correlation With Aggressive Clinical Presentation and Hemorrhagic Risk

BACKGROUND High-grade dural arteriovenous fistulas (dAVFs) can present shunts with very different angio-architectural characteristics. Specific hemodynamic factors may affect clinical history and determine very different clinical courses. OBJECTIVES To evaluate the relationship between some venous angio-architectural features in high-grade dAVFs and clinical presentation. Specific indicators of moderate or severe venous hypertension were analyzed, such as altered configurations of the dural sinuses (by a single or a dual thrombosis), or overload of cortical vessels (restrictions of outflow, pseudophlebitic cortical vessels, and venous aneurysms). METHODS The institutional series was retrospectively reviewed (49 cases), and the pattern of venous drainage was analyzed in relationship with clinical presentation (benign/aggressive/hemorrhage). RESULTS Thirty-five of 49 cases displayed cortical reflux (high-grade dAVFs). This subgroup displayed a benign presentation in 31.42% of cases, an aggressive in 31.42%, and hemorrhage in 37.14%. CONCLUSIONS Our data confirm that within high-grade dAVFs, 2 distinct subpopulations exist according to severity of clinical presentation. Some indicators we examined showed correlation with aggressive nonhemorrhagic manifestations (outflow restriction and pseudophlebitic cortical vessels), while other showed a correlation with hemorrhage (dual thrombosis and venous aneurysms). Current classifications appear insufficient to identify a wide range of conditions that ultimately determine the organization of the cortical venous drainage. Intermediate degrees of venous congestion correlate better with the clinical risk than the simple definition of cortical reflux. The angiographic aspects of venous drainage presented in this study may prove useful to assess dAVF hemodynamic characteristics and identify conditions at higher clinical risk.

Vertebra plana: reappraisal of a contraindication to percutaneous vertebroplasty

PURPOSE We evaluated the efficacy of percutaneous vertebroplasty (PVP) in treating symptomatic vertebra plana, which is considered a relative contraindication to the procedure. METHODS Out of 540 levels treated in 260 patients, we treated 40 patients (mean age: 74 years) with vertebra plana between T6 and L3 (37 osteoporotic and 3 metastatic levels). In most cases, the vertebra was accessed with fluoroscopic guidance from a single, transpedicular approach. All patients underwent a preliminary MRI examination, an immediate, post-procedure radiological examination, and a follow-up examination (mean duration, 6 months). RESULTS Both immediate and follow-up examinations showed that the mean pain and physical disability scores were significantly reduced compared to the scores before treatment (p ≤ 0.001). No complications occurred during the procedures. In 23/40 cases, asymptomatic intradiscal cement leakage occurred. Posterior or perivertebral leakage never occurred. In most cases, an intravertebral cleft was present, and we filled it with polymethylmethacrylate, which healed the pseudarthrosis. Partial vertebral height was restored in 7 cases. In 6 cases, a new fracture occurred between 1 and 3 months at a different level from the treated level. CONCLUSION Our preliminary results showed that PVP was a safe, effective treatment for symptomatic vertebra plana; thus, it should not be discounted for this group of patients. In most cases, the procedure was favored by the presence of an intravertebral cleft that appeared to contribute to minimizing the risk of posterior cement leakage. Filling the cleft with polymethylmethacrylate allowed intravertebral stabilization.

Large middle cerebral artery dissecting aneurysm mimicking hemorrhagic stroke

Dissection of intracranial arteries is a rare cause of cerebrovascular diseases commonly presenting as an ischemic stroke. We report a patient with middle cerebral artery dissection who developed a large middle cerebral artery dissecting aneurysm mimicking a hemorrhagic stroke.

Vertebroplasty for symptomatic monostotic Paget disease.

Paget disease (PD) is a chronic metabolically active bone disorder. The spine is the second most commonly involved site; the pathologic changes can cause back pain, myeloradiculopathy, and vertebral fracture. Symptomatic patients are treated medically, and surgery is required when certain complications occur. A case is presented of monostotic vertebral PD treated by percutaneous vertebroplasty (PV) with successful outcome characterized by pain relief and improved disability at 6-month follow-up. PV is proposed as a primary treatment for back pain secondary to PD when unresponsive to conservative therapy and when not associated with other complications.

Giant Basilar Artery Aneurysm Involving the Origin of Bilateral Posterior Cerebral and Superior Cerebellar Arteries: Neck Reconstruction with pCONus-Assisted Coiling

Giant aneurysms of the basilar artery are rare and are frequently associated with obstructive hydrocephalus and brainstem compression. Treatment still remains a challenge both for neurosurgeons and for interventional neuroradiologists. Cases reported in the literature are anecdotal and, overall, their outcomes are poor. We present the case of a patient with a giant aneurysm of the basilar artery tip, involving the origin of both the posterior cerebral and superior cerebellar arteries, who underwent coiling and ventriculoperitoneal shunting for associated obstructive hydrocephalus. A pCONus ® stent (Phenox; Bochum, Germany) was detached with its petals opened over the ostia of the parent vessels, with the aim being to reconstruct the neck of the aneurysm and to preserve the flow in the parent vessel. Moreover, the presence of the stent was useful to maintain the coils within the dome of the aneurysm. The pCONus is a new neurovascular device that is also useful for treating cases of complex basilar artery aneurysms when the ostia of the parent vessel origin is at the level of the aneurysm neck.

Endovascular Treatment of the Posterior Cerebral Artery Aneurysms: Single-Center Experience and a Systematic Review

BACKGROUND Endovascular treatment of posterior cerebral artery aneurysms is challenging because of the particular features of posterior circulation vessels. We performed a systematic review of the literature, to assess safety and efficacy associated to their endovascular treatment. METHODS Through a literature search, we identified 20 studies that met our inclusion criteria. We also performed a retrospective analysis of patients treated at our institution during the last 10 years. Demographics, angiographic features, clinical presentation, and outcome were extracted from each study. Data were combined using a random effects model and heterogeneity was assessed by I(2). RESULTS We retrieved 7 patients from our institutional series and 246 from the literature. Overall, 253/259 patients/aneurysms were included in this study. A selective coiling was performed in 27% of cases, a stent-assisted coiling in 2%, and a parent artery occlusion in 62%. Immediate complete/near-complete occlusion was obtained in 96% of cases and maintained in 90% at follow-up. No differences were observed between ruptured and unruptured aneurysms. Ischemic complications were reported in 15% of cases, although the most frequent was a hemianopsia in 7%; a hemiparesis was reported in only 2% of cases. Mortality was overall 1%. Ischemic complications were more frequent among patients who underwent nonselective treatment (P < 0.01). CONCLUSIONS Endovascular treatment of posterior cerebral artery aneurysms is associated with increased degree of occlusion and low recurrence rate. However, a parent artery occlusion implies complications, even although most of them are minor events such as hemianopsia.

Preliminary experience using N-butyl cyanoacrylate for management of bleeding after percutaneous transhepatic biliary drain placement: a technical note

Bleeding complications occur in 2–3% of percutaneous biliary drain [1–4]. The most common clinical presentations are represented by hemobilia and bleeding from the percutaneous biliary drain [3, 4] as a result of a transaction/ extravasation, pseudoaneurysm of hepatic artery, or an arterioportal fistulae. If an arterial injury is suspected, a hepatic angiogram is required to detect and eventually embolize the involved artery. In acute arterial bleeding, the goal of procedure is to control the hemorrhage and stabilize the vital signs. Transcatheter arterial embolization has been used for many years to control acute arterial bleeding [5–12]. Microcoils have emerged as the currently preferred agent when superselective catheterization can be performed. These agents are usually adequate in achieving hemostasis; however, ineffective embolization occurs in a minority of cases as a result of numerous collateral vessels, tortuous or narrow vascular anatomy, vessel spasm, or coagulopathy [13, 14]. Here we describe two cases of bleeding after percutaneous transhepatic biliary drain placement that was successfully treated with N-butyl cyanoacrylate without significant procedural complications.

Percutaneous vertebroplasty: optimizing the procedure after treatment of 250 vertebral levels under fluoroscopic guidance

PurposePercutaneous vertebroplasty (PVP) is a minimally invasive treatment for symptomatic vertebral compression fractures (VCFs). The aim of this study was to assess the effectiveness, complications and progress of results of PVP optimized in terms of technique, costs, time and strategic protocol after 3 years of procedures performed under fluoroscopic guidance alone.Materials and methodsWe treated 250 VCFs in 120 consecutive patients after assessing clinical and radiological indications. The effectiveness of the procedure was determined by statistical analysis of numerical scores for pain, mobility and drug consumption before and after treatment.ResultsNo major complications and only three minor complications occurred. Clinically relevant improved mobility and reduction of pain and analgesics were observed, with overall significant results (p<0.0001) in all patients at 24 h after PVP and in 83 available patients at 6 months. A total of five asymptomatic refractures of cemented vertebrae and 14 new symptomatic vertebral fractures at different levels were observed between 1 and 10 months after the procedure.ConclusionsPVP is a safe, rapid, effective and costeffective therapy for VCFs, requiring only brief hospital admission and with long-lasting clinical results, when performed under good-quality radiological guidance, when correct indications are respected and when it is associated with rehabilitation therapy in the follow-up. It is a valid alternative to conservative therapy, which is burdened by high healthcare costs and often requires long-term immobilisation of frail and elderly patients at risk of clinical complications.RiassuntoObiettivoLa vertebroplastica percutanea (VPP) è un trattamento mininvasivo per le fratture vertebrali sintomatiche da compressione (FVC). Scopo del presente lavoro è quello di valutare l’efficacia, le complicanze e la progressione dei risultati della VPP ottimizzata in termini di tecnica, costi, tempi e protocollo strategico dopo 3 anni di procedure effettuate sotto esclusiva guida fluoroscopica.Materiali e metodiSono state trattate 250 FVC in 120 pazienti consecutivi dopo valutazione delle indicazioni cliniche e radiologiche. L’efficacia della procedura è stata determinata attraverso l’analisi statistica di score numerici per il dolore, la mobilità e l’uso di farmaci antalgici prima e dopo il trattamento.RisultatiNon si sono verificate complicanze maggiori e solo 3 complicanze minori. È stato osservato un miglioramento della mobilità e riduzione del dolore e dell’uso di farmaci antalgici clinicamente rilevanti con risultati significativi (p<0,0001) in tutti i pazienti a 24 ore dalla VPP e, in 83 pazienti reperibili, a distanza di 6 mesi. Sono stati rilevati 5 nuovi cedimenti asintomatici in vertebre precedentemente trattate e 14 nuove fratture sintomatiche su livelli differenti da 1 a 10 mesi dopo la procedura.ConclusioniLa VPP costituisce un trattamento sicuro, rapido, efficace, poco costoso, che richiede solo un ricovero breve e con risultati clinici duraturi qualora sia impiegato un sistema di guida radiologica di buona qualità, siano rispettate le corrette indicazioni e venga associata una terapia riabilitativa nel follow-up. Rappresenta una valida alternativa alla terapia conservativa, quest’ultima gravata da elevati costi sanitari e che richiede spesso l’immobilizzazione prolungata di pazienti fragili e anziani, a rischio di complicanze cliniche.

Embolization of Dural Arteriovenous Fistula of the Cavernous Sinus Through Percutaneous Ultrasound-Guided Puncture of the Facial Vein

BACKGROUND The goal of dural arteriovenous fistula of the cavernous sinus treated with coils through ultrasound-guided access to the facial vein is to interrupt the fistulous communications and decrease the pressure in the cavernous sinus and consequently in the ophthalmic veins. The traditional approach in the treatment of these fistulae is transvenous endovascular occlusion of the cavernous sinus. Transvenous embolization has been proven to be safe and can provide complete and permanent occlusion of the fistula in a single session. The most commonly used venous pathway is the inferior petrosal sinus, but, if it is inaccessible, then, the superior ophthalmic vein is considered; nonetheless, it can require a surgical exposure. Other pathways include the transfemoral transfacial vein. An arterial approach is considered usually when venous approach pathways fail. Arterial occlusion of feeders supplying the fistula is associated with a greater risk of embolic complications. CASE DESCRIPTION We report a case of dural arteriovenous fistula of the cavernous sinus treated with coils through ultrasound-guided access to the facial vein. CONCLUSIONS We propose an alternative pathway when the conventional transvenous approach through the inferior petrosal sinus is excluded. An ultrasound-guided facial vein approach can be considered as a direct and safe alternative to reach the cavernous sinus and obtain exclusion of the fistula.