Andreas Chemelli

Language Lateralization in Temporal Lobe Epilepsy: A Comparison between fMRI and the Wada Test

Summary:  Purpose: Recent studies have claimed that language functional magnetic resonance imaging (fMRI) can identify language lateralization in patients with temporal lobe epilepsy (TLE) and that fMRI‐based findings are highly concordant with the conventional assessment procedure of speech dominance, the intracarotid amobarbital test (IAT).

Type a Dissection following Endovascular Thoracic Aortic Stent-Graft Repair:

Purpose: To describe our experience with endovascular stent-graft repairs in the thoracic aorta focusing on the secondary complication of type A dissection. Methods: Between January 1996 and April 2004, 73 patients were treated for traumatic thoracic aortic rupture (n=15), type B dissection (n=22), or atherosclerotic descending thoracic aortic aneurysms (TAA, n=36). A retrospective review of the records found 5 (6.8%) patients (3 men; median age 64 years, range 43–87) who experienced a type A dissection at a median 20 days (range 2–124) after thoracic stent-graft repair for 3 type B dissections, 1 TAA, and a late type I endoleak that appeared 28 months after initial stent-graft repair of a traumatic dissection. Results: In 3 patients (2 dissections, 1 endoleak), a tear in the aortic wall at the proximal stent-graft was responsible for a retrograde type A dissection. Underlying disease was the cause of the type A dissection in the 2 other patients (1 dissection, 1 TAA) and was unrelated to the stent-grafts. Three patients underwent open surgery at 3, 26, and 124 days after stent-graft placement; 2 procedures were successful, but the third patient died 3 months later due to multiorgan failure. Two type A dissections were untreated: one patient died from cardiac tamponade 14 days after successful stent-graft exclusion of the type I endoleak; the other patient refused further treatment and survived. The procedure-related mortality following acute retrograde type A dissection was 40%. Conclusions: Endovascular stent-graft repair of the thoracic aorta is associated with lower morbidity and mortality rates than surgical repair, although potentially lethal complications, acute or delayed, may occur.

Endovascular repair or medical treatment of acute type B aortic dissection? A comparison

INTRODUCTION The aim of this retrospective study was to compare the outcome of thoracic endovascular aortic repair (TEVAR) to that of medical therapy in patients with acute type B aortic dissection (TBD). MATERIALS AND METHODS From July 1996 to April 2008, 88 patients presenting with acute TBD underwent either TEVAR (group A, n=38) or medical therapy (group B, n=50). Indications for TEVAR were intractable pain, aortic branch compromise resulting in end-organ ischemia, rapid aortic dilatation and rupture. Follow-up was performed postinterventionally, at 3, 6 and 12 months and yearly thereafter and included clinical examinations and computed tomography (CT), as well as aortic diameter measurements and assessment of thrombosis. RESULTS Mean follow-up was 33 months in group A and 36 months in group B. The overall mortality rate was 23.7% in group A and 24% in group B, where 4 patients died of late aortic rupture. In group A, complications included 9 endoleaks and 4 retrograde type A dissections, 3 patients were converted to open surgery and 2 needed secondary intervention. None of the patients developed paraplegia. In group B, 4 patients were converted to open surgery and 2 to TEVAR. The maximal aortic diameter increased in both groups. Regarding the extent of thrombosis, our analyses showed slightly better overall results after TEVAR, but they also showed a tendency towards approximation between the two groups during follow-up. CONCLUSION TEVAR is a feasible treatment option in acute TBD. However, several serious complications may occur during and after TEVAR and it should therefore be reserved to patients with life-threatening symptoms.

Endovascular Repair of Isolated Iliac Artery Aneurysms

Purpose: To retrospectively evaluate a 12-year experience with endovascular repair of isolated iliac artery aneurysm (IAA). Methods: From August 1997 through July 2009, 91 patients (81 men; mean age 71 years, range 31–90) underwent endovascular treatment for isolated IAA at our department. Of these, 77 patients received stent-grafts either alone or in combination with coils or an Amplatzer vascular plug (n=2); 1 patient received a Smart stent combined with coils, and 13 patients were treated with coil embolization only. The aneurysms were classified according to location: type I=common iliac artery (CIA), type II=internal iliac artery (IIA), type III5CIA and IIA, and type IV=external iliac artery with/without CIA and/or IIA involvement. Results: Primary technical success was 90.1% for all aneurysm types and 93.6%, 80%, 88.8%, and 93.3% for types I, II, III, and IV, respectively. Secondary technical success was 96.7% for all types and 97.8%, 95%, 100%, and 93.3%, respectively, for each type. Clinical success was 93.4% for all types and 97.8%, 85%, 100%, and 86.7%, respectively, by type. Complications in 18 (19.8%) patients included 7 type I endoleaks, 3 type II endoleaks, 2 enlarged aneurysm sacs (incomplete embolization), 5 cases of buttock claudication, and 2 stent-graft thromboses. Two patients were converted to open surgery; 10 underwent secondary interventions. Mortality rates were 1.1% (n=1) at 30 death days and 23.1% (n=21) over a mean follow-up of 45.9 months (no aneurysm-related death). Cumulative overall survival was 97.7% at 1 year and 47.6% at 10 years. Freedom from aneurysm-related complications was 88.6% at 1 year and 83.5% at 5 years. Conclusion: Endovascular repair of isolated IAA is a safe and minimally invasive alternative to surgery. However, it may be associated with several complications and must, therefore, be carefully planned.

Transcatheter arterial embolization for the management of iatrogenic and blunt traumatic intercostal artery injuries

OBJECTIVE The purpose of this retrospective study was to evaluate transcatheter arterial embolization (TAE) for the management of iatrogenic and blunt traumatic intercostal artery (ICA) injuries associated with hemothorax and clinical deterioration. METHODS From May 1999 through April 2007, 24 consecutive patients (17 men, 7 women; mean age 53 years) presenting with active ICA hemorrhage underwent TAE mainly by means of coils combined with polyvinyl alcohol (PVA) particles. Eleven of them had blunt traumatic injuries (group A, n = 11) and 13 had iatrogenic injuries (group B, n = 13). In all patients, ICA injuries resulted in acute bleeding with clinical deterioration and hemothorax. Before discharge, all patients underwent clinical examination, laboratory tests, and chest x-ray. After discharge, no specific follow-up protocol was required, and the patients were questioned on their state of health at regular intervals and underwent CT or chest x-ray as needed. RESULTS Primary technical success (PTS) was achieved in 21 of 24 patients (87.5%). In group A, it was achieved in all but one patient (90.9%) and in group B in 11 of 13 patients (84.6%). A total of three patients needed secondary interventions, which failed in one of them, amounting to a secondary technical success rate (STS) of 8.3%. The total cumulative mortality rate was 37.5% (n = 9). In group A, it was 9.1% (n = 1) and in group B, it was 61.5% (n = 8). 30-day-mortality was 9.1% in group A, where one patient died due to multiple severe associated injuries, and 30.8% (n = 4) in group B, where one patient died due to treatment failure and three patients due to severe comorbidities. During follow-up, no more deaths occurred in group A, while in group B, four more patients died due to severe comorbidities, amounting to a late mortality rate of 30.8%. No technical complications and no complications such as chest wall or spinal cord ischemia were observed. The mean observation period was 44.6 months in group A and 23.8 months in group B. CONCLUSION TAE of ICAs is a minimally invasive, safe, and reliable treatment option to control massive intrathoracic hemorrhage, especially in patients with serious comorbidities and/or multiple injuries. However, it should be performed only by experienced interventionalists and exact knowledge of the anatomic features of the affected artery and of collateral pathways is mandatory to avoid complications.

Endovascular Repair of Acute Type B Aortic Dissection: Midterm Results

Purpose: To evaluate midterm results of endovascular stent-graft placement for acute Stanford type B dissection (TBD). Methods: A retrospective review was conducted of 35 consecutive patients who were treated with stent-graft implantation for acute TBD between July 1996 and July 2007. Computed tomographic (CT) volumetric analysis of the true lumen (TL) and false lumen (FL) changes in 23 patients was performed, as well as evaluation of the influence of re-entry points and length of stent-graft coverage on volume changes. In addition, complications were evaluated. Follow-up was performed at 6 and 12 months and yearly thereafter Results: The technical success rate was 82.7%, and the 30-day mortality rate was 8.5%. Mean follow-up was 34 months. The overall survival rate at 5 years was 78.4%. Complications included retrograde type A dissections in 3 patients during the perioperative period and in 1 patient during midterm follow-up. In addition, 5 early and 3 late endoleaks were observed. Three patients were converted to open surgery and 2 needed secondary interventions. In the stented segment, stabilization of the aorta was achieved even during midterm follow-up, with a TL volume increase of 59% at 5 years and nearly stable FL volume. The segment from the distal end of the stent-graft to the celiac artery, however, showed unstable TL and FL volumes, with high standard deviations after the first postinterventional year and circumferential aneurysmal dilatation of the aorta immediately adjacent to the stent-graft in 5 patients. The abdominal aorta showed no substantial volume changes over time. The length of stent-graft coverage and the occurrence of reentries greatly influenced FL volume changes distal to the stent-graft. Conclusion: Serious complications can occur during and after endovascular repair of TBD. Therefore, it should be reserved for high-risk patients.

Hemispheric disconnection in Marchiafava-Bignami disease: Clinical, neuropsychological and MRI findings

We report a single-case study of a patient suffering from Marchiafava-Bignami disease (MBD), a rarely intra vitam diagnosed syndrome with focal demyelination in the corpus callosum, which is usually found in patients with chronic alcohol abuse. Our study explored a variety of motor, sensory and visual functions. Striking features were left apraxia caused by two lesions in the rostral area, and left hemidyslexia related to a large splenial lesion demonstrated by MRI. As symptoms of disconnection may remain undetected clinically, MRI is a most useful tool for the diagnosis of MBD.

Basilar Artery Dissection: Series of 12 Consecutive Cases and Review of the Literature

Background: Current knowledge on primary or isolated basilar artery dissection (IBAD) is limited to case vignettes and small patient series. Objective: To delineate the frequency and clinical presentations of IBAD along with short-term outcome, specific prognosis and targeted management. Methods: Data were derived from a series of 12 consecutive patients and a review of 88 cases reported in the literature. In all the cases, the dissection was confined to the basilar artery. Results: Disease incidence was estimated at 0.25 per 100,000 person-years. IBAD accounted for roughly 1.0% of all subarachnoid hemorrhage events and for no less than 10.5 and 4.5% of posterior circulation and brain-supplying artery dissections, respectively. The main clinical presentations were subarachnoid hemorrhage (46%) and posterior circulation brain ischemia (42%). Subarachnoid hemorrhage typically manifested at a higher age than brain ischemia (mean age, 48.9 vs. 41.4 years) and was more prevalent among women. Rebleedings related to pseudoaneurysm formation in patients with subarachnoid hemorrhage and recurrent ischemia in stroke patients were common in the acute phase (26.1 and 33.3%, respectively) but were rare in the long term. The outcome was generally favorable in stroke patients but variable in subarachnoid hemorrhage (case fatality rate, 21.7%). The mainstay of therapy for subarachnoid hemorrhage related to IBAD was endovascular occlusion of the aneurysm pouch whereas stroke patients were usually put on anticoagulants. Conclusions: IBAD is probably an underrecognized disease with heterogeneous clinical presentation and prognosis. It should be considered as a differential diagnosis in peritruncal subarachnoid hemorrhage, classic subarachnoid hemorrhage and posterior circulation stroke, especially in young individuals. Case management is challenging and has to be tailored to each patient.

Evaluation of volumetric measurements in patients with acute type B aortic dissection – thoracic endovascular aortic repair (TEVAR) vs conservative

OBJECTIVE The aim of this retrospective study was to evaluate aortic volume changes in patients with acute type B aortic dissection (TBD), treated either by thoracic endovascular aortic repair (TEVAR) or conservatively. MATERIALS AND METHODS From July 1996 through March 2008, 76 patients presenting with acute TBD were referred to our department. To ensure a follow-up of at least 24 months, only 64 of them were included in the present study, with the cut-off for inclusion being March 2006. Twenty-nine of these patients underwent TEVAR and 35 patients underwent conservative treatment. Indications for TEVAR were life-threatening symptoms. Follow-up was performed postinterventionally in patients after TEVAR and at 3, 6, and 12 months, and yearly thereafter in both groups. It included clinical examinations, computed tomography (CT) scans, analysis of volume changes in true thoracic lumen (TTL), false thoracic lumen (FTL), thoracic lumen (TL), abdominal lumen (AL), and aortic diameter measurements. In addition, the extent of thrombosis and its influence on volume changes were assessed. RESULTS Mean follow-up was 41 months after TEVAR and 46 months in the conservatively-treated patients. At 60 months, cumulative rates of freedom from dissection-related death and rupture-free survival were 82.6% and 93.1% in the TEVAR group, respectively. They were 74.9% and 88.5% in the conservatively-treated group, respectively. In the conservatively-treated patients, 3 patients died of late aortic rupture, 4 were converted to open surgery, and 2 to TEVAR. Evaluation of volume changes showed better results in the TEVAR group within 24 months. However, within 60 months the difference between the two groups was no longer relevant. Relating to thrombosis of the FTL, analyses showed slightly better overall results and promotion of thrombus formation after TEVAR. However, at 60 months the results showed a tendency towards approximation between the two groups. CONCLUSION Our data suggest that TEVAR seems to delay the natural course of the disease but not to stop it.

Endovascular therapy of distal anterior cerebral artery aneurysms : an effective treatment option

BACKGROUND Surgical treatment of APAs is associated with relatively high morbidity and mortality. The aim of this study was to illustrate the technical achievements of endovascular procedures in the distal anterior cerebral artery area, technical difficulties and how they can be overcome, and the outcome of endovascular treatment of APAs. METHODS Between 1997 and 2006, of 49 patients with APAs at our institution, 29 were treated endovascularly (4.1% of all endovascularly treated aneurysms; F:M = 3.8; mean age, 52.8 +/- 11.5 years), and 12 were treated surgically. Twenty-one (72.4%) of the endovascularly treated patients had a subarachnoid hemorrhage. The mean observation period was 25 +/- 22.8 months. RESULTS In 27 (93.1%) cases, complete occlusion of the aneurysm was achieved. The intervention led to 5 (17.2%) cases of minor complications with no neurologic deficits: 2 thromboembolisms, 1 local thrombus, 1 occlusion, and 1 recurrent hemorrhage. Mortality related to the intervention was 3.4%. There was no morbidity associated with the elective procedures. The dome-to-neck ratio is the main predictor of reperfusion. The most important factor impairing the outcome in terms of the GOS status is the presence of an intraparenchymal hematoma, followed by thrombembolic complications. CONCLUSION Endovascular treatment of APAs is feasible, safe, and effective. Mortality and morbidity are comparable with surgical therapy. An intraparenchymal hematoma has a severe negative influence on the patients condition after rehabilitation. In these cases, surgical intervention should be considered. In case of incomplete occlusion of the aneurysm, prompt reintervention is required.