Caterina Michelozzi

Role of diffusion tensor magnetic resonance tractography in predicting the extent of resection in glioma surgery

Diffusion tensor imaging (DTI) tractography enables the in vivo visualization of the course of white matter tracts inside or around a tumor, and it provides the surgeon with important information in resection planning. This study is aimed at assessing the ability of preoperative DTI tractography in predicting the extent of the resection achievable in surgical removal of gliomas. Patients with low-grade gliomas (LGGs; 46) and high-grade gliomas (HGGs; 27) were studied using a 3T scanner according to a protocol including a morphological study (T2, fluid-attenuated inversion-recovery, T1 sequences) and DTI acquisitions (b = 1000 s/mm(2), 32 gradient directions). Preoperative tractography was performed off-line on the basis of a streamline algorithm, by reconstructing the inferior fronto-occipital (IFO), the superior longitudinal fascicle (SLF), and the corticospinal tract (CST). For each patient, the relationship between each bundle reconstructed and the lesion was analyzed. Initial and residual tumor volumes were measured on preoperative and postoperative 3D fluid-attenuated inversion-recovery images for LGGs and postcontrast T1-weighted scans for HGGs. The presence of intact fascicles was predictive of a better surgical outcome, because these cases showed a higher probability of total resection than did subtotal and partial resection. The presence of infiltrated or displaced CST or infiltrated IFO was predictive of a lower probability of total resection, especially for tumors with preoperative volume <100 cm(3). DTI tractography can thus be considered to be a promising tool for estimating preoperatively the degree of radicality to be reached by surgical resection. This information will aid clinicians in identifying patients who will mostly benefit from surgery.

[Bronchial and nonbronchial systemic artery embolization in managing haemoptysis: 31 years of experience].

PurposeThe authors report on 31 years of experience with bronchial (BAE) and/or nonbronchial (NBAE) systemic artery embolisation for managing haemoptysis.Materials and methodsA total of 534 patients who underwent bronchial artery angiography for haemoptysis between 1979 and 2010 were retrospectively evaluated. Of these patients, 477 (89%) had active bleeding and underwent BAE and/or NBAE (295 males and 182 females, aged between 12 and 71 years). Embolisation techniques, materials, major and minor complications and relapses were recorded.ResultsComplete resolution of haemoptysis was achieved within 24 h in 458/477 (96%) cases and within 48 h in 2% of cases. The aetiology of haemoptysis was as follows: cystic fibrosis (23%), bronchiectasis (13%), tuberculosis sequelae (8%), chronic obstructive pulmonary disease (COPD) (6%) and no apparent cause (21%). Major complications were recorded in 3/477 (0.6%): stroke (n=1), transient ischaemic attack (TIA) (n=1) and transient quadriplegia (n=1). Minor complications were recorded in 143/477 (30%): chest pain 86/143 (60%) and dysphagia 29/143 (20%). During a mean follow-up period of 14 (8–36) months, haemoptysis recurrence was observed in 42/110 cases (38%) of cystic fibrosis and in 77/367 cases of other diseases (21%).ConclusionsBAE and NBAE are effective and safe for acute treatment of haemoptysis, with low recurrence and complication rates. Interventional radiologist experience is crucial to the successful haemoptysis control and preventing complications.RiassuntoObiettivoScopo del nostro lavoro è riportare l’esperienza di 31 anni nell’embolizzazione delle arterie bronchiali (BAE) e/o sistemiche non bronchiali (NBAE) nel controllo dell’emottisi.Materiali e metodiDal 1979 al 2010, 534 pazienti sottoposti ad angiografia delle arterie bronchiali per emottisi sono stati retrospettivamente valutati; 477 (89%) avevano sanguinamento attivo e hanno eseguito BAE e/o NBAE (295 maschi e 182 femmine, etá compresa tra 12 e 71 anni). Sono state riportate tecniche di embolizzazione, materiali impiegati, complicanze maggiori e minori e recidive.RisultatiQuattrocentocinquantotto/477 (96%) dei casi presentarono risoluzione completa dell’emottisi entro 24 ore, 2% entro 48 ore. L’eziologia dell’emottisi è stata fibrosi cistica (23%), bronchiectasie (13%), esiti tubercolari (8%), broncopneumopatia cronica ostruttiva (BPCO) (6%) e sine materia (21%). Tre/477 (0,6%) pazienti presentarono complicanze maggiori: ictus cerebrale (1), attacco ischemico transiente (TIA) (1) e tetraparesi transitoria (1); 143/477 (30%) presentarono complicanze minori: dolore toracico 86/143 (60%) e disfagia 29/143 (20%). Il follow-up medio fu di 14 mesi (8–36 mesi), recidiva di emottisi nella fibrosi cistica 42/110 (38%) e nelle altre patologie 77/367 (21%).ConclusioniLa BAE e NBAE sono tecniche efficaci e sicure nel trattamento acuto dell’emottisi, con bassa percentuale di recidive e complicanze. L’esperienza del radiologo interventista è un fattore molto importante nel successo del controllo dell’emottisi e nella prevenzione delle complicanze.Obiettivo Scopo del nostro lavoro e riportare l’esperienza di 31 anni nell’embolizzazione delle arterie bronchiali (BAE) e/o sistemiche non bronchiali (NBAE) nel controllo dell’emottisi.

Embolizzazione delle arterie bronchiali e/o sistemiche non bronchiali nel controllo dell’emottisi: 31 anni d’esperienza

PurposeThe authors report on 31 years of experience with bronchial (BAE) and/or nonbronchial (NBAE) systemic artery embolisation for managing haemoptysis.Materials and methodsA total of 534 patients who underwent bronchial artery angiography for haemoptysis between 1979 and 2010 were retrospectively evaluated. Of these patients, 477 (89%) had active bleeding and underwent BAE and/or NBAE (295 males and 182 females, aged between 12 and 71 years). Embolisation techniques, materials, major and minor complications and relapses were recorded.ResultsComplete resolution of haemoptysis was achieved within 24 h in 458/477 (96%) cases and within 48 h in 2% of cases. The aetiology of haemoptysis was as follows: cystic fibrosis (23%), bronchiectasis (13%), tuberculosis sequelae (8%), chronic obstructive pulmonary disease (COPD) (6%) and no apparent cause (21%). Major complications were recorded in 3/477 (0.6%): stroke (n=1), transient ischaemic attack (TIA) (n=1) and transient quadriplegia (n=1). Minor complications were recorded in 143/477 (30%): chest pain 86/143 (60%) and dysphagia 29/143 (20%). During a mean follow-up period of 14 (8–36) months, haemoptysis recurrence was observed in 42/110 cases (38%) of cystic fibrosis and in 77/367 cases of other diseases (21%).ConclusionsBAE and NBAE are effective and safe for acute treatment of haemoptysis, with low recurrence and complication rates. Interventional radiologist experience is crucial to the successful haemoptysis control and preventing complications.RiassuntoObiettivoScopo del nostro lavoro è riportare l’esperienza di 31 anni nell’embolizzazione delle arterie bronchiali (BAE) e/o sistemiche non bronchiali (NBAE) nel controllo dell’emottisi.Materiali e metodiDal 1979 al 2010, 534 pazienti sottoposti ad angiografia delle arterie bronchiali per emottisi sono stati retrospettivamente valutati; 477 (89%) avevano sanguinamento attivo e hanno eseguito BAE e/o NBAE (295 maschi e 182 femmine, etá compresa tra 12 e 71 anni). Sono state riportate tecniche di embolizzazione, materiali impiegati, complicanze maggiori e minori e recidive.RisultatiQuattrocentocinquantotto/477 (96%) dei casi presentarono risoluzione completa dell’emottisi entro 24 ore, 2% entro 48 ore. L’eziologia dell’emottisi è stata fibrosi cistica (23%), bronchiectasie (13%), esiti tubercolari (8%), broncopneumopatia cronica ostruttiva (BPCO) (6%) e sine materia (21%). Tre/477 (0,6%) pazienti presentarono complicanze maggiori: ictus cerebrale (1), attacco ischemico transiente (TIA) (1) e tetraparesi transitoria (1); 143/477 (30%) presentarono complicanze minori: dolore toracico 86/143 (60%) e disfagia 29/143 (20%). Il follow-up medio fu di 14 mesi (8–36 mesi), recidiva di emottisi nella fibrosi cistica 42/110 (38%) e nelle altre patologie 77/367 (21%).ConclusioniLa BAE e NBAE sono tecniche efficaci e sicure nel trattamento acuto dell’emottisi, con bassa percentuale di recidive e complicanze. L’esperienza del radiologo interventista è un fattore molto importante nel successo del controllo dell’emottisi e nella prevenzione delle complicanze.Obiettivo Scopo del nostro lavoro e riportare l’esperienza di 31 anni nell’embolizzazione delle arterie bronchiali (BAE) e/o sistemiche non bronchiali (NBAE) nel controllo dell’emottisi.

Arterial embolization with Onyx of head and neck paragangliomas

Object To report the morbidity and long term results in the treatment of paragangliomas by transarterial embolization with ethylene vinyl alcohol (Onyx), either as preoperative or palliative treatment. Methods Between September 2005 and 2012, 18 jugulotympanic, 7 vagal, and 4 carotid body paragangliomas (CBPs) underwent Onyx embolization, accordingly to our head and neck multidisciplinary teams decision. CBPs were embolized preoperatively. Jugulotympanic and vagal paragangliomas underwent surgery when feasible, otherwise palliative embolization was carried out alone, or in combination with radiotherapy or tympanic surgery in the case of skull base or tympanic extension. Treatment results, and clinical and MRI follow-up data were recorded. Results In all cases, devascularization of at least 60% of the initial tumor blush was obtained; 6 patients underwent two embolizations. Post-embolization, 8 patients presented with cranial nerve palsy, with partial or complete regression at follow-up (mean 31 months, range 3–86 months), except for 2 vagal and 1 hypoglossal palsy. 10 patients were embolized preoperatively; 70% were cured after surgery and 30% showed residual tumor. 19 patients received palliative embolization, of whom 5 underwent radiotherapy and 3 received tympanic surgery post-embolization. Long term follow-up of palliative embolization resulted in tumor volume stability (75%) or extension in intracranial or tympanic compartments. Onyx embolization of CBPs resulted in more difficult surgical dissection in 2 of 4 cases. Conclusions Onyx embolization is a valuable alternative to surgery in the treatment of jugulotympanic and vagal paragangliomas; tympanic surgery or radiosurgery of the skull base should be considered in selected cases. Preoperative Onyx embolization of CBPs is not recommended.

PTA Stent of Dural Sinuses in Brain DAVF

Background and PurposeType I and IIa dural arteriovenous fistulas (DAVFs) have a low hemorrhagic risk, but are often the cause of debilitating tinnitus that requires treatment. While Onyx® and PHIL™ (Precipitating hydrophobic injectable liquid) transarterial embolization represent the first endovascular option, there are occasional cases where performing angioplasty and stenting of the affected sinus may lead to satisfactory results.Material and MethodsWe retrospectively analyzed four consecutive cases of patients with DAVF-induced pulsatile tinnitus secondary to type I and II DAVFs who were treated with angioplasty and stenting of the sinus only. All the patients had clinical and radiological long-term follow-up.ResultsWe noticed a significant radiological and clinical improvement in all the cases. Of the patients two were completely cured at follow-up with eradication of the neurological symptoms as well as the fistula, one was retreated with Onyx® for a very small residual shunt despite having no more tinnitus, and one showed improvement in venous drainage (from type IIa+b to type I fistula) without resolution of the fistula.ConclusionIn cases of type I and II DAVFs associated with sinus stenosis, angioplasty and stenting alone seem to be safe and effective. This treatment probably compresses the venules within the sinus walls, promoting thrombosis of the shunts thus solving the underlying cause of the fistula.