Erick Clavier

Predictors of failed pelvic arterial embolization for severe postpartum hemorrhage.

OBJECTIVES: To estimate what factors are associated with a failed pelvic arterial embolization for postpartum hemorrhage and to attempt to estimate efficacy of pelvic arterial embolization in rare conditions. METHODS: This was a retrospective cohort study including all consecutive women who underwent pelvic arterial embolization trial for postpartum hemorrhage between 1994 and 2007 at a tertiary care center. Pelvic arterial embolization failure was defined as the requirement for subsequent surgical procedure to control postpartum hemorrhage. RESULTS: Pelvic arterial embolization was attempted in 0.3% of deliveries by the same radiologist in 87% of cases. Failures occurred in 11 of 100 cases (11%) and in 4 of 17 cases (24%) of placenta accreta or percreta. The major complication rate after pelvic arterial embolization was low (3%). Fifty patients (50%) were transferred from nine other institutions. Pelvic arterial embolization was performed in 11 cases (11%) after a failed conservative surgical procedure and in eight cases (8%) for secondary postpartum hemorrhage, with success rates of 91% and 88%, respectively. Pelvic arterial embolization demonstrated a patency throughout one ligated pedicle in 9 of the 11 cases of failed conservative surgical procedure (82%). Twin pregnancy, chorioamnionitis, operative vaginal delivery, hospital-to-hospital transfer, nature of embolizing agent and arteries embolized, failed surgical procedure, secondary postpartum hemorrhage, cause of postpartum hemorrhage, and more than one pelvic arterial embolization were not found to be significantly associated with failed pelvic arterial embolization. CONCLUSION: The only factors significantly associated with failed pelvic arterial embolization were a higher rate of estimated blood loss (more than 1,500 mL) and more than 5 transfused red blood cell units. Attempted pelvic arterial embolization after a failed vessel ligation procedure and for a secondary postpartum hemorrhage is a good option with high success rates. LEVEL OF EVIDENCE: III

Fertility and pregnancy following pelvic arterial embolisation for postpartum haemorrhage

Objectives  To determine and compare the fertility and pregnancy outcomes following embolisation with or without uterine‐sparing surgery for postpartum haemorrhage, and to attempt to identify specific risk factors associated with an increased likelihood of intrauterine synechia.

Interdisciplinary treatment of ruptured cerebral aneurysms in elderly patients

OBJECT The aim of the study was to assess postprocedural neurological deterioration and outcome in patients older than 70 years of age in whom treatment was managed in an interdisciplinary context. METHODS This prospective longitudinal study included all patients 70 years of age or older treated for ruptured cerebral aneurysm over 10 years (June 1997-June 2007). The population was composed of 64 patients. The neurovascular interdisciplinary team jointly discussed the early obliteration procedure for each aneurysm. Neurological deterioration during the postprocedural 2 months and outcome at 6 months were assessed during consultation according to the modified Rankin Scale (mRS) as follows: favorable (mRS score < or = 2) and unfavorable (mRS score > 2). RESULTS Aneurysm sac obliteration was performed by microvascular clipping in 34 patients (53.1%) and by endovascular coiling in 30 (46.9%). Postprocedural neurological deterioration occurred in 30 patients (46.9%), related to ischemia in 19 (29.7%), rebleeding in 1 (1.6%), and hydrocephalus in 10 (15.6%). At 6 months, the outcome was favorable in 39 patients (60.9%). By multivariate regression logistic analysis, the independent factors associated with unfavorable outcome were age exceeding 75 years (p = 0.005), poor initial grade (p < 0.0001), and the occurrence of ischemia (p < 0.0001). CONCLUSIONS The baseline characteristics of SAH in the elderly were only slightly different from those in younger patients. In the elderly, the interdisciplinary approach may be considered useful to decrease the ischemic consequences.

Long‐term psychological impact of severe postpartum hemorrhage

Objective. To estimate the long‐term psychological impact of severe postpartum hemorrhage in women whose uterus was preserved. Design. Retrospective study. Setting. University‐affiliated tertiary referral center. Population. All consecutive women who underwent embolization for postpartum hemorrhage between 1994 and 2007 and whose uterus was preserved were included. Methods. Data were retrieved from medical files and semi‐structured telephone interviews. In semi‐structured interviews, women were asked about their perceptions and memories of the experience. Main Outcome Measures. Perceptions and memories of the postpartum hemorrhage during and after delivery. Results. Follow‐up was successful for 68 of the 91 (74.7%) women included. Of the 46 (67.6%) who reported negative memories of the delivery and postpartum period, the main memory for 24 was a fear of dying (35.3%). Of the 28 (41.2%) who reported continued repercussions, 16 (23.5%) thought about this delivery and its complications at least once a month, five (7.3%) reported persistent fear of dying, four (5.9%) reported sexual problems, and three (4.4%) women considered that the event was, at least in part, responsible for their subsequent divorce. Of the 15 women who had a subsequent full‐term pregnancy, nine (60%) reported intense anxiety throughout the pregnancy, and one (6.7%) developed depression requiring antidepressant treatment during pregnancy. Conclusions. Severe postpartum hemorrhage may have a long‐term psychological impact on women despite uterine preservation.

Subarachnoid hemorrhage due to cerebral aneurysmal rupture during pregnancy

Cerebral aneurysmal complications rarely occur during pregnancy. Telling the difference between eclampsia and cerebral hemorrhage due to aneurysmal rupture can prove to be difficult. Aneurysmal management should be performed in an emergency but fetal prognosis should be considered. We report a series of eight pregnant women presenting aneurysmal complications and we have assessed their management and outcome. Both maternal and perinatal mortality rates were correlated with the maternal clinical score. We stress the role of combined care by both neurosurgeons and obstetricians. An emergency cesarean section followed by aneurysmal treatment appears to be a widely accepted strategy in pregnant women with cerebral aneurysmal complications.

Usefulness of multislice computerized tomography angiography in preoperative diagnosis of ruptured cerebral aneurysms

OBJECTIVE Non-invasive imaging methods have become primordial in subarachnoid hemorrhage. The aim of our study was to evaluate the sensitivity and specificity of multislice computed tomographic angiography (MSCTA) for the diagnosis of cerebral aneurysm. METHODS The 28 included consecutive patients with SAH underwent both MSCTA and digital subtraction angiography (DSA). The MSCTA studies were interpreted by two independent readers (A and B) for the presence, the location and size of the aneurysm comparatively to the DSA as reference examination. RESULTS In 20 patients, 38 aneurysms were diagnosed and in eight no aneurysm was found. Per patient basis, the diagnostic sensitivity and specificity were excellent. Per aneurysm basis, the diagnostic sensitivity and specificity of MSCTA were, respectively, 97.4 and 100% for reader A, 100 and 100% for reader B. For aneurysms less than 3mm, sensitivity was 100% for both readers. Interobserver agreement was excellent for the detection of aneurysm (kappa=0.98, 95% CI [0.96-1]). Intertechnique and interobserver agreements were excellent for the measurement of aneurysms (slope=0.86, r=0.91 p=3.1x10(-7) and slope=1.04, r=0.99, p<10(-6), respectively). CONCLUSION MSCTA was an accurate and reproducible non-invasive imaging technique for preoperative diagnosis of ruptured cerebral aneurysm. The MSCTA may be proposed in first intention after the diagnosis of SAH was established, with special care regarding injection procedure and a strict reading method using native images and thin MPR.

Middle meningeal artery aneurysm associated with diffuse calvarial metastases: A case report and review of the literature

Aneurysms of the middle meningeal artery (MMA) are xtremely rare. They are divided into traumatic pseudo aneurysms nd non-traumatic aneurysms, the latter being the less frequent ype. Pseudoaneurysms of the MMA are usually associated with rauma or an iatrogenic injury. These pseudoaneurysms tend to radually enlarge, resulting in delayed rupture, clinical deterioraion, and acute intracranial bleeding [1]. Because there is a risk f secondary rupture, most pseudoaneurysms and true ruptured neurysms require treatment, although some cases of spontaneous hrombosis have been reported. The therapeutic methods used to reat these conditions include endovascular embolization and surical resection, assisted by hematoma evacuation when necessary 2]. A true aneurysm in the MMA resembles a common cereral aneurysm, often originates from its branches, and is usually ssociated with increased hemodynamic stress or a pathological ondition in the MMA. Under physiological conditions, this artery s not submitted to hemodynamic stress and closely adheres to the nternal aspect of the skull, making the development of aneurysms xtremely rare [3]. When the middle meningeal artery passes hrough the foramen spinosum into the cranial cavity, its histologcal appearance changes from that of a muscular artery to that of a hin-walled intracranial artery on which aneurysms can grow conecutively to abnormal blood flow conditions [2]. Almost all cases of rue aneurysms of the MMA have been associated with a pathologcal condition that increased hemodynamic stress to its walls [3]. his article describes the first case of MMA aneurysm associated ith diffuse calvarial metastases, a hemodynamic stress inducing athology.

NR-WP-10 Aspects radiologiques des atteintes du systeme nerveux central de la maladie de rendu-osler

Objectifs pedagogiques Connaitre et illustrer les aspects radiologiques des atteintes neurologiques de la maladie de Rendu-osler (MRO). Messages a retenir Les formes neurologiques de la MRO sont rares mais meritent d’etre connues car elles peuvent etre revelatrices de la maladie notamment les formes secondaires compliquant une MAV pulmonaire.