Giulio Guidetti

Vertebral hemangiomas with cord compression: The role of embolization in five cases

Five new cases of vertebral hemangioma with cord compression are reported. The role of preoperative selective angiography with embolization in the management of these lesions is discussed in the light of the most important literature on this topic.

Anterior Communicating Aneurysm Missed at Angiography: Report of Two Cases Treated Surgically

We report two young adults with definite clinical and computed tomographic (CT) signs of subarachnoid hemorrhage in whom initial angiography showed spasm of the anterior portion of the circle of Willis, but no aneurysm. Repeat angiography some days later, when the vascular spasm had cleared, was likewise negative. In both patients, operation revealed an anterior communicating artery aneurysm, which was successfully excluded from the circulation. Our aims in reporting this unusual experience are to stress the practical importance of CT scanning in the diagnosis and treatment of subarachnoid hemorrhage and to discuss the decision to operate.

Regression of an internal carotid artery pseudoaneurysm after therapeutic embolization of a post-traumatic carotid-cavernous fistula secondary to gunshot injury.

SummaryA case is reported of a 53-year-old woman who was hit by a bullet which penetrated the skull base and caused a left carotid-cavernous fistula of the direct type and a pseudoaneurysmal dilation of the high cervical portion of the left internal carotid artery. The fistula was succesfully embolized by positioning a balloon into the fistula itself by means of the Debrun technique: unexpectedly the size of the pseudoaneurysm decreased after the embolization; the possible explanations for this event are discussed.

Magnetic Resonance Angiography for Evaluation of Intracranial Aneurysms Treated with Guglielmi Detachable Coils

Thirteen cases of cerebral aneurysms submitted to endovascular treatment using Guglielmi detachable coils (GDC) are described. Control MRI-angiography 3D TOF was performed three and six months later. In order to spare patients the discomfort and risks related to repeated trauma and iodate contrast injection, we examined the possibility of an alternative non-invasive diagnostic method. For this purpose, the digital subtraction angiograms performed three and six months after embolisation were compared with the MR-angiograms obtained in the same period, all using the same tomograph at middle field intensity (0.5T). We discuss the outcome of this comparison and the limits of the MR-angiography method in the follow-up of aneurysms submitted to endovascular treatment.

Brain AVMs: an endovascular, surgical, and radiosurgical update.

Brain arteriovenous malformations (bAVMs) are complex vascular lesions. Despite multiple studies, several classifications, and a great interest of the scientific community, case selection in AVM patients remains challenging. During the last few years, tremendous advancements widened therapeutic options and improved outcomes spreading indications for patients harboring lesions deemed inoperable in the past. Anatomical and biological case specific features, and natural history with a focus on presenting symptoms should be evaluated case by case and always kept in mind while planning a therapeutic management for a bAVMs. A multidisciplinary approach is strongly recommended when dealing with bAVMs and should involve physicians expertise in this kind of challenging lesions. The goal of this paper is to provide a focused review of the most recent acquisitions and therapeutic strategies regarding surgical, endovascular, and radiosurgical treatment.

Contrast-enhanced transcranial color-coded duplex sonography versus computed tomography and magnetic resonance angiography in the follow-up of basilar stenting.

The annual risk of stroke in patients with basilar artery stenosis is 2.5% to 11%, and even despite aggressive medical treatment, the prognosis of basilar artery thrombosis is fatal. For these reasons, invasive therapeutic approaches have been developed for cases of stroke due to vertebrobasilar circulation stenosis and occlusion. 1 In specialized centers, both intra-arterial thrombolysis performed in cases of basilar occlusion and intracranial stenting nowadays are becoming available suitable procedures to restore vascularization in cases of vertebrobasilar stenosis. 2,3 Nonetheless, restenosis is the major complication, with rates of 30% to 41% and an overall annual periprocedural complication rate of 6.6%. 4,5 It is therefore important to perform an accurate postprocedural follow-up to determine stent lumen patency. Conventional digital subtraction angiography (DSA) is still the most sensitive technique for visualizing the residual lumen after stenting, but it is invasive and not free of complications. Postprocedural follow-up is then usually performed by computed tomographic angiography (CTA) or magnetic resonance angiography (MRA). These techniques are both expensive and have limitations due to stent-induced artifacts, which may hide the residual lumen. 2 Transcranial color-coded duplex sonography (TCCD) has been a well-established diagnostic tool for visualization of the basal cerebral arteries since the early 1990s, although it is limited by the quality of the temporal acoustic bone window.6 With the introduction of sonographic contrast agents, vessel visualization has become easier and feasible in daily practice, at the bedside of the patient, with low costs and excellent results. 7 We report a case of a patient with a stroke and basilar artery stenosis who underwent a stenting procedure and follow-up studies with MRA, CTA, DSA, and TCCD.

Endovascular Treatment of Large and Giant Carotid Aneurysms with Flow-Diverter Stents Alone or in Combination with Coils: A Multicenter Experience and Long-Term Follow-up

BACKGROUND Although flow diverters (FDs) have been widely accepted by neurointerventionists, their safety has yet to be fully defined. Stratification by aneurysm size and location is essential for correct evaluation of treatment outcomes and risks of flow diversion. OBJECTIVE To compare neurological and anatomic outcomes and evaluate the risk of complications after endovascular treatment of large or giant internal carotid artery (ICA) aneurysms with FD/FDs alone or together with coil embolization. METHODS We reviewed all patients with large or giant, ruptured or unruptured ICA aneurysms who underwent endovascular treatment with flow diversion alone (group A) or with concomitant coiling (group B) in 4 international institutions between 2010 and 2015. Anatomic outcome was evaluated using the Byrne scale on digital subtraction angiography and/or angioMRI and/or angioCT scans 3, 6, 12, and 24 months postoperatively. RESULTS We collected 44 patients with large or giant ICA aneurysms. Four patients (9%) presented with aneurysmal subarachnoid hemorrhage (SAH). FD/FDs were used alone in 26 patients and in combination with coil embolization in the 18 remaining patients. The mortality rate due to procedure-related and/or neurological complications was 2.2%. Twelve months after the procedure, 88.6% (n = 39) of patients had a favorable neurological outcome. One year after the procedure, the aneurysm was completely occluded in 72.7% of patients: 61.5% (16/18) in group A and 88.9% (16/26) in group B. CONCLUSION Clinical outcomes and rates of intraoperative and postoperative complications did not differ significantly between the groups. Better anatomic results using FD/FDs combined with coils were documented 6 months after the procedure; this option seems to provide a higher aneurysm occlusion rate and reduce the need for retreatment.

Neuroplastic Changes in the Brain: A Case of Two Successive Adaptive Changes Within the Motor Cortex

We describe a case of neuroplasticity associated with both arteriovenous malformation (AVM) and stroke, which occurred in two successive events in the same patient.

Hemodynamic Features of Non-Aneurysmal Subarachnoid Hemorrhage in a Case of Familial Moyamoya Disease: A Transcranial Doppler Ultrasound Study

Willis circle with absence of the ACAs and of L-MCA and multiple tortuous vessels branching from the R-MCA (‘moyamoya vessels’). No aneurysms or vascular malformations were found ( fig. 1 ). Based on these findings, the patient was diagnosed with MMD. No neurological deficits were noted on the patient’s physical examination. Upon admission, we performed a Carotid Duplex ultrasound and a TCD, which showed an increase in mean blood flow velocity of R-MCA. This was initially attributed to vasospasm and nimodipine therapy was started. We also performed a progressive TCD follow-up; hemodynamic parameters of the first ultrasound examination as well as those from TCD follow-up are summarized in table 1 (we exclusively reported follow-up values from the R-MCA, which were the only ones that showed significant changes through time). The patient had a very favorable outcome and is currently asymptomatic. Particularly interesting is the monitoring of hemodynamic state of brain vessels done in our case. According to previous studies performed on asymptomatic MMD patients [6] , we found at T0 that both the ICAs showed normal flow velocity and low resistance, while the remaining intracranial vessels showed a consistent hemodynamic pattern in terms of high flow velocity and low resistance. This pattern re

The only case of mycotic aneurysm of the PICA: Clinical-radiological remarks and review of literature

We present the first and only case, reported in literature, of a 67-years-old man with a mycotic aneurysm (MA) of the left posterior inferior cerebellar artery (PICA), caused by group B Streptococcus, that we surgically treated, performing neck aneurysm clipping, preserving patency of parent vessel. Moreover the peculiarity of this case is represented by the fact that the MA is originated from a tooth abscess, treated about two years before. To date, there have been only 10 cases of association between MA with either tooth pathologies or dental surgical procedures and our case is the only one originating from PICA. Therefore an extensive literature analysis was performed. Hence if we observe a patient with a fusiform aneurysm in posterior intracranial circulation and clinical history of fever and/or persistent neck swelling after dental pathologies, it is mandatory to consider the possibility of a MA, for a correct differential diagnosis. If the diagnosis is confirmed, it is necessary to research the origin of infection and to set the specific antibiotics therapy.